Patients with Parkinson's disease and a history of falls have decreased cerebellar grey matter volumes in the cognitive cerebellum

The objective of this study was to determine if cerebellar gray matter (GM) structure differs between fallers and non-fallers with Parkinson's disease (PD) and their respective association to cognitive function. A total of 48 fallers and 63 non-fallers with PD were identified from the Parkinson's Progression Markers Initiative database. Fallers were categorized as those who self-reported a fall within the past year. Unified Parkinson's Disease Rating Scale-III (UPDRS-III), Montreal Cognitive Assessment (MoCA), Trail Making Test parts A (TMT-A) and B (TMT-B) scores were collected for each patient. Cerebellar GM volumes were derived from magnetic resonance imaging data. Analyses of covariance were used to compare group differences. Partial Pearson's correlations were used to assess the relationship between cerebellar GM volumes to UPDRS-III and cognitive outcomes. Significance was set at P ≤ 0.01. Fallers had significantly decreased GM volumes in lobules V, Crus-1, Crus-2, and VIIb (P<0.01). Cerebellar GM volumes in non-fallers demonstrated little-to-no relationship with UPDRS-III, MoCA, and TMT-B (P>0.01). However, TMT-A performance demonstrated significant, fair association to GM volumes in lobules I-IV, V, VI, Crus-1, and Crus-2 (r=-0.44 - -0.34, P<0.01) in non-fallers. Patients with PD and a history of falls have significantly decreased GM volumes in cerebellar lobules associated with cognitive functions. However, these lobule volumes become disassociated with cognitive function compared to non-fallers.

SosCaregivers: piloting of a psycho-social service for family caregiver in a hard-to-reach setting

Background

”Ageing-in-place” may improve elderly citizens' quality of life and the sustainability of welfare systems. In this process engaging family caregivers is crucial.

Methods

A community-based participatory research in the remote area of Vallecamonica was enacted. First, we surveyed unmet needs of family caregivers. Then, a scoping literature review on existing interventions for engaging family caregivers was performed. Third, 4 co-design workshops were conducted to co-generate a new service. Finally, the service was piloted for a period of 6 months and evaluated.

Results

51 caregivers participated in the survey: they were mainly females, mean 60 y.o and with medium-low level of education. The scoping review resulted in only 14 interventions targeted to elderly's caregivers in remote areas. The workshops involved 27 caregivers and co-designed a new psycho-social service (SOSCargivers) articulated into: 1) a structured informative platform to facilitate health literacy and information seeking; 2) a tailored educational program focused on medical and practical aspects related to elderly care; 3) a set of peer-to-peer meetings for experience sharing and mutual support; 4) a “caregivers board” was created to lead the service. In the piloting 5 training sessions, 5 peer-to-peer meetings, 3 meeting with the “citizens board” were enabled.

Conclusions

The service was positively received by caregivers, although participation wasn't high. Co-designing the service with its expected users facilitates the depth understanding of local people's needs and expectations. SOSCaregivers may support family caregivers of elderly citizens in hard to reach areas by both delivering more value and giving them an active role in the social-care network.

Key messages

Family caregivers’ engagement is crucial for integrated and sustainable services in hard to reach communities. Co-designing the service with its expected users facilitates the Department understanding of local people’s needs and expectations.

A-25 The Effect of Cognitive Dual-Tasks on Dynamic Postural Sway During Sub-Maximal Gait on a Treadmill

Objective

To investigate the effect of a cognitive task on postural control during treadmill walking. We hypothesized that postural sway acceleration would decrease during dual-task compared to single-task gait.

Method

Ten (5 females, 5 males) physically active, healthy young adults (Age: 22.50 ± 3.01) with no history of cognitive deficits or head injury were recruited from a University campus for this cross-sectional study. Participants reported to a biomechanics laboratory for a single testing session and completed two, 5-minute walking trials on a treadmill at 90% of maximal gait-speed under single and dual-task conditions while instrumented with a single inertial measurement unit (IMU) on the lower-back. During dual-task gait, participants concurrently performed a Stroop Test displayed on a mounted screen in front of the treadmill during the entire trial. Root mean square (RMS) of acceleration was analyzed in the medial-lateral, anterior-posterior, superior-inferior, and resultant planes during the dual-task trial. Paired t-tests and effect sizes (ES) were calculated for each sway plane between single and dual-tasks.

Results

No differences were identified between single and dual-task RMS acceleration in the medial-lateral (p = 0.98, ES = 0.01), anterior-posterior (p = 0.49, ES = 0.23) or superior-inferior (p = 0.98, ES = 0.01) planes. However, the RMS acceleration in the resultant plane was lower in the dual-task condition (Mean Difference: 0.031 ± 0.037; p = 0.02, ES = 0.85).

