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ABSTRACT: The reorganization of the healthcare system in Tuscany aims at characterizing the hospitals as a place for the treatment of acute patients. This event, together with the improvement of long-term survival after orthotopic liver transplantation (OLT), calls for a management network able to ensure effective continuity of care for patient needs in the posttransplantation period.
An observational study of prevalence has been carried out with the primary objective to evaluate patients' needs and criticalities both in routine daily life and in urgency in the posttransplantation period and the capacity of the regional health system to support them. A survey, using a semi-structured questionnaire consisting of 27 questions, was administered to all patients resident in Tuscany who underwent transplantation from 2000 to 2010. The survey tool assessed the following: socio-demographic data, personal, family and social difficulties, problems emerged in the clinical routine and urgency, resolution modality, relationships with the general practitioner and the referral specialist, and services the patients would appreciate receiving in their province of residence.
In the study, 346 patients matched the inclusion criteria of the study, 324 gave telephone consent to participate in the survey, and 225 responded (69.4%). The most frequent difficulties were as follows: depression (39.5%), difficulty in returning to work (29.3%), low income (22.6%), lack of self-sufficiency (22.6%), addictions (19.1%) (cigarette smoking 16.4%), 12.4% eating disorders, and 18.9% other difficulties (social isolation, absence of a family network, and so on). The main reasons for dissatisfaction were as follows: difficulty to obtain the required laboratory tests and lack of a reference structure at the local health facility. Few patients have a referral specialists in their area and most of them primarily refer to the Transplant Center even late after the procedure.
Early diagnosis of specific conditions (depression, addiction, and eating disorders) should be implemented in the follow-up period and services such as counselling, dietary support, rehabilitation, and social services should be provided locally. An integrated management system between the transplantation center and the local facilities (hospitals, general practitioners, primary care, and laboratories) should be implemented and referral specialized centers should be identified locally.
Transplantation Proceedings 04/2013; 45(3):1276-8. · 1.00 Impact Factor
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M L Bindi,
M Miccoli,
M Marietta,
L Meacci,
M Esposito,
M Bisà,
R Mozzo,
A Mazzoni,
A Baggiani,
F Scatena, F Filipponi,
G Biancofiore
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ABSTRACT: BACKGROUND: Although orthotopic liver transplantation (OLT) is nowadays considered standard practice at experienced centres, it can still be affected by a significant risk of massive bleeding and its related complications. Solvent/detergent plasma (S/D Plasma) has been proposed as an alternative to fresh frozen plasma (FFP) to curtail such complications. This study aimed at evaluating the efficacy of S/D Plasma in OLT patients by comparing it to FFP. MATERIALS AND METHODS: Sixty-three OLT patients were randomized into two groups depending on whether they were transfused with FFP or S/D plasma. A thromboelastography-based protocol aimed at achieving and maintaining predetermined coagulation goals was used to guide plasma transfusions. At the beginning and the end of surgery, standard laboratory coagulation tests were performed together with the assessment of the VII, VIII, V, XII factors and S protein blood levels. RESULTS: The two study groups equally achieved the thromboelastography goals but with a reduced amount of transfusions in the S/D plasma group (P < 0·0001). At the end of surgery, factors V and XII and S protein blood levels were lower in the S/D plasma patients who also showed lower INR, aPTT and antithrombin III levels. CONCLUSION: In cirrhotic patients undergoing OLT, the use of S\D plasma associated with thromboelastography allows the same clinical results but with a significant reduction in the amount of plasma transfusions.
