Poor prognosis of pregnancy in women with autoimmune type 1 diabetes mellitus masquerading as gestational diabetes.

AIM: To describe the clinical presentation and the prognosis of autoimmune type 1 diabetes (T1D) that was first revealed during pregnancy masquerading as gestational diabetes mellitus (GDM). METHODS: We reviewed the files of 21 women in whom diabetes was revealed during a pregnancy ("index pregnancy") and progressed to T1D after delivery, and in whom GAD and/or IA-2 autoantibodies were found. RESULTS: The median age and BMI of the women were 31 years and 19.8 kg/m(2). Eleven women had at least one risk factor for GDM. Eight of the 12 multiparous women had had an abnormal outcome of previous pregnancy, including GDM in five. GDM was diagnosed at week 26 (range: 4-38) of gestation by screening in 18, because of macrosomia in two and during hyperglycaemic crises in three. All were treated with insulin, from the time of diabetes diagnosis in 10 and after 4 weeks (range: 2-15) in 11. Term of delivery was 38 (range: 26-41) weeks. Abnormal outcomes occured in 14 pregnancies, including two fetal deaths, four preterm deliveries and eight macrosomic infants. No congenital malformations were reported. After delivery, insulin therapy was stopped in 18 women for 6 months (range: 2-48). The diagnosis of the autoimmune origin of diabetes was established during the index pregnancy in only eight cases. CONCLUSION: T1D may reveal as GDM in women with or without risk factors for GDM and is associated with a poor prognosis, partly because the correct diagnosis and treatment are delayed. Whether screening for autoimmune markers of T1D should be performed more systematically in women with GDM deserves to be studied.

Pulmonary hypertension as a predictor of postoperative complications and mortality after liver transplantation.

Most transplant centers consider severe pulmonary hypertension (PHT) to be an absolute contraindication for orthotopic liver transplantation (OLT). We retrospectively examined the outcome of 24 patients with PHT (group 1) who underwent OLT compared with 24 matched patients (group 2) without PHT, who also underwent OLT. Based on right cardiac catheterization measurements made after the induction of anesthesia for OLT, PHT was defined as mild or moderate-to-severe if the mean pulmonary arterial pressure exceeded 25 or 35 mm Hg, respectively. The incidence of PHT was 9.8% (24/244); 21/24 PHT patients showed mild and 3/24 moderate PHT. Kaplan-Meier survival analysis did not show a significant difference between the two groups. The incidence of pulmonary infections was significantly greater in group 1 (P < .05). The duration of ventilation and intensive care unit stay was similar in the two groups. Echocardiography detected only the three moderate cases of PHT and not the twenty-one cases of mild PHT. Our analysis suggested that mild PHT was common and did not affect patient outcomes after OLT; moderate or severe PHT was uncommon. The two patients with moderate PHT survived OLT and did not succum to PHT during long-term follow-up.

Liver transplantation in patients aged 65 and over: a case-control study.

INTRODUCTION: The average age of patients undergoing liver transplantation (LT) is consistently increasing. The aim of this case-control study is to evaluate survival and outcome of patients ≥65 yr compared to younger patients undergoing LT. MATERIALS AND METHODS: From 10/00 to 4/08 we performed 330 primary LT, 31 (9.4%) of these were in patients aged 65-70. Following a case-control approach, we compared these patients with 31 patients aged between 41 and 64 yr and matched according to sex, LT indication, viral status, cadaveric/living donor, LT timing, and Model for End-Stage Liver Disease (MELD) score. RESULTS: There were no statistically significant differences in demographic and surgical donor characteristics. The mean MELD score was under 18 in both groups. Post-LT complications occurred with a similar incidence in the two groups. one-, three-, and five-yr survival was 83.9%, 80.6%, and 80.6%, respectively, for the elderly group, and 80.6%, 73.8%, and 73.8%, respectively, for the young group (p = 0.61). DISCUSSION: Patients aged between 65 and 70 with low MELD score who undergo LT have the same short- and middle-term survival expectancy, morbidity, and outcome quality as younger patients with the same indication and same pre-LT pathology severity, whatever they might be. Thus, chronological age alone should not deter LT workup in patients >65 and <70.