Conclusions

This novel dual-task gait paradigm utilized constant sub-maximal gait speed to investigate the influence of a sustained cognitive dual-task on postural sway using a single IMU. These preliminary results indicate that this dual-task gait paradigm may affect gross postural sway in healthy adults.

The management of patients with acute ischemic stroke while on direct oral anticoagulants (DOACs): data from an Italian cohort and a proposed algorithm

Approximately 1-2% of patients with non-valvular atrial fibrillation have an acute ischemic stroke (AIS) while on direct oral anticoagulant (DOAC) treatment every year. However, current evidence on stroke subtypes, pathophysiology and factors leading to the failure of DOAC preventive therapy in a "real world" setting is still scanty. This study aimed at investigating whether there is any relationship between DOAC plasma levels and the stroke occurrence, on the basis of the phenotypic classification and pathophysiology of the stroke, in a cohort of DOAC-treated patients admitted to our hospital for AIS over 1-year period. A total of 28 patients had DOAC plasma levels determined in emergency and were included in the study, nine patients receiving dabigatran, 11 rivaroxaban and 8 apixaban. The DOAC levels were low in 8/28 patients (28.6% of the sample), intermediate in 4 (14.3%) and high in 16 (57.1%). The most prevalent stroke subtype was the small vessel disease, according to the A-S-C-O phenotypic classification, in 53.6% of our sample. The most common clinical presentation was "minor stroke" in 71.4% of the cases. There was a significantly higher proportion of patients with high DOAC levels in the small vessel group, compared to the cardioembolic group without other phenotypes. The question arises as to the most suitable clinical management of AIS in these patients on DOACs. In the current absence of clear evidence, taking into account the DOAC levels (low/intermediate/high) and the underlying stroke pathophysiology, we present a flowchart of our proposed clinical management of ischemic stroke in patients while on DOAC.

Torque Teno Virus--cause of viral liver disease following liver transplantation: a case report

Torque Teno Virus (TTV), a nonenveloped human virus of the Circoviridae family, is hepatotropic, causing liver damage, cirrhosis, and, rarely, fulminant hepatitis. It prevails in 10% to 75% of blood donors due to environmental differences, independent of chronic hepatitis B virus (HBV)/HCV hepatitis, cryptogenic cirrhosis, alcoholic cirrhosis, and in fulminant hepatitis non-A-G. Reports about the efficacy of clinical alpha interferon are rare. In July 2007, a 65-year-old man who was serologically negative for A-E viruses presented with acute liver failure due to a ruptured hepatic artery aneurysm and underwent orthotopic liver transplantation (OLT). Immunosuppression was based on cyclosporine and steroids. At postoperative day 20, there was persistent hypertransaminasemia with otherwise normal liver function. A percutaneous hepatic biopsy documented pattern suggestive of a viral etiology. Multiple tests for hepatotropic viruses in the donor and the recipient from the pre- and post-OLT periods remained negative. Only the TTV qualitative test, assessed by polymerase chain reaction (PCR) on patient sera, was positive. Immunosuppressive therapy was not changed; no antiviral therapy was undertaken. At 6 months posttransplantation, transaminase levels spontaneously normalized and the clinical situation was unchanged. No complications were observed; the patient is in good clinical condition. No graft rejection was observed. In histologically proven non-A-E viral hepatitis, it is important to consider TTV as an incidental pathogenic agent. It may be useful to extend virological tests to TTV among transplant recipients and donors and to gain further knowledge about this virus.

Pattern of care and effectiveness of treatment for glioblastoma patients in the real world: Results from a prospective population-based registry. Could survival differ in a high-volume center?

BACKGROUND

As yet, no population-based prospective studies have been conducted to investigate the incidence and clinical outcome of glioblastoma (GBM) or the diffusion and impact of the current standard therapeutic approach in newly diagnosed patients younger than aged 70 years.

METHODS

Data on all new cases of primary brain tumors observed from January 1, 2009, to December 31, 2010, in adults residing within the Emilia-Romagna region were recorded in a prospective registry in the Project of Emilia Romagna on Neuro-Oncology (PERNO). Based on the data from this registry, a prospective evaluation was made of the treatment efficacy and outcome in GBM patients.

RESULTS

Two hundred sixty-seven GBM patients (median age, 64 y; range, 29-84 y) were enrolled. The median overall survival (OS) was 10.7 months (95% CI, 9.2-12.4). The 139 patients ≤aged 70 years who were given standard temozolomide treatment concomitant with and adjuvant to radiotherapy had a median OS of 16.4 months (95% CI, 14.0-18.5). With multivariate analysis, OS correlated significantly with KPS (HR = 0.458; 95% CI, 0.248-0.847; P = .0127), MGMT methylation status (HR = 0.612; 95% CI, 0.388-0.966; P = .0350), and treatment received in a high versus low-volume center (HR = 0.56; 95% CI, 0.328-0.986; P = .0446).