Vox Sanguinis 02/2013; · 2.86 Impact Factor
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P Marchetti,
R Lupi,
M Bugliani,
C L Kirkpatrick,
G Sebastiani,
F A Grieco,
S Del Guerra,
V D'Aleo,
S Piro,
L Marselli,
U Boggi, F Filipponi,
L Tinti,
L Salvini,
C B Wollheim,
F Purrello,
F Dotta
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ABSTRACT: AIMS/HYPOTHESIS: Glucagon-like peptide 1 (GLP-1) is a major incretin, mainly produced by the intestinal L cells, with beneficial actions on pancreatic beta cells. However, while in vivo only very small amounts of GLP-1 reach the pancreas in bioactive form, some observations indicate that GLP-1 may also be produced in the islets. We performed comprehensive morphological, functional and molecular studies to evaluate the presence and various features of a local GLP-1 system in human pancreatic islet cells, including those from type 2 diabetic patients. METHODS: The presence of insulin, glucagon, GLP-1, proconvertase (PC) 1/3 and PC2 was determined in human pancreas by immunohistochemistry with confocal microscopy. Islets were isolated from non-diabetic and type 2 diabetic donors. GLP-1 protein abundance was evaluated by immunoblotting and matrix-assisted laser desorption-ionisation-time of flight (MALDI-TOF) mass spectrometry. Single alpha and beta cell suspensions were obtained by enzymatic dissociation and FACS sorting. Glucagon and GLP-1 release were measured in response to nutrients. RESULTS: Confocal microscopy showed the presence of GLP-1-like and PC1/3 immunoreactivity in subsets of alpha cells, whereas GLP-1 was not observed in beta cells. The presence of GLP-1 in isolated islets was confirmed by immunoblotting, followed by mass spectrometry. Isolated islets and alpha (but not beta) cell fractions released GLP-1, which was regulated by glucose and arginine. PC1/3 (also known as PCSK1) gene expression was shown in alpha cells. GLP-1 release was significantly higher from type 2 diabetic than from non-diabetic isolated islets. CONCLUSIONS/INTERPRETATION: We have shown the presence of a functionally competent GLP-1 system in human pancreatic islets, which resides in alpha cells and might be modulated by type 2 diabetes.
Diabetologia 09/2012; · 6.81 Impact Factor
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ABSTRACT: Frataxin (FXN) is a mitochondrial protein involved in iron metabolism and in the modulation of reactive oxygen and/or nitrogen species production. No information is currently available as for the role of frataxin in isolated human pancreatic islets. We studied islets from pancreases of multi-organ donors with (T2DM) and without (Ctrl) Type 2 diabetes mellitus. In these islets, we determined FXN gene and protein expression by qualitative and quantitative Real-Time RT-PCR, nitrotyrosine concentration, and insulin release in response to glucose stimulation (SI). FXN gene and protein were expressed in human islets, though the level of expression was much lower in T2DM islets. The latter also had lower insulin release and higher concentration of nitrotyrosine. A positive correlation was apparent between SI and FXN gene expression, while a negative correlation was found between nitrotyrosine islet concentration and FXN expression. Transfection of Ctrl islets with siRNA FXN caused reduction of FXN expression, increase of nitrotyrosine concentration, and reduction of insulin release. In conclusion, in human pancreatic islets FXN contributes to regulation of oxidative stress and insulin release in response to glucose. In islets from T2DM patients FXN expression is reduced while oxidative stress is increased and insulin release in response to glucose impaired.
Hormone and Metabolic Research 03/2012; 44(6):471-5. · 2.19 Impact Factor
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ABSTRACT: Post-transplant diabetes mellitus represents an important complication of prolonged immunosuppressive treatment after solid organ transplantation. The immunosuppressive toxicity, responsible for a persistent impairment of glucose metabolism in pancreatic islet-transplanted patients, is mainly attributed to calcineurin inhibitors and steroids, while other immunosuppressive molecules (azathioprine and mycophenolic acid, MPA) are considered not to have a toxic effect. In the present study, in vitro effects of MPA have been investigated in mouse beta-cell lines (βTC-1 and βTC-6) and in purified human pancreatic islets. βTC-1, βTC-6, and human pancreatic islets were exposed to various concentrations of MPA for different times. Consequently, we evaluated the viability, the induction of apoptosis, the glucose-stimulated insulin secretion, and the expression of β-cell function genes (Isl1, Pax6, Glut-2, glucokinase) and apoptosis-related genes (Bax and Bcl2). βTC-1, βTC-6, and human islets treated, respectively, for 48 and 72 h with 15-30 nM MPA showed altered islet architecture, as compared with control cells. We observed for βTC-1 and βTC-6 almost 70% reduction in cell viability; three to sixfold induction of TUNEL/apoptotic-positive cells quantified by FACS analysis. A twofold increase in apoptotic cells was observed in human islets after MPA exposure associated with strong inhibition of glucose-stimulated insulin secretion. Furthermore, we showed significant down-regulation of gene expression of molecules involved in β-cell function and increase rate between Bax/Bcl2. Our data demonstrate that MPA has an in vitro diabetogenic effect interfering at multiple levels with survival and function of murine and human pancreatic β-cells.
