A geo-chemo-mechanical study of a highly polluted marine system (Taranto, Italy) for the enhancement of the conceptual site model.

The paper presents the results of the analysis of the geo-chemo-mechanical data gathered through an innovative multidisciplinary investigation campaign in the Mar Piccolo basin, a heavily polluted marine bay aside the town of Taranto (Southern Italy). The basin is part of an area declared at high environmental risk by the Italian government. The cutting-edge approach to the environmental characterization of the site was promoted by the Special Commissioner for urgent measures of reclamation, environmental improvements and redevelopment of Taranto and involved experts from several research fields, who cooperated to gather a new insight into the origin, distribution, mobility and fate of the contaminants within the basin. The investigation campaign was designed to implement advanced research methodologies and testing strategies. Differently from traditional investigation campaigns, aimed solely at the assessment of the contamination state within sediments lying in the top layers, the new campaign provided an interpretation of the geo-chemo-mechanical properties and state of the sediments forming the deposit at the seafloor. The integrated, multidisciplinary and holistic approach, that considered geotechnical engineering, electrical and electronical engineering, geological, sedimentological, mineralogical, hydraulic engineering, hydrological, chemical, geochemical, biological fields, supported a comprehensive understanding of the influence of the contamination on the hydro-mechanical properties of the sediments, which need to be accounted for in the selection and design of the risk mitigation measures. The findings of the research represent the input ingredients of the conceptual model of the site, premise to model the evolutionary contamination scenarios within the basin, of guidance for the environmental risk management. The study testifies the importance of the cooperative approach among researchers of different fields to fulfil the interpretation of complex polluted eco-systems.

Conversion of stable kidney transplant recipients from a twice-daily to once-daily everolimus regimen.

Once-daily everolimus administration is a further option to improve compliance to immunosuppressive therapy. We randomized 23 stable kidney transplant recipients already on everolimus therapy to receive a single daily morning dose or to continue the twice-daily regimen. The everolimus levels evaluated after 2 weeks showed a slight reduction from 5.13 +/- 1.61 ng/mL at baseline to 4.76 +/- 1.61 ng/mL, which was not statistically significant. After 2 weeks we also evaluated cyclosporine (CsA) levels together with renal function parameters, neither of which showed episodes, any difference between the converted versus twice-daily groups. We did not record any adverse event, such as an infection, an acute rejection episode, or graft loss, over the 6-month study period. Single dosing of everolimus is possible and safe and may achieve better patient compliance to multiple-drug immunosuppressive therapy.

[Is body surface area (BSA) suitable for indexing renal and dialysis clearances and other physiological parameters? A theoretical approach and a critical analysis (part 3)]. / E opportuno utilizzare la Body Surface Area (BSA) per normalizzare le clearance renali e dialitiche ed altri parametri fisiologici? Un approccio teorico ed un'analisi critica (III parte).

Many parameters of biological functions, interesting different branches of medicine, have to be indexed by the same value for each other comparison between single individuals or between-within groups. Body Surface Area (BSA) and 1.73 m2 reference value are probably the most used tools for indexation, but a growing number of scientific papers emphasize the risk of under or over estimates of data by BSA indexation in overweight--obese or on the contrary underweight individuals. This study has been planned to evaluate this problem a) by a theoretical approach, indexing to 1.73 m2 the creatinine clearance (CtCl) in an ideal population and b) analysing and debating the doubts and problems about the indexation by BSA in many fields, the possibilities of indexation by other methods, or to use BSA with different approach, to reduce the risk of bias, evaluating the possibility of this target in a real population of 45 men and 84 women undergoing Peritoneal Dialysis (PD)--III--There is a lack of significative correlation between BSA and GFR, this one on the contrary significantly correlated with lean body mass and body water, possible alternatives to BSA. Researches performed to validate the indirect estimates of above variables by creatinine excretion and bioimpedance don't seem up till now to give sufficient evidences for a general acceptance. In conclusion, it would be advisable or to drop the indexing by BSA or, if necessary, to use it by different methods, as theoretically shown in this paper.

[Is body surface area (BSA) suitable for indexing renal and dialysis clearances and other physiological parameters? A theoretical approach and a critical analysis (Part 2)]. / E opportuno utilizzare la Body Surface Area (BSA) per normalizzare le clearance renali e dialitiche ed altri parametri fisiologici? Un approccio teorico ed un'analisi critica (II Parte).