CONCLUSIONS

The median OS following standard temozolomide treatment concurrent with and adjuvant to radiotherapy given to (72.8% of) patients aged ≤70 years is consistent with findings reported from randomized phase III trials. The volume and expertise of the treatment center should be further investigated as a prognostic factor.

Impact of Model for End-Stage Liver Disease score on transfusion rates in liver transplantation

BACKGROUND

Liver transplantation (OLT) can entail a high risk of blood loss requiring transfusions, which increase morbidity and mortality. In recent years many efforts have been spent to improve the surgical and anesthetic management to decrease transfusion rates during OLT. Preoperative predictors for transfusion in OLT, remain uncertain.

METHODS

We retrospectively reviewed the 219 OLT performed from 2005 to 2011 focusing on blood product (BP) transfusions. Statistical analysis sought the impact of transfusions on OLT outcomes to identify possible independent predictors of higher BP requirements.

RESULTS

The 1- and 3-year survival rates were 86.6% and 76.45% for patients and 81.0% and 71.8% for grafts respectively. The mean intra- and perioperative red blood cell (RBC) transfusion rates were 12.3 ± 11.7 U and 15.5 ± 13.0 U respectively. A statistical analysis demonstrated a significant influence of BP transfusion on post-OLT complications and survivals. Multivariate logistic regression analysis showed the Model for End-Stage Liver Disease (MELD) score to be the only independent predictor of perioperative RBC transfusions.

CONCLUSIONS

Our results confirmed the link between intra- and perioperative transfusions and outcome of OLT patients. MELD score resulted the only independent variable associated with increased perioperative RBC transfusions.

The "seagull cry" in a patient with a cerebral arteriovenous malformation

INTRODUCTION

The "seagull cry" is an acoustic phenomenon heard during duplex ultrasound. It is caused by harmonic covibrations of a vessel wall in the presence of high-velocity blood flow. It has been reported in a few cases of cerebrovascular disease, such as severe intracranial stenosis, vasospasm or carotid-cavernous fistula.

MATERIAL AND METHODS

A 35-year-old man underwent transcranial color-coded sonography (TCCS) for work-up of a severe new-onset headache.

RESULTS

Doppler spectral analysis of the right intracranial carotid bifurcation revealed multiple pairs of mirror-image parallel strings, and a high-frequency seagull cry was heard. Computed tomography-angiography and magnetic resonance imaging of the brain showed an arteriovenous malformation in the right temporal lobe.

DISCUSSION

The seagull cry is a "musical murmur" with single or multiple frequency that sounds like a musical tone. This is the first report of this phenomenon in a cerebral arteriovenous malformation.

Updating on Italian stroke units: the "CCM study"

The stroke units (SUs) have been demonstrated to be efficient and cost effective for acute stroke care. Nevertheless, the level of stroke unit implementation in Italy does not correspond to expectations yet. This study is a survey, which aims at assessing the current status of in-hospital stroke care in the Italian regions and at updating SUs. The survey was conducted by means of a semi-structured questionnaire, based on 18 stroke care "quality indicators", submitted to all the Italian centres that had taken part in the SITS-MOST study, and to other centres advised by the coordinator of SITS studies and by regional opinion leaders of stroke. SUs were defined as acute wards, with stroke-dedicated beds and dedicated teams that had been formally authorised to administer rt-PA. A statistical analysis was performed by a descriptive statistics and logistic regression model. The study was carried out from November 2009 to September 2010. A total of 168 forms were sent out and 153 replies received. Seven centres, which had not performed any thrombolytic treatment, and 16 which did not fulfil the criteria for the definition of SU were excluded from the study. Most of the centres reported more than 100 stroke patient admissions per year, i.e., 122 (84%) from 100 to 500, 18 (12%) more than 500. The 19% of the centres admitted more than 30% of patients within 3 h from the symptom onset and only 30% admitted more than 30% of patients within 4.5 h. The mean number of thrombolyses performed in the last 6 months was 10 for centres with a doctor on duty 24 h a day, 6 for those that have a doctor on duty from 8 a.m. to 8 p.m. and a doctor on call for night, and 5 for centres with a doctor on call 24 h a day. The territorial distribution of the SUs is remarkably heterogeneous: 87 SUs (67%) are located in the North of Italy, 28 (22%) in the central part of Italy and only 15 (11%) in the South. The last few years have witnessed a rise in both the diffusion of SUs and access to thrombolytic therapy in Italy. Despite this, there are a few large areas, mostly in the south, where the requirements of healthcare legislation are not met, and access to a dedicated SU and thrombolytic treatment is still limited and poor.