Acta Diabetologica 01/2012; · 2.78 Impact Factor
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ABSTRACT: This was a single-center, mixed-design, cross-sectional and retrospective study to assess the performance of the 4-item, self-reported CAGE (Cut down, Annoyed, Guilty, Eye-opener) questionnaire in predicting histology-proven alcohol-related liver graft injury (ARLGI).
A total of 316 liver transplant (LT) patients between six months and five years were enrolled. Based on previous research, problem alcohol drinking (PAD) was defined as any score ≥ 1 on the CAGE, while a cut-off of 2 was assumed for alcohol dependence (AD).
Responders were 195, 45 (23.1%) had a CAGE score ≥ 1 and 30 (15.3%) scored ≥ 2. After controlling for confounders, PAD was associated with hyperlipidemia (P=0.01), while AD with a male gender (P=0.01), hyperlipidemia (P=0.03) and alcohol as native diagnosis (P=0.03). PAD and AD were both associated with a significantly higher prevalence of ARLGI, i.e. 53.3% and 63.3%, respectively (P<0.0001). Hepatitis C virus (HCV) patients with PAD showed more steatosis (P=0.04), portal infiltrate (P=0.03), and pericellular/perivenular fibrosis (P=0.02). The likelihood ratios for CAGE scores ranging from 0 to 4 in predicting ARLGI were 0, 5.2, 7.8, 7.8, and 100, respectively.
By use of a self-report instrument we found a 23.1% prevalence of PAD and a 15.3% prevalence of AD among LT patients between six months and five years. A variable degree of ARLGI was present in 53.3% of PAD and 63.3% of AD, respectively. HCV patients with PAD had more steatosis, portal inflammation, and pericellular fibrosis. Transplant physicians might improve their ability to predict the probability for ARLGI using the CAGE.
Minerva gastroenterologica e dietologica 12/2011; 57(4):345-59.
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ABSTRACT: Studies suggest that insulin-signaling molecules are present in the pancreatic islets. For this reason, the effects of insulin glulisine, insulin aspart and regular human insulin (RHI) on the function and molecular features of isolated human pancreatic islets were investigated.
Human pancreatic islets were prepared by collagenase digestion and density-gradient purification of pancreata from multiple organ donors. Islets were then cultured for 48 h in the presence of 5.5 (normal) or 22.2 (high) mmol/L of glucose with and without glulisine, aspart and RHI (10 or 100 nmol/L). Functional (glucose-stimulated insulin secretion) and molecular (quantitative RT-PCR and immunoblot) studies were performed at the end of the different incubation conditions.
Glucose-stimulated insulin secretion was blunted in islets cultured in 22.2 mmol/L of glucose, with no significant effects from the exogenous added insulins. In islets maintained at 5.5 mmol/L of glucose, insulin receptor (IR) expression was reduced by low RHI, while phosphatidylinositol-3 kinase p110-alpha (PI3K) was enhanced by both concentrations of glulisine and aspart, and by high RHI. In islets preexposed to high glucose, IR expression was increased by both concentrations of aspart and RHI, but not by glulisine. Glulisine at high concentration significantly (P<0.05) increased PI3K expression. Glulisine and RHI significantly increased IRS-2 phosphorylation compared with control and aspart (P<0.05).
Insulin analogues have differential effects on the expression of insulin-signaling molecules in human pancreatic islets that are also dependent on the degree of glucose exposure.