Many parameters of biological functions, interesting different branches of medicine, have to be indexed by the same value for each other comparison between single individuals or between-within groups.Body Surface Area (BSA) and 1.73 m2 reference value are probably the most used tools for indexation, but a growing number of scientific papers emphasize the risk of under or over estimates of data by BSA indexation in overweight-obese or on the contrary underweight individuals. This study has been planned to evaluate such a problem: a) by a theoretical approach, indexing to 1.73 m2 the creatinine clearance(CtCl) in an ideal population, and b) analysing and debating the doubts and problems about the indexation by BSA in many fields, the possibilities of indexation by other methods, or to use BSA with different approach, to reduce the risk of bias, evaluating the possibility of this target in a real population of 45 men and 84 women undergoing Peritoneal Dialysis (PD) - II - The feasibility to agree to an identical value of normal or abnormal renal function for every age or, on the contrary, to have a normal range for each age, are analysed and discussed.About BSA as indexing tool, it is pointed out: a) the lack of significative correlation between BSA and GFR and other parameters b) the increasing gap during years between 1.73 m2 BSA and the average BSA.

[Is body surface area (BSA) suitable for indexing renal and dialysis clearances and other physiological parameters? A theoretical approach and a critical analysis (Part 1)]. / E opportuno utilizzare la Body Surface Area (BSA) per normalizzarele clearance renali e dialitiche ed altri parametri fi siologici?Un approccio teorico ed un'analisi critica (I Parte).

Many parameters of biological functions, interesting different branches of medicine, have to be indexed by the same value for each other comparison between single individuals or between-within groups. Body Surface Area (BSA) and 1.73 m2 reference value are probably the most used tools for indexation, but a growing number of scientific papers emphasize the risk of under or over estimates of data by BSA indexation in overweight--obese or on the contrary underweight individuals. This study has been planned to evaluate this problem: a) by a theoretical approach, indexing to 1.73 m2 the creatinine clearance (CtCl) in an ideal population and b) analysing and debating the doubts and problems about the indexation by BSA in many fields, the possibilities of indexation by other methods, or to use BSA with different approach, to reduce the risk of bias, evaluating the possibility of this target in a real population of 45 men and 84 women undergoing Peritoneal Dialysis (PD). The effects of indexing 1.73 m2, according different weights on the CtCl of the ideal population and on the values of BSA estimation according different formulae. Results, methods, and the problems due to abnormal fluctuation of weight compared to normal range of standard value according height are analyzed and discussed.

Excellent long-term results in de novo renal transplant recipients treated with proliferation signal inhibitors and reduced calcineurin inhibitors exposure.

BACKGROUND: A new class of immunosuppressants, proliferation signal inhibitors (PSI)--sirolimus and everolimus--has the potential to prevent chronic allograft nephropathy (CAN). This retrospective analysis reports a 6-year practice using PSI at a single center, comparing a regimen based on reduced-dose calcineurin inhibitors (CNI) and PSI versus full-dose CNI and mycophenolic acid (MPA). METHODS: The study population included 70 patients (group A) who received de novo PSI therapy in combination with reduced dose of CNI, standard steroids, and basiliximab induction, and 216 patients (group B) with full-dose CNI, MPA, steroids, and basiliximab induction. RESULTS: No statistically significant differences were recorded in the baseline donor and recipient characteristics. A difference was observed in cold ischemia time, which could represent a bias for the analysis. No differences were recorded in actuarial patient survival, delayed graft function, biopsy-proven acute rejection rates, and renal function analysis. A significant difference was recorded in the actuarial graft survival rate at years 2, 3, and 4 (P< .01), as well as overall graft survival rates (P= .025). DISCUSSION: The reduction of cold preservation time seemed to be an important factor to improve both short- and long-term renal function. This regimen revealed a long-term trend toward better renal function and graft survival. The use of PSI with reduced doses of CNI seems to be indicated for suboptimal grafts, especially when a reduced quality of the kidney is associated with prolonged cold ischemia time.

Analysis of posttransplant diabetes mellitus prevalence in a population of kidney transplant recipients.