A single-center analysis to evaluate kidney function parameters after liver transplantation in adult patients

Severe renal dysfunction may occur after orthotopic liver transplantation (OLT). In this study, we retrospectively analyzed a single-center series of adult liver recipients (n = 62) seeking to identify patients prone to develop renal dysfunction during follow-up. Liver recipients (age range, 53.54 ± 8.19 years; female/male: 21/41) who underwent a first OLT from a brain dead donor were enrolled according to strict criteria. We enrolled only liver recipients with 5 serum creatinine (SCr) measurements after hospital discharge and at least 1 measurement/year with a follow-up period of not less than 2 years. We estimated glomerular filtration rate (eGFR) using the formula developed by the Mayo Clinic. The average rate of SCr change after OLT was 0.0065 ± 0.013 mg/dL/mo. By calculating the per-patient slope, the average rate of SCr change was 0.000165 ± 0.000383 mg/dL (0.000007 ± 0.000017 mg/dL/mo). In regression models evaluated with SCr as the dependent variable versus post-OLT time, no significance was observed (P = .130). The average rate of eGFR change after OLT was -0.462 ± 0.883 mL/min/mo. By calculating the per-patient slope, the average rate of eGFR change was -0.009 ± 0.0026 mL/min (-0.0004 ± 0.0012 mL/min/mo). In the regression models evaluated with eGFR as dependent variable versus post-OLT time, no significance occurred (P = .168). By applying the regression prediction to SCr at 3 to 5 versus the 1 to 2 post-OLT measurements, we noted 3 male liver recipients (MLR) whose SCr values were significantly higher than the predicted values: MLR1: P = .048 at measurement 4; MLR2: P = .019 at measurement 4; and MLR3: P = .017 at measurement 5. Conversely, we did not observed a significant difference between observed versus predicted eGFR values. Clinical decisions on immunosuppressive treatments for liver recipients should be determined also on the basis of the series of post-OLT kidney function, which should be studied with rigorous evaluation of fitted regression models.

Inter-critical and critical excessive daily sleepiness in episodic migraine patients

The objective of this study was to determine the relationship between sleepiness and migraine in the intercritical period and to evaluate the time course of critical drowsiness during the attacks. One hundred patients fulfilling IHCD 2nd (2004) criteria for migraine without aura were compared to 100 healthy subjects. Habitual excessive daily sleepiness, evaluated by means of Epworth Sleepiness Scale, was not more frequent in patients with episodic migraine than in controls (12% migraineurs vs. 8% controls, NS). The analysis of critical sleepiness by means of Stanford Sleepiness Scale (SSS) revealed a beginning of sleepiness increase before the attack onset, starting 12 h before, a peak of SSS values at the migraine attack onset and then a gradual decrease to reach baseline values only 12-24 h later. Moreover, patients responding to symptomatic drugs showed a greater and faster decrease of critical sleepiness in comparison with non-responder migraineurs; this finding allows excluding the role of medications in promoting critical somnolence and together with critical drowsiness time-course supports the hypothesis that vigilance impairment could be related to migraine pathogenesis.

Does sphenopalatine endoscopic ganglion block have an effect in paroxysmal hemicrania? A case report

The authors report the case of a 69-year-old woman suffering from paroxysmal hemicrania (PH), intolerant to indomethacin and resistant to multiple therapies, in which sphenopalatine endoscopic ganglion block (SPG) dramatically modified the clinical outcome. SPG blockade could be considered a reasonable alternative in drug-resistant PH cases where indomethacin is contraindicated.

Preliminary results of liver transplantation for hepatocellular carcinoma among allocation organ policy strategies, neoadjuvant treatments, and intention-to-treat analysis

We retrospectively evaluated the impact of our strategy for patients with hepatocellular carcinoma (HCC) according to an intention-to-treat analysis and drop-out probability. We evaluated only patients within the Milan criteria. We analyzed the outcomes of neoadjuvant strategies for HCC, organ allocation policy, and systematic application of strategies to increase the deceased donor pool as the current tendency to expand transplantability criteria for those patients. Kaplan-Meier survival probability rates at 1, 3, and 5 years according to an intention-to-treat analysis were 87.02%, 74.53%, and 65.93% for transplanted patients (n=108), and 50%, 14.29%, and 14.29% for the excluded or waiting list group (n=13), respectively (P< .0001). Drop-out risk at 3, 6, and 12 months was 2.40%, 8.59%, and 16.54%, respectively. During the same period, the mortality probability rates at 3, 6, and 12 months among patients without HCC awaiting orthotopic liver transplantation (OLT) were 3.60%, 9.50%, and 18.34%, respectively. Drop-out rate was lower among patients treated before OLT (P< .0001). On the basis of the neoadjuvant treatment results to reduce drop-out risk, we suggest avoiding the high priority for the HCC cohort, particularly within the first 6 months from entrance on the waiting list, because this approach can reduce the chances of patients with end-stage liver disease (ESLD) alone.