Diabetes & Metabolism 02/2011; 37(4):324-9. · 2.41 Impact Factor
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ABSTRACT: GLP-1 and GIP are incretins known to affect beta-cell function and turnover. However, information on the direct actions of these hormones on human islet cells is limited. We tested the effects of acute (45min) or prolonged (2days) exposure to GLP-1 or GIP, alone or in combination, on the function and some molecular features of human islets isolated from non-diabetic and type 2 diabetic multiorgan donors. Acutely, both GLP-1 and, more markedly so, GIP, significantly potentiated glucose-stimulated insulin release, with no apparent synergic action. Some of these effects were observed with type 2 diabetic islets as well. Following prolonged exposure to the incretins, improved insulin secretion was observed, and transcription of insulin, PDX-1 and Bcl-2 was increased in both non-diabetic and diabetic islets, with the combination of GLP-1 and GIP showing more significant effects. Although it is still unclear at what extent these beta-cell direct actions of individual or combined incretins occur in-vivo in humans, nevertheless the results of the present study suggest that enhancing the exposure of pancreatic islets to circulating levels of both incretins may be useful for therapeutical purposes.
Regulatory Peptides 12/2010; 165(2-3):129-32. · 2.11 Impact Factor
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ABSTRACT: Long-term prophylaxis of hepatitis B virus (HBV) positive liver transplanted subjects with intravenous hepatitis B immunoglobulin (HBIG) is effective, however use of intramuscular HBIG could be as effective with fewer adverse events and lower cost.
We conducted a prospective, non-randomized, clinical study to assess the efficacy and safety of HBIG from Grifols, Igantibe, for the prophylaxis of HBV reactivation.
Eighteen adult patients submitted to liver transplantation for HBV-related disease more than 18 months earlier were treated with doses of 2000 I.U. intramuscular Igantibe every 14 days for 6 months.
Mean trough serum HBsAb IgG titers from months 4 to 6 (primary efficacy variable) were protective (>or=150 I.U./L) at each time point. Individual measurements were also protective throughout the study. HBV replication remained negative for all available subjects until study completion. Pharmacokinetic analysis showed a half-life of 27 days and extensive exposure to the study drug. Safety and tolerability of intramuscular Igantibe were good, with only one adverse event.
Standard-dose intramuscular Igantibe administration proved efficacious in post-liver transplantation prophylaxis by attaining protective levels for up to 6 months, was safe and well tolerated. Pharmacokinetic analysis revealed a long half-life and extensive exposure.
Digestive and Liver Disease 10/2009; 42(7):509-14. · 3.05 Impact Factor
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ABSTRACT: GPR40 is a membrane-bound receptor paired with medium and long-chain fatty acids (FFA) as endogenous ligands. Its acute activation potentiates insulin secretion from beta cells, whereas prolonged binding might contribute to the deleterious effects of chronic exposure to FFA. Little information is available on the expression of GPR40 and its regulation in human islets (HI).
HI were prepared by enzymatic digestion and gradient separation from the pancreas of 20 non-diabetic (Ctrl) and 13 type 2 diabetic (T2DM) multiorgan donors, and functional and molecular studies were then performed.
By qualitative and quantitative PCR experiments, mRNA expression was shown in HI. Both in T2DM islets and in Ctrl islets pre-exposed for 24 h to 1.0 mmol/l FFA (palmitate:oleate, 2:1), GPR40 mRNA expression was significantly reduced (p<0.01) in the T2DM cells as compared to Ctrl cells. A significant positive correlation was found between glucose-stimulated insulin secretion and GPR40 expression.
These results show the expression of GPR40 in human pancreatic islets which are regulated by FFA. The finding that T2DM islets have a lower GPR40 expression, and the correlation of these genes with insulin secretion, raises the possibility of an involvement of GPR40 in human diabetes beta-cell dysfunction.