AIM: The onset of posttransplant diabetes mellitus (PTDM) among kidney recipients is associated with an increased risk of graft failure and death. Minimizing the risk of PTDM is a priority for long-term improvement in survival rates. We sought to evaluate the prevalence of PTDM and impaired fasting glucose (IFG) among a population of kidney transplant recipients to identify the risk factors and to evaluate graft and patient survivals. METHODS: We analyzed 250 consecutive Caucasian patients who received kidney allografts in our center between May 2000 and December 2005, with a median follow-up of 32 months (range, 1-78 months). RESULTS: We observed altered glucose metabolism in 17% of patients; specifically, the prevalences of PTDM and IFG were 12.2% and 4.8%, respectively. Patients who developed PTDM or IFG were overweight (BMI, 26.4+/-3.4 and 28.1+/-3.4 kg/m(2), respectively), whereas the normal glucose (NG) group's BMI was 23.8+/-3.5 kg/m(2) (P= .002 and P= .004, respectively). Prevalence of acute rejection was higher in the PTDM and IFG patients compared with the NG patients (60.7%, 63.6%, and 32.1%, respectively; P= .006; P< .04), while no difference was observed in terms of graft and patient overall survival. CONCLUSION: In our series of patients, we showed that being overweight represents a major risk factor for the development of PTDM, which results in an increased acute rejection rate. These results confirmed the importance of appropriate weight control among patients undergoing kidney transplantation, which should also be strictly monitored for all risk factors associated with the development of impaired glucose metabolism.

Long-term outcome of renal transplantation from marginal donors.

Long-term survival of kidneys from suboptimal donors is known to be not as good as that from optimal ones. However, the shortage of donors has led many transplant centers to consider accepting older donors with comorbidities. We analyzed 238 patients who received deceased donor renal transplants in the period 2000-2005. The recipients were matched to be no more than 15 years older or younger than the corresponding donors. Among them 125 received a single and 18 a double transplantation from donors considered marginal, according to UNOS criteria for expanded criteria donor (ECD). Most kidneys were evaluated with a pretransplant biopsy, using the scoring system introduced by Karpinski in 1999. The analysis indicated clearly better results in the non-ECD group: both patients and graft survival rates were 10% higher at 1, 2, and 3 years. However, the ECD group showed satisfactory outcomes, confirming the utility of this procedure. The long-term survival rates of single or double grafts from marginal donors are satisfactory, confirming the practice of allocating kidneys after a preimplantation histological evaluation, allowing expansion of the donor pool and providing older patients access to the waiting lists.

Cytomegalovirus infection with multiple colonic perforations in a renal transplant recipient.

Cytomegalovirus (CMV) continues to be potentially the most important pathogen affecting organ transplant recipients. Severe gastrointestinal complications have been reported to occur in about 10% of renal transplant recipients, sometimes with dramatic presentations. We report the case of a 57-year-old CMV-seropositive woman with end-stage renal failure who developed CMV-related colonic multiple perforation 30 days after cadaveric CMV-positive renal transplantation. CMV pp65 antigenemia test and CMV-PCR had always been negative on all the weekly controls routinely performed in the postoperative period. Only after the sudden onset of this complication did the antigenemia and PCR become positive. The relationship between infection and perforation has been established beyond any doubt, as the histology of the resected colonic segment revealed florid CMV infection with evidence of typical inclusions in both macrophages and endothelial cells. Colonic perforations are often fatal in transplant recipients because of inability to contain the perforation, and only a rapid diagnosis and an aggressive surgical treatment can improve the prognosis.

Kidney transplantation from donors aged 65 years or more as single or dual grafts.

AIM: The organ shortage and aging donor population force transplant centers to accept donors previously considered unusable for kidney transplantation. We report the experience of two Italian transplant centers with single (SKTx) and dual (DKTx) kidney transplantation from donors aged 65 years or more. METHODS: The study population comprised 75 SKTx (mean donor age 70.5 years) and 28 DKTx (mean donor age 75.0 years). Kidneys from donors with a calculated admission creatinine clearance <50 mL/min, a Karpinski's score on kidney biopsy between 5 and 7, or both were allocated to DKTx. Grafts with better function or lower biopsy scores were employed for SKTx. RESULTS: Delayed graft function occurred in 45.3% of SKTx and in 39.3% of DKTx. After a mean follow-up period of 30.0 +/- 19.5 months, the acute rejection rate was 24.0% in SKTx and 7.1% in DKTx. Mean serum creatinine was 1.8 +/- 0.9 and 1.8 +/- 1.3 mg/dL in SKTx, and 1.8 +/- 1.6 mg/dL and 1.3 +/- 0.2 mg/dL in DKTx at 1 and 5 years, respectively. Patient survival was 93.3% and 91.2% in SKTx, and 92.9% and 92.9% in DKTx at 1 and 5 years, respectively. Graft survival was 92.0% and 88.3% in SKTx, and 89.3% and 89.3% in DKTx at the same time intervals. Keeping preservation time below 16 hours and avoiding calcineurin inhibitors were both associated with improved graft survival and function. CONCLUSION: Careful donor selection, short preservation time, and tailored immunosuppression allow safe and efficient use of elderly donor kidneys.