Model for End-Stage Liver Disease (MELD) score and organ allocation from cadaveric donors for 198 liver transplantation procedures performed in a single center

Since February 2002, the United Network for Organ Sharing (UNOS) proposed to adopt a modified version of the Model for End-Stage Liver Disease (MELD) to assign priority on the waiting list for orthotopic liver transplantation (OLT). In this study, we evaluated the impact of MELD score on liver allocation in a single center series of 198 liver recipients (mean age of patients, 52.21+/-8.92 years), considering the relationship between clinical urgency derived from MELD score (overall MELD, 18.7+/-6.83; MELD <15 in 69 patients, MELD >or=15 in 129 patients) and geographical distribution of cadaveric donors (inside/outside Liguria Region, 125/73). The waiting time for OLT was 230+/-248 days, whereas the 3-month and 1-year patient survivals were 87.37% and 79.79%, respectively. No difference was observed for MELD score retrospectively calculated for patients who underwent OLT before February 2002 (n=71) compared with MELD score calculated for patients who received a liver thereafter (18.26+/-6.68 vs 18.94+/-6.92; P= .504). No significant difference was found in waiting time before and after adoption of MELD score (213+/-183 vs 238+/-278 days; P= .500), or by stratifying patients for MELD <15/>or=15 (225+/-234 vs 232+/-256 days; P= .851). Using the geographical distribution of donors as a grouping variable (outside vs inside Liguria Region), no significance occurred for MELD score (19.68+/-7.42 vs 18.17+/-6.42; P= .135) or waiting time (211+/-226 vs 242+/-261 days; P= .394). In our series, more OLTs were performed among sicker patients and no differences were found in the management of livers procured from cadaveric donors outside or inside Liguria Region. However, further efforts are needed to reduce the waiting time among patients with higher MELD scores.

Medical report type in liver transplantation as a quality system document: new prospects for computerization

The usage of a computerized system to organize data and ease the activity procedures of liver transplantation is useful in clinical transplantation. Preliminary cognitive research on systems of clinical transplantation database concerning medical reports was performed to verify their development level. The survey highlighted that, so far, there has been no experimentation that can be applied to a medical report type devoted to liver transplantation. Regulations in force substantially point out that the medical report ought to contain all items that have to be taken into account in handling the patient from pretransplantation to follow-up. The Department of Transplantation of Genoa chose its medical report model for liver transplantation. The medical report model included the following items: personal data; case history; diagnosis; initial examination for prelisting; fitness for transplantation; assistance context; clinical data including subjective, objective, and instrumental parameters; pharmacological therapies; informed consent, evaluation of fitness; nursing data; counseling and clinical evaluations according to protocols and guidelines of the national transplantation centers. If the computing is well trained, it is supposed to help maintain a whole data view provided it is supplied information in an adequate way. Immediate clinical procedural advantages and useful scientific observations may be obtained from a high-quality database. In fact, all functions have to be applied to specific clinical, administrative needs to be remotely shared and conveniently integrated with each other to make the liver transplantation medical report an easy and handy instrument for inputting and handling data. It must be a precise, complete instrument that may be accessible in real time from any site connected with the intranet network, be unchangeable, and be protected to ensure certification and forensic medicine value.

Split liver transplantation for acute Wilson's disease: new option for urgent recipient?

Wilson's disease is a rare metabolic disorder that may lead to fulminant hepatitis and subsequent liver failure. Herein, we present a case of split liver transplantation performed on a patient with acute Wilson's disease. A 27-year-old female with acute presentation of Wilson's disease and advanced neurological impairment, received a Right Split liver Graft (Segments: IV, V, VI, VII and VIII) transplant. The graft was obtained by an in situ splitting technique. The graft implantation was performed in a standard fashion. No acute rejection episodes of the organ occurred. The postoperative course was uneventful. The graft function, ceruloplasmine level and copper levels progressively normalized. The patient totally recovered from neurological symptoms and the Kayser-Fleischer rings disappeared within one month. At 13 months of follow-up, the patient presented with no symptoms and in good condition. The current literature reports high preoperative mortality rate in patients that underwent partial liver graft for acute hepatic failure. However, our experience indicates that in situ split technique of liver may be a feasible and effective alternative to whole graft transplantation in urgent cases. Moreover, to our knowledge, this is the first successfully case of in situ split liver transplantation for acute Wilson's disease described in literature.

A pharmacoeconomic evaluation of oral triptans in the treatment of migraine in Italy

AIM

The goal of this economic evaluation was to compare the cost-efficacy of oral triptans currently used in the treatment of migraine in Italy.

METHODS

The cost analysis of drugs was conducted through a structured decision tree, built up taking into account the National Healthcare System perspective. Data on the clinical efficacy and tolerability of oral triptans were derived from a published meta-analysis of 53 randomized, controlled trials. Drug cost-allocation included either the oral triptans price and costs related to management of treatment-associated chest and central nervous system (CNS) adverse events. Necessary resources for management of the unwanted events were identified by asking an experienced panel of experts how they would treat patients with triptan-related chest and CNS adverse events. To further improve the economic scenario and to allow a broader inference of pharmacoeconomic analysis, the number needed to treat (NNT) to attain 100 sustained pain free (SPF) patients, and 100 patients with SPF and no adverse events (SNAE) were also calculated.