Nutrition, metabolism, and cardiovascular diseases: NMCD 09/2009; 20(1):22-5. · 3.52 Impact Factor
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ABSTRACT: To evaluate the effects of exposure to high glucose (HG) levels and sulphonylurea on isolated human islet-cell function, and to investigate some of the mechanisms that might be involved.
Islet cells were isolated, using collagenase digestion and gradient purification, from 13 pancreata from non-diabetic multiorgan donors (age: 61.2+/-11.5 years; gender: 7 men/6 women; body mass index: 25.1+/-2.8kg/m(2)). The cells were then cultured for 5 days with normal glucose (NG) concentrations (5.5mmol/L), or NG and HG (16.7mmol/L) levels (alternating every 24h), with or without the addition of therapeutic concentrations of gliclazide (10micromol/L) or glibenclamide (1.0micromol/L). At the end of incubation, functional (glucose-stimulated insulin secretion), morphological (electron microscopy) and molecular (gene and protein expression) studies were performed.
Insulin secretion differed significantly between study groups, with marked decreases in the presence of HG plus glibenclamide. Compared with NG, insulin expression decreased significantly with HG, and increased similarly with gliclazide as with glibenclamide. However, exposure to gliclazide, but not glibenclamide, significantly induced expression (at both gene and protein levels) of PDX-1, a fundamental beta-cell differentiation transcription factor, and Ki67, a marker of proliferation. However, gliclazide and glibenclamide did not differ in terms of effects on gene expression of the antiapoptotic molecule Bcl2 (increased significantly with both) and the proapoptotic molecule Bax (decreased significantly with both).
Gliclazide and glibenclamide have different effects on the changes induced by prolonged exposure of human islet cells to high levels of glucose.
Diabetes & Metabolism 07/2009; 35(4):293-8. · 2.41 Impact Factor
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C Tascini,
G Gemignani,
R Doria,
G Biancofiore,
L Urbani,
C Mosca,
P Malacarne,
F Papineschi,
C Passaglia,
L Dal Canto,
M Procaccini,
G Furneri,
G Didoni, F Filipponi,
F Menichetti
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ABSTRACT: In randomized studies linezolid, indicated for Gram-positive infections, was as effective as teicoplanin in critical ill patients or was superior to teicoplanin in skin infection, pneumonia and bacteremia. We performed a 2-year comparative, retrospective study of patients treated with linezolid or teicoplanin in a single hospital for the same indications. We collected information about the type of infection, the responsible pathogen, therapy administered before study drugs, antibiotic associated with the study drugs, length of hospital stay (LOS), adverse events and outcome of the infections. The aim of the study was to evaluate the efficacy of linezolid in this retrospective patients series. Overall we identified 169 patients treated with linezolid and 91 with teicoplanin. Response to therapy, (resolution or improvement of infection) was better in patients treated with linezolid compared to teicoplanin (83.9% versus 69.2%, p=0.002). Response to therapy by type of pathogen showed the superior efficacy of linezolid against Staphylococcus aureus (including MRSA) and enterococci; although not statistically significant because of the small number of patients enrolled, they were close to significance (p<0.056 for S. aureus, p<0.055 for MRSA, p<0.061 for enterococci). Overall LOS in linezolid-treated patients was 4.6 days (p<0.041) less. Empirical use of linezolid reduced lOS by 6 days (p<0.038), especially in VAP and bacteremia patients (p<0.05). Mortality due to infection was 9.8% in both groups, and adverse events were most frequently documented in linezolid-treated patients. Linezolid was clinically superior to teicoplanin in the treatment of Gram-positive infections.
Journal of chemotherapy (Florence, Italy) 07/2009; 21(3):311-6. · 1.08 Impact Factor
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ABSTRACT: In light of the persistent donor scarcity, it has been advocated to shift the current region-based allocation model for liver transplantation (OLT) to an interregional one, so as to allow sicker patients on the wait list to obtain timely transplantations. Being convinced that tackling the challenge of organ donor scarcity requires appropriate measures, we have suggested some initiatives to be taken at different levels. First, definition of the real need for OLT, since it is largely unknown to transplant physicians and still represents the starting line for any initiative in the field. Second, we recommend creation of liver transplant care processes organized around the concept of smooth, seamless, and prompt referral of liver disease patients. Third, we suggest continued efforts in the field of deceased donation, so as to reduce the chasm between organ donation and demand and limit the persistent variability among regions. Fourth, we favor patient mobility, so as to expand the opportunity for transplantation for sicker patients. Finally, we seek to improve the efficiency of interregional coordination by prompt referral of extended criteria donors, sicker patients, or patients with rare diseases, so as to expand the opportunity for better donor-to-recipient matching at a national level.