Daily use of the physio dialysis system: long-term experience.

BACKGROUND: Hypovolaemia has been implicated as a major causal factor of morbidity during haemodialysis (HD). In order to avoid the appearance of destabilising hypovolaemia a biofeedback control system for intra-HD blood volume (BV) change modelling has been developed (Hemocontrol, Hospal Italy). It is based on an adaptive controller incorporated into a HD machine (Integra, Hospal Italy). The Hemocontrol biofeedback system (HBS) monitors BV contraction during HD with an optical device; furthermore, HBS modulates BV contraction rates (by adjusting the ultrafiltration rate--UFR) and the refilling rate (by adjusting dialysate conductivity--DC) in order to obtain the desired pre-determined BV trajectories. METHODS: Nineteen patients prone to hypotension (7 males, 12 females, mean age 64.5 +/- 3.0 SEM years, on maintenance HD for 80.5 +/- 13.2 months) volunteered for the prospective study which aimed to compare the efficacy and safety of bicarbonate HD treatmentequipped with HBS, as a whole (HBS),with the gold standard, bicarbonate treatment, equipped with a constant UFR and DC (BD). The study included one period of 6 months of BD always preceding a follow-up period of HBS treatment ranging from 14 to 30 months (mean 24.0 +/- 1.6). RESULTS: The overall occurrence of symptomatic hypotension and muscle cramps was significantly less in HBS treatment. Self-evaluation of intra- and inter-HD symptoms (the worst score was o and the best one 10) did reveal a statistically significant difference, as far as post-HD fatigue is concerned (6.2 +/- 0.2 in HBS vs. 4.3 +/- 0.1 in BD treatment, p < 0.0001). No difference between the two treatments was observed when comparing pre- and post-HD lying blood pressure, heart rate, body weights and body weight changes. CONCLUSIONS: HBS is an effective treatment. Hypovolaemia-associated morbidity occurs less in BD treatment than HBS. Furthermore, HBS is a safe treatment in the medium-term because these results are achieved without potentially harmful changes in blood pressure, body weight and serum sodium concentration.

Bariatric surgery: early results with a multidisciplinary team.

BACKGROUND: Bariatric surgery depends on complete preoperative study of morbid obesity, in order to obtain the treatment of choice. A multidisciplinary group was founded in 1998 at the University of Siena. METHODS: During 1998, 16 patients, with median weight 121.8 +/- 31 kg and median body mass index (BMI) 43 +/- 6, underwent bariatric surgery. A multidisciplinary assessment was used in order to evaluate psychological status, food intake problems and patient compliance, and hemodynamic, respiratory, metabolic and arthritic functions. 13 patients were submitted to laparoscopic surgery: in 11 adjustable gastric banding was performed and 2 were submitted to a vertical gastroplasty plus adjustable gastric banding. Three patients were operated via traditional laparotomy, due to previous abdominal surgery in 2 cases (submitted to an adjustable gastric banding) and one woman was submitted to a bilio-intestinal bypass according to the Hallberg technique, for her psychiatric troubles and coexisting systolic hypertension and uncontrolled diabetes. Monthly follow-up for each patient continues after 6 months. RESULTS: No morbidity or mortality has occurred. The median weight loss at three months, was 19.5 kg. Two cases required injection of 1 ml more of fluid into the port, respectively at 4 and 9 months. Fifteen days after surgery, seven patients (46%) had vomiting episodes, due to rapid food intake. All patients have shown an improvement of their comorbidities after surgery. CONCLUSION: Early results via the multidisciplinary team and laparoscopic banding have been satisfactory thus far.

[Hip protectors: what is their role in the prevention of femoral fractures?]. / Protecteurs de hanche: quelle est leur place dans la prévention des fractures fémorales?

In elderly persons, hip fracture is frequent and associated with serious physical, functional and psychological consequences. Hip protectors seem promising for preventing hip fractures, especially in frail, institutionalized elderly persons. Despite methodological limitations, five randomized trials have reported positive results, with up to 85% risk fracture reduction in some trial. Interestingly, although 13 hip fractures occurred in subjects assigned to wear hip protector, only one occurred while the protector was actually worn. Adherence with wearing hip protectors remains a problem. Several ongoing trials will further enhance our knowledge on hip protectors effectiveness and cost-effectiveness to better define their role in hip fracture prevention.