RESULTS

Study results show cost-effective differences among oral triptans. The best cost-efficacy ratios were attained by almotriptan 12.5 mg and rizatriptan 5 mg, with 18.47 Euro and 26.37 Euro respectively per patient successfully treated (SPF). Similarly, the NNT analysis favoured almotriptan, which requires 386 patients to attain 100 SPF patients, and 393 patients to attain 100 SNAE patients. Rizatriptan 10 mg resulted the closest competitor, requiring 395 and 457 patients, respectively.

CONCLUSIONS

On the basis of published data and within the limitations of this model analysis that included several assumptions, results suggest the economical advantage of almotriptan 12.5 mg among the oral triptans approved for the treatment of migraine in Italy. This evidence could drive selection of the most appropriate oral treatment for acute migraine attacks based on both individual patient's needs and cost-effective drugs.

The extent of right-to-left shunt fails to correlate with severity of clinical picture in migraine with aura

Several investigations have documented an increased incidence of right-to-left shunt (RLS) in migraine with aura (MA) and have emphasised its role in the physiopathology of aura; so far, however, no data are available concerning a possible correlation between the extent of the RLS and the clinical picture of MA patients. To investigate the possible relationship between the extent of the RLS, revealed by the number of microbubbles (MB) detected during transcranial Doppler with IV injection of ultrasound contrast (TCDc), and the clinical characteristics of MA (age at first onset of migraine, mean annual frequency of attacks and mean duration of the aura phase), 30 consecutive patients with typical aura and migraine headache positive on TCDc evaluation for RLS were enrolled. Permanent RLS was found in 12 patients and latent RLS was found in 18 patients; of these, 6 had a high-grade RLS, 5 medium-grade RLS and 7 low-grade RLS. No correlation has been documented between the number of MBs and the clinical parameters of both patients with latent shunts and those with permanent ones, nor between the clinical parameters of the two groups of patients. These data show that RLS does not seem to affect the clinical manifestation of MA and that the extent of RLS fails to correlate with the severity of the clinical picture of the disorder.

Brainstem involvement in Legionnaires' disease

OBJECTIVE

To report a case of Legionella pneumonia with unusual neurologic involvement.

INTERVENTION

Chest X-ray, lumbar puncture, magnetic imaging of the brain, electroencephalography, audiometry, brainstem acoustic evoked potentials and institution of oral antibiotics and steroids.

MAIN RESULT

Gradual clinical improvement of neurologic and pulmonary illness within 4 weeks.

CONCLUSION

Legionellosis should be considered in the differential diagnosis of neurologic involvement in the setting of pneumonia.

Impact of ischemia/reperfusion on transplanted livers procured from elderly cadaveric donors

The increasing number of clinical indications for liver transplantation has forced physicians to use livers procured from elderly cadaveric donors to expand the graft pool. However, the degree of ischemia/reperfusion damage in elderly livers remains poorly investigated. In this study, the outcomes of livers procured from a group (I) of young donors (n=12; 38 +/- 12 years; range: 21-58) were compared with a group (II) from elderly donors (n=7; 68 +/- 7 years; range: 62-84) for changes in reduced glutathione, the main hepatic free radical scavenger. Reduced and oxidized glutathione were assayed by high performance liquid chromatography in liver biopsies performed just before cold ischemia and during early reperfusion. A significant decrease in reduced glutathione was observed at the time of reperfusion in both groups I (P=.0195) and II (P=.002). Before cold ischemia and during early reperfusion, no differences between young versus elderly donors were noted in the oxidized/reduced glutathione ratio, in conventional graft function markers or in liver-related hemostatic parameters. Comparable glutathione contents were measured at the time of early reperfusion in livers obtained from young and elderly cadaveric donors, suggesting that livers procured from elderly donors might be adequately protected against ischemia/reperfusion damage.

Impact of Different Cadaveric Donor Age Cut-Offs on Adult Recipient Survival After Liver Transplantation: A Single-Center Analysis

The increase in the number of patients awaiting liver transplantation (OLT) has forced the use of cadaveric donors (CD) with suboptimal characteristics. Of these, donor age is perhaps the most investigated parameter. Although excellent outcomes were observed for OLT using CD aged over 60 years, the European Liver Transplant Registry (ELTR) Group found an increased risk by using CD of more than 55 years. The Italian National Transplant Center has recently assumed that CD age more than 60 years is a potential risk factor for OLT. In this study, a single-center analysis was performed by stratifying CD by three age cut-offs (< or =55 or >55, < or =60 or >60, and < or =65 or >65 years) to evaluate effects on OLT outcome. Although no significant difference in 6-month and 1-year patient or graft survival occurred after stratification for each donor age cut-off, a better survival was observed with OLT performed using livers procured from CD >55 years. A significant increase in cold ischemia time (CIT) was observed among OLT performed with grafts procured from CD < or =55 and < or =65 years (P = .007), and there was an inverse correlation between overall CIT and donor age (R = -0.300; P = .0022). However, no impact on 1-year patient survival was observed by introducing CIT in univariate logistic regression models as well as donor age, recipient age, donor/recipient age ratio, donor/recipient sex mismatch, ELTR diagnostic categories, and UNOS status. The results of this study suggest the suitability of CD of more than 55 years for OLT and the need to further investigate the cut-off value for CIT-related risk.