Transplantation Proceedings 06/2009; 41(4):1081-3. · 1.00 Impact Factor
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ABSTRACT: Quality monitoring of the donation process requires appropriate indicators. We performed a retrospective review of all patients with encephalic lesions (ELs) reported to the Tuscany Quality Program of Donation during 2003 to 2007, seeking to assess whether there were differences in the brain-death-to-patients-with-encephalic-lesions (BD/EL) ratio, which is a current indicator of the efficiency of the donation process. The theoretical framework was that the type of disease may influence the probability of BD, and the subsequent donation process. During the study period 2555 patients were reported to display ELs. The overall BD/EL ratio was 48.1%, that is, 1229 patients were reported to be BD donors to the regional coordinating center at a later time point during patient hospitalization. With regard to the etiology, 1374 (53.8%) patients suffered cerebrovascular (CV disease); 514 (20.1%) traumatic (T); 397 (15.5%) postanoxic (PA); 55 (2.1%) neurological neoplasms (NN); and 215 (8.4%) other diseases (O). The BD/EL ratio by disease type was 57.2% for CV (786/1374); 58% for T (298/514); 19.4% for PA (77/397); 36.4% for NN (20/55); and 22.3% for O subjects (48/215). Despite its limitations, the current analysis advocates stratification of deceased donors by type of disease to allow better understanding and monitoring of the donation process.
Transplantation Proceedings 06/2009; 41(4):1090-1. · 1.00 Impact Factor
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ABSTRACT: We retrospectively investigated the impact on renal function (RF) of conversion from calcineurin inhibitors (CNI) to everolimus (EVL) monotherapy in orthotopic liver transplant (OLT) recipients. Between January 2006 and July 2007, 70 deceased donor OLT recipients including 51 men and 19 women of overall mean age of 55.9 +/- 11 years were enrolled into a program of conversion to EVL monotherapy at a mean interval of 45 +/- 35.9 months from transplantation (range, 7-192 months). The indication for conversion was deteriorating RF in 64 (91.4%). Efficacy failure was defined as the persistence of CNI, EVL discontinuation, death, graft loss, loss to follow-up, or need for dialysis at 12 months. Twelve months after switching, 53 patients (75.7%) were on EVL monotherapy. Their mean change in creatinine clearance (CrCl) from baseline (day 1 before EVL introduction) to endpoint (12 months) was 5.8 +/- 13.1 mL/min. On univariate and multivariate analyses, the clinical variable correlated with the greatest probability of improvement was the baseline CrCl (P < .0001). Conversion from CNI to EVL monotherapy was successful in 75.7% of cases with improvement in RF correlated with baseline CrCl. These data supported preemptive minimization of CNI in the posttransplant course, seeking to delay the decline in RF.
Transplantation Proceedings 05/2009; 41(4):1300-2. · 1.00 Impact Factor
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Journal of chemotherapy (Florence, Italy) 05/2009; 21(2):236-8. · 1.08 Impact Factor
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ABSTRACT: Beta cell loss contributes to type 2 diabetes, with increased apoptosis representing an underlying mechanism. Autophagy, i.e. the physiological degradation of damaged organelles and proteins, may, if altered, be associated with a distinct form of cell death. We studied several features of autophagy in beta cells from type 2 diabetic patients and assessed the role of metabolic perturbation and pharmacological intervention.
Pancreatic samples were obtained from organ donors and isolated islets prepared both by collagenase digestion and density gradient centrifugation. Beta cell morphology and morphometry were studied by electron microscopy. Gene expression studies were performed by quantitative RT-PCR.