Liver transplantation utilizing grafts from donors with genitourinary cancer detected prior to liver implantation.

Expansion of the donor pool has led to reconsideration of selection criteria to obtain the largest number of grafts without compromising recipient outcomes. This reconsideration concerns the utilization of donors with malignancies. Herein we have analyzed the outcomes, survivals, and risks of cancer transmission among patients who received a liver transplant from a donor with a genitourinary malignancy. Six of 363 patients (1.5%) who underwent transplantation at our center received an organ from a donor with a genitourinary cancer which was detected prior to the surgical harvest. Donors affected by low-grade renal cell carcinoma (Fuhrman grade 1 or 2) or low-grade intraprostatic prostate carcinoma (Gleason score

Use of recombinant factor IX and thromboelastography in a patient with hemophilia B undergoing liver transplantation: a case report.

Hemophilia B is a congenital recessive disorder caused by deficiency of coagulation factor IX (FIX). Surgical procedures can be performed in patients with hemophilia using high-purity and/or recombinant FIX, which has been shown to be safe and effective in surgical hemostasis. Liver transplantation is the only potentially curative treatment available for these patients, providing a long-term phenotypic cure for hemophilia. End-stage liver disease together with hemophilia exposes patients to greater risks of bleeding complications during the perioperative period with consequent difficulties in managing coagulopathy. The limited experiences reported by different investigators and the various strategies for clotting factor replacement make it difficult to define a single approach with respect to the optimal dose and method of administering FIX to achieve perioperative hemostasis. The limits of plasma-based coagulation tests--prothrombin time, activated partial thromboplastin time--have made thromboelastography a valid alternative in this kind of surgery. It has been demonstrated to be a useful tool for real-time analysis of clot formation using a whole-blood assay format. Further, it accurately illustrates the clinical effects of procoagulant or anticoagulant interventions. In this article, we have described the usefulness of thromboelastography to monitor the ability of high-purity FIX supplementation to restore a normal coagulation state and to guide the perioperative administration of blood products in a successful orthotopic liver transplantation in a hemophilic patient with deficiencies of factors IX and X, presenting with hepatitis C virus-related cirrhosis and hepatocellular carcinoma.

Right ventricular end-diastolic volume index as a predictor of preload status in patients with low right ventricular ejection fraction during orthotopic liver transplantation.

OBJECTIVE: The objective of this study was to compare the accuracy of 2 variables: pulmonary artery occlusion pressure (PAOP) and right ventricular end diastolic volume index (RVEDVI) as predictors of the hemodynamic response to fluid challenge as well as definition of the overall correlation between RVEDVI and change in PAOP, right ventricular ejection fraction (RVEF), central venous pressure (CVP), and determination of the right ventricular function during orthotopic liver transplantation. MATERIALS AND METHODS: A modified pulmonary artery catheter equipped with a fast response thermistor was used to determine RVEF, allowing calculation of RVEF end-diastolic volume index (EDVI, as the ratio of stroke index [SI] to EF). The above-mentioned hemodynamic measures were taken in 4 phases: T0, after induction of anesthesia; T1, during anhepatic phase; T2, 30' after graft reperfusion; and T3, at the end of surgery. RESULTS: The variation of the REF value was 36 +/- 4% and 39 +/- 6%. Linear regression analysis showed a significant correlation between RVEDVI (range, 133 +/- 33-145 +/- 40 mL/m(2)) and stroke volume index (SVI) in each phase (r(2) = 0.49, P < .01; r(2) = 0.57, P < .01) at T0 and T1, respectively, and at T2 and T3 (r(2) = 0.51, P < .01; r(2) = 0.44, P < .01), respectively. No significant variations in the linear regression analysis between RVEDVI, PAOP, CVP, and RVEF were observed. No relationship was found between PAOP (range, 10 +/- 2-6 +/- 2 mm Hg) and SVI. CONCLUSION: RVEDVI may be the best clinical estimate of right ventricular preload. In fact, minor changes of RVEF have been recorded, confirming that RV function was not altered during uncomplicated orthotopic liver transplantation.

[Outcome of isolated small bowel transplantation in adults: experience from a single Italian center]. / Risultati del trapianto di intestino isolato nell'adulto: esperienza di un singolo centro italiano.