Rizatriptan does not change cerebral blood flow velocity during migraine attacks

Rizatriptan represents a major advance in the treatment of migraine attack: inhibition of peripheral trigeminal nerve and constriction of intracranial extracerebral blood vessels have been proposed as its main antimigraine mechanisms of action. Although many studies may suggest that rizatriptan causes highly selective vasoconstriction within intracranial extracerebral vessels (i.e., meningeal arteries), no literature data are available to date on possible cerebral hemodynamic changes in humans after treatment with rizatriptan. The aim of this study was to evaluate the effect of rizatriptan on cerebral blood flow velocity performing transcranial Doppler during spontaneous attacks of migraine without aura. Fourteen patients suffering from migraine without aura were monitored to evaluate mean flow velocity changes on both middle cerebral arteries during migraine attack 30 min before and 120 min after oral administration of rizatriptan 10mg. Monitoring was repeated for 30 min during the pain-free period. All patients turned out to be drug responders and no significant mean flow velocity changes were observed between the pain-free period and pre-treatment phase; besides no significant difference in mean flow velocity value have been detected between the periods after the drug administration during the attack versus both pre-treatment period and pain-free phase. These findings indicate that the antimigraine action of rizatriptan is not associated with clear intracranial cerebral hemodynamic changes and may support its cerebrovascular safety.

Simultaneous liver-kidney transplantation for glycogen storage disease type IA (von Gierke's disease)

INTRODUCTION

Glycogen storage disease type Ia (GSDIa) is due to the deficiency of glucose-6-phosphatase activity in the liver, kidney, and intestine. Although significant progress has been achieved in the management of patients with GSDIa, complications still emerge. The potential for development of liver adenomatosis and kidney failure makes these patients candidates for simultaneous liver-kidney transplantation (SLKT). Herein, we describe such a transplantation in a patient affected by this rare storage disease.

METHODS

A 25-year-old female patient with GSDIa developed hepatic adenoma and kidney failure despite dietary therapy. The patient underwent an SLKT from a cadaveric donor.

RESULTS

The operative time was 8 hours without hemotransfusion. Only a transitory lactic acidosis was observed. Laboratory results normalized on postoperative day 7. The patient was discharged on postoperative day 9. After 4 months, the patient is in good condition with well-functioning kidney and liver allografts.

CONCLUSION

Patients with end-stage renal disease secondary to GSDIa should be considered for SLKT, especially when the disease is in an early stage.

Potential predictive value of the MELD score for short-term mortality after liver transplantation

In the last years, a model for end-stage liver disease (MELD) was suggested as a disease severity score for patients with end-stage liver disease awaiting liver transplantation. In the early 2002, United Network for Organ Sharing (UNOS) has proposed to replace the current status 2A, 2B, and 3 by a modified version of the original MELD score based upon patient risk for 3-month mortality on the waiting list. In this study UNOS status and MELD score were evaluated retrospectively for postoperative 3-month mortality in patients who underwent liver transplantation from 2000 to 2001. Liver recipients were stratified for UNOS status 2A, 2B, and 3, and the corresponding MELD score was calculated for each patient. A receiver operating characteristic (ROC) analysis was performed for both conventional UNOS status and MELD score by fitting patient deaths within 3 months after liver transplantation. The MELD score revealed a better prediction rate for 3-month mortality after the first LT than conventional UNOS status, although no statistical significance was evident by ROC curve comparison. This preliminary study seems to suggest a potentially better predictive rate for the MELD score than conventional UNOS status concerning short-term mortality after liver transplantation.

Split liver transplantation in Italy

The role of split liver transplantation has been well established. The limitation to this technique is the number of potential recipients for a left lateral segment graft. The optimal use of the donor pool is to split the liver to provide 2 grafts suitable for adults obtaining right or left lobe. We explored the potential increase in the number of liver grafts gained from systematically using the technique of splitting on national basis. The crucial factor appeared to be creation of guidelines for the use of optimal livers to optimize organ allocation while minimizing pretransplantation mortality and maximizing post-orthotopic liver transplantation outcome.