[A case of postprandial hypotension in an elderly subject]. / Un cas d'hypotension postprandiale chez un sujet âgé.

This is a case report of a 74-year old woman who from March 1994 to April 1995 was admitted to our hospital because of three episodes of syncope. Each general physical examination was normal except for a grade 2/6 systolic murmur. No abnormalities were disclosed after several resting electrocardiograms and Holter monitoring. The Schellong and the tilt tests were normal. During the last admission the patient had a syncope 30 minutes after a meal. Blood pressure reduction was documented and postprandial hypotension was diagnosed. Postprandial decreases in systolic blood pressure in the elderly may predispose the subject to symptomatic hypotension and to falls, dizziness, weakness, angina pectoris, stroke and syncope. The mechanism of postprandial hypotension is not fully understood. It is defined as a decrease in postprandial systolic blood pressure of 20 mmHg or more. Because postprandial hypotension is a common problem in older, frail, institutionalized patients, all physicians caring for elderly patients should be aware of the hypotensive effects of food intake and should consider postprandial hypotension in the evaluation of falls, syncope and other ischemic cerebral symptoms.

[Cervical esophageal perforation caused by a foreign body: a clinical case]. / Perforazione esofagea cervicale da corpo estraneo: caso clinico.

The Authors report a case of cervical esophageal perforation from foreign body. Comparing their experience with data from literature, they point out the diagnostic importance of both X-ray studies, in order to demonstrate the site of the lesion, and CT scans, to have accurate information on perilesional infective complications (abscesses). Early surgical treatment, with primary closure of perforation and adequate drainage, associated with antibiotics and enteral or total parenteral nutrition, allows good results in most cases.

[Nutritional status of CAPD patients in Lazio]. / Stato nutrizionale dei pazienti in CAPD nel Lazio.

Uremic patients have been shown to be frequently malnourished. The amount of glucose absorbed from dialysis solution makes caloric malnutrition unusual among CAPD (Continuous Ambulatory Peritoneal Dialysis) patients. Protein malnutrition is more likely because of loss of nutrients into the dialysate and inhibition of appetite. Present study evaluates nutritional status of 29 patients (20 F, 9 M), 60.31 +/- 16.04, on CAPD since 15.2 months (4-50). Dialysis was scored adequate in all patients, based on the Clinical Assessment Score proposed by the Columbia University Group. Nutritional status was evaluated with (1) Marckmann score, based on relative body weight (RBW), triceps skin fold (TSF), midarm muscular circumference (MAMC), S-transferrin, and (2) Subjective Global Assessment (SGA) based on history, physical examination, anthropometric (BW, skin folds, % body fat according to Durnin, MAMC) and laboratory data (S-albumin, C3, S-transferrin, Hb, lymphocyte count, creatinine appearance rate [CAR], urea nitrogen appearance normalized by BW [NUNA], protein catabolic rate [pcr]). RBW was 118.2% because of excess stored fat; % body fat was > 40% in 6 females and 34.4 +/- 5 in 14 females. Lymphocytes, total proteins, S-albumin, S-transferrin, C3, IgG were normal. CAR (12.2 +/- 3.2 mg/kg/die) and NUNA (101.1 +/- 37.3 mg/kg/die) were lower than normal, as reported for dialysis patients. Marckmann score (26 patients) defined 10 cases of slight malnutrition; SGA (29 patients) identified 2 severely and 14 slightly malnourished patients. Marckmann and SGA scoring however agreed only in 13 over 26 patients. Slight or severe malnutrition has been assessed in CAPD patients in spite of clinically adequate dialysis.(ABSTRACT TRUNCATED AT 250 WORDS)

[The Alagille syndrome. Apropos 3 cases]. / Síndrome de Alagille. A propósito de tres casos.

The clinical, biochemical, and histopathological characteristics of three patients who had jaundice and other findings suggestive of the syndrome are reported. Studies showed the presence of hypoplasia of the intrahepatic biliary ducts associated with facial, vertebral, cardiovascular, and eye abnormalities and a delay in the weight-height development. This group of abnormalities establish the Alagille syndrome, an entity which has not, until now, been extensively studied in our country.