AIM: Isolated small bowel transplantation is becoming the treatment of choice for adult patients with serious parenteral nutrition (PN) related complications: we report our three-year experience (December 2000-December 2003) from a single Italian center (Modena-Italy), with one of the larger European series. METHODS: We transplanted 14 patients, with a previous mean PN course of 27 months and a mean 21-month post-transplantation follow-up (range 3-36 months), obtaining a one-year actuarial survival rate of 92.3% with no intraoperative deaths. RESULTS: We lost 1 patient (7.2%), died for post-transplantation overwhelming sepsis following Cytomegalovirus (CMV) enteritis. Thirteen patients are alive, with one-year actuarial graft survival rate of 85.1%: 1 patient underwent graft removal (7.2%) for intractable severe acute rejection. Our immunosuppressive regimen was based on tacrolimus and 3 induction protocols: daclizumab (8 patients) with steroids, alemtuzumab (4 patients) and thymoglobulin (2 patients) without steroids. In 9 cases, we added sirolimus. Nine recipients experienced 22 episodes of acute cellular rejection (ACR), treated successfully in all cases but one. One patient (7.2%) was treated successfully for Post Transplant Lymphoproliferative Disease (PTLD) and is disease-free after 8 months. CONCLUSIONS: Small bowel transplantation can achieve optimal results depending on appropriate immunosuppressive management and candidate selection, added to shorter ischemia time and careful donor and graft selection.

Modifications of plasma concentrations of hormonal and tissue factors during mechanical ventilation with positive end-expiratory pressure.

AIM: The aim of this study is to analyse if the decrease of cardiac performance due to positive end-expiratory pressure (PEEP) application, within low values applied in clinical practice (5 cm H(2)O) is able to trigger a response of the main endogenous factors which control and maintain the mean arterial pressure (MAP). METHODS: This study was applied to 18 patients, admitted to the Intensive Care Unit (ICU) of the University Hospital of Modena, who underwent oro-tracheal intubation and mechanical ventilation. On admission, patients did not suffer from cardiac or lung disease. This study analyses plasma concentrations of epinephrine, norepinephrine, ET-1, NO metabolites, renin, aldosterone at 4 different times: before PEEP application, 60 minutes after the beginning of mechanical ventilation with PEEP, and respectively 30 and 60 minutes after withdrawal of PEEP. At the same time, MAP values and heart rate (HR) have been observed. RESULTS: Results show an increase of epinephrine and norepinephrine after PEEP application and a decrease to basal values at PEEP withdrawal. All variations are statistically significant. After PEEP introduction, ET-1 showed an increased concentration, although it was not statistically significant, while a significant decreasing trend was observed after PEEP withdrawal. A significant increase of NO metabolite values has been observed together with the increase of ET-1, followed by a decrease to basal values after the withdrawal of PEEP. Concentrations of renin increased when PEEP was applied even though they were not significant and decreased significantly when PEEP was withdrawn. A similar trend was revealed by aldosterone even though it underwent constant significant variations. CONCLUSION: The administration of PEEP produces an effective response of endogenous substances whose function is to maintain a proper tissue perfusion.

Intraoperative effects of combined versus general anesthesia during major liver surgery.