Portal vein pressure and graft oxygen consumption monitoring during liver transplantation

Abnormal splanchnic circulation (ASC) is often detected too late, when hepatic circulation is already irreversibly compromised. If we could detect surgical or metabolic problems early after graft reperfusion, we might be able to correct them immediately before the damage becomes irreversible. The aim of this study was to determine if ASC can be predicted early after liver transplantation (LT) using portal vein pressure measurements and graft oxygen consumption monitoring.

PATIENTS AND METHODS

Twenty-patients (13 men, 7 women of mean age 46 years) undergoing LT with the piggyback technique for hepatitis C virus (HCV)/hepatitis B virus (HBV)-related cirrhosis were retrospectively divided in two groups. Group A (16 patients), in which LT was successful, and group B (4 patients) in which LT was unsuccessful because of primary nonfunction (2 patients), infrahepatic portal vein thrombosis (1 patient), or hepatic vein kinking (1 patient). We then compared the portal blood pressure values and the prehepatic and posthepatic oxygen content difference (p-pDO(2)) before portal clamping; at the end of anhepatic phase; 5, 15, and 25 minutes after portal vein (PV) reperfusion; and 5, 20, 40, and 100 minutes after hepatic artery anastomosis.

RESULTS

Early after graft reperfusion; portal pressure decreased to levels lower than that at baseline in group A, but remained high until the end of surgery in group B. At the end of surgery, p-pDO(2) increased more among group B than group A.

CONCLUSION

ASC, specifically an increased PV resistance, can be predicted early after LT by portal vein pressure measurements and graft oxygen consumption monitoring.

Effect of zafirlukast on methacholine and ultrasonically nebulized distilled water challenge in patients with mild asthma

BACKGROUND

Bronchial asthma is a chronic inflammatory disease characterized by airway inflammation and hyperresponsiveness due to the release of multiple mediators, such as cysteinyl-leukotrienes (cys-LTs).

OBJECTIVE

Our study was designed to investigate whether oral pretreatment with zafirlukast (a cys-LTs receptor antagonist) reduces bronchoconstriction against methacholine (MC) and ultrasonically nebulized distilled water (UNDW) challenge in patients with mild asthma.

METHODS

Fourteen non-atopic patients (8 males, 20-42 years, forced expiratory volume in 1 s (FEV(1)) 97% SD +/- 0.4) with mild, intermittent bronchial asthma performed a sequential weekly pulmonary function test following challenge with MC or UNDW 2 h after zafirlukast or placebo administration, according to a single-blind method.

RESULTS

We found that pretreatment with zafirlukast significantly decreased bronchoconstriction MC (maximum FEV(1) drop -10.75% SD +/- 1.89, p < 0.001) and UNDW induced (maximum FEV(1) drop -12% SD +/- 0.15, p < 0.001), while pretreatment with placebo did not protect patients against FEV(1) drop following MC (maximum FEV(1) drop -33.22% SD +/- 1.42, p < 0.001) and UNDW challenge (maximum FEV(1) drop -30.02% SD +/- 0.4, p < 0.001).

CONCLUSIONS

Pretreatment with zafirlukast significantly reduced bronchoconstriction against MC and UNDW challenge in individuals with mild intermittent asthma, indicating that cys-LTs receptor antagonists might be useful as preventive therapy in these patients population.

In situ splitting of a liver with middle hepatic vein anomaly

In situ liver splitting provides a way to expand the graft pool, minimize cold ischemia time, and improve hemostasis at the cut surface of the graft. Vascular anomalies of the liver may make the splitting procedure very difficult or even impossible to perform. The in situ splitting procedure, performed on a liver with a middle hepatic vein (MHV) anomaly, is described here. The MHV drained directly into the segment III vein within the hepatic parenchyma instead of draining into the left hepatic vein to form the common trunk. In situ splitting was performed during multiorgan procurement from a 33-year-old man who died of isolated cerebral trauma. The MHV was reconstructed on the back table to secure right graft venous drainage using an iliac vein graft. The resultant right graft, segments I and IV to VIII, and left graft, segments II and III, were transplanted successfully into an adult and a child, respectively. The 2 transplant recipients are currently alive with normal hepatic function 20 months after transplantation.

Orthotopic liver transplantation in a young adult (33 years old) using an 84-year-old donor

Shortage of liver donors and the increasing number of patients on the waiting list for liver transplantation have led to a widening of the definition of liver donor suitability. Although the age limit for liver donors is controversial, current opinion is towards using liver allografts from donors older than 60 years. However, to date only a few cases that showed a good performance of liver graft by donors older than 60 years have been described. In this case report, orthotopic liver transplantation in a 33-year-old patient who received a graft from an 84-year-old donor is presented. A careful evaluation of the conventional donor-related risk factors (hemodynamics, hepatic function and histologic features) was carried out. Moreover, free radical scavenger glutathione was measured before cold ischemia and at the time of reperfusion in hepatic biopsies. After a 1-year follow-up, the recipient exhibits good general conditions and normal liver function values.