AIM: The study compares the intraoperative effects of combined versus general anesthesia during major liver surgery. METHODS: In this prospective randomized study, 70 patients were divided into 2 group of 35 subjects. Group A received general anesthesia (thiopentone, fentanyl, vecuronium, sevoflurane in a closed circuit) 15 minutes after placement of an epidural catheter (D9-D10) and induction of epidural anesthesia (6 ml 2% naropine). Continuous epidural infusion was initiated before surgical incision and continued with 0.2% naropine (7 ml/h) until the end of the operation. Group B received combined intraoperative anesthesia wit fentanyl doses according to hemodynamic parameters and 0.1 mg/kg morphine 30-4 minutes before cutaneous suture. Hemodynamic values were measured at base line (T0), and then at 15, 30, 60, 120 and 180 minutes after induction of general anesthesia (T1, T2, T3, T4 and T5, respectively). On recovery, patients were assessed for pain at rest and on movement reported on a visual analog scale; degree of motor blockade according to the Bromage scale; appearance of side effects; use af analgesic. RESULTS: A statistically significant decrease in the mean arterial blood pressure (ABP) and heart rate (HR) was noted within each group at 15 minutes after induction of general anesthesia. Significant differences in ABP were found between the 2 groups at T1 to T5, whereas HR values were substantially similar. The mean intraoperative use of fentanyl was significantly higher in Group B than in Group A, as was that of vecuronium. Pain intensity on recovery in patients who received epidural anesthesia was lower both at rest and on movement; only the patients in Group B required additional analgesics. No motor blockade was observed in either group. Nausea and vomiting were more frequent in Group B; hypotension was more frequent in Group A. CONCLUSION: The study confirms the safety of locoregional anesthesia in liver surgery, with good hemodynamic stability and absence of major side effects. The lower intraoperative use of opioids and muscle relaxants in patients who received epidural anesthesia confirms the neurovegetative protection this method provides. The data support the hypothesis that greater intraoperative use of opioids may be responsible for the higher incidence of side effects. Therefore, the intraoperative use of combined low-concentration anesthetic agents alone appears to offer a reasonable treatment option that provides adequate pain control at recovery from general anesthesia, with only minor side effects typically associated with analgesic (motor blockade) and opioids (nausea and vomiting). Given the complications associated with the technique, it should be performed by an expert anesthetist.

Differential subcellular localization of ENaC subunits in mouse kidney in response to high- and low-Na diets.

Previous electrophysiological experiments on renal cortical collecting ducts indicated that dietary sodium intake and variations in aldosterone plasma levels regulate the abundance of functional epithelial Na channels (ENaC) in the apical plasma membrane. In mouse kidney we investigated by immunohistochemistry whether feeding for 3 wk a diet with high (3% Na) and low (0.05% Na) Na content influences the distribution pattern of ENaC. In mice of all experimental groups, ENaC was apparent in cells from the late portion of the distal convoluted tubule (DCT2) down to the medullary collecting duct (CD). In mice on a high-Na diet (plasma aldosterone: 40.8 +/- 2.0 ng/dl), the alpha-subunit was undetectable, and the beta- and gamma-ENaC were detected in the cytoplasm, but not in the apical plasma membrane of the cells. In contrast, in mice on a low-Na diet (plasma aldosterone: 93.6 +/- 9.3 ng/dl) all three ENaC subunits were displayed in the subapical cytoplasm and in the apical membrane of DCT2, connecting tubule (CNT), and, although less prominent, in cortical CD cells. Apical plasma membrane immunostaining progressively decreased along the cortical CD, simultaneously with increasing cytoplasmic staining for beta- and gamma-ENaC. Thus our data on mice adapted to moderately low and high Na intake suggest that regulation of ENaC function in vivo involves shifts of beta- and gamma-subunits from the cytoplasm to the apical plasma membrane and vice versa, respectively. The insertion of these subunits into the apical plasma membrane coincides with upregulation of the alpha-subunit and its insertion into the apical plasma membrane.

[Cardiac rupture in thoracic trauma]. / Rottura di cuore da trauma toracico.

Thoracic trauma frequently involve damage to the cardiac structures and in the worst cases, the progressive degeneration and necrosis of the damaged tissue lead to cardiac rupture. The high mortality resulting from cardiac tamponade requires the prompt execution of diagnostic tests to provide as much useful information as rapidly as possible in order to start immediate therapy. A case of cardiac rupture manifested by the onset of atrial fibrillation in a patient admitted to Intensive Care after a car accident is described. The scarce significance of objective examination, the aspecific nature of chest X-ray and ECG alterations prompted the execution of a more thorough diagnosis. Transthoracic and transesophageal ultrasonography are both minimally invasive and highly specific: in a short time, not only did they confirm cardiac rupture, but they also focalised the site of the lesion, thus allowing a more targeted and rapid surgical approach. The relative frequency of cardiac lesions following closed thoracic trauma, the lack of incontrovertible signs and symptoms of late cardiac rupture, and the extreme severity of its clinical consequences argue in favour of using specific and sensitive diagnostic tests that can not only exclude or ascertain the presence of these lesions, but also allow subsequent serial controls aimed at diagnosing late cardiac ruptures.