Using electron microscopy, we observed more dead beta cells in diabetic (2.24 +/- 0.53%) than control (0.66 +/- 0.52%) samples (p < 0.01). Massive vacuole overload (suggesting altered autophagy) was associated with 1.18 +/- 0.54% dead beta cells in type 2 diabetic samples and with 0.36 +/- 0.26% in control samples (p < 0.05). Density volume of autophagic vacuoles and autophagosomes was significantly higher in diabetic beta cells. Unchanged gene expression of beclin-1 and ATG1 (also known as ULK1), and reduced transcription of LAMP2 and cathepsin B and D was observed in type 2 diabetic islets. Exposure of non-diabetic islets to increased NEFA concentration led to a marked increase of vacuole accumulation, together with enhanced beta cell death, which was associated with decreased LAMP2 expression. Metformin ameliorated autophagy alterations in diabetic beta cells and beta cells exposed to NEFA, a process associated with normalisation of LAMP2 expression.
Beta cells in human type 2 diabetes have signs of altered autophagy, which may contribute to loss of beta cell mass. To preserve beta cell mass in diabetic patients, it may be necessary to target multiple cell-death pathways.
Diabetologia 04/2009; 52(6):1083-6. · 6.81 Impact Factor
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Diabetes & Metabolism 04/2009; 35(2):155-6. · 2.41 Impact Factor
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G Biancofiore,
L A H Critchley,
A Lee,
L Bindi,
M Bisà,
M Esposito,
L Meacci,
R Mozzo,
P DeSimone,
L Urbani, F Filipponi
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ABSTRACT: The pulmonary artery catheter is invasive and may cause serious complications. A safe method of cardiac output (CO) measurement is needed. We have assessed the accuracy and reliability of a recently marketed self-calibrating arterial pulse contour CO monitoring system (FloTrac/Vigileo) in end-stage liver failure patients undergoing liver transplant. The pattern of alterations known as cirrhotic cardiomyopathy, and the transplant procedure itself, provided an evaluation under varying clinical conditions.
The cardiac index was measured simultaneously by thermodilution (CI(TD): mean of four readings) using a pulmonary artery catheter and pulse contour analysis (CI(V): mean value computed by the FloTrac/Vigileo over the same time period). Readings were made at 10 time-points during liver transplant surgery (T1-T5) and on the intensive care unit (T6-T10). CI(V) was computed using the latest Vigileo software version 01.10.
A total of 290 paired readings from 29 patients were collected. Mean (SD) CI(TD) was 5.2 (1.3) and CI(V) was 3.9 (0.9) litre min(-1) m(-2), with a corrected for repeated measures bias between readings of 1.3 (0.2) litre min(-1) m(-2) and 95% limits of agreement of -1.5 (0.2) to 4.1 (0.3) litre min(-1) m(-2). The percentage error (2SD(Bias)/meanCI(TD)) was 54%, which exceeded a 30% limit of acceptance. Low peripheral resistance and increasing bias were related (r=0.69; P<0.001). The Vigileo system failed to reliably trend CI data, with a concordance compared with thermodilution below an acceptable level (at best 68% of sequential readings).
In cirrhotic patients with hyperdynamic circulation, the Vigileo system showed a degree of error and unreliability higher than that considered acceptable for clinical purposes.
BJA British Journal of Anaesthesia 02/2009; 102(1):47-54. · 4.24 Impact Factor
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ABSTRACT: Sinonasal undifferentiated carcinoma (SNUC) is a relatively newly described malignancy of the nasal cavity and paranasal sinuses with a reported 25% to 30% risk for distant metastases. We have reported herein the case of a patient who underwent orthotopic liver transplantation (OLT) for hepatic metastases of SNUC. At 13 months follow-up she is alive with no sign of local or distant-site recurrence. Despite the limited follow-up, the present case suggests that a long disease-free survival after primary surgery, absence of local-regional recurrence, and stability of disease after chemotherapy may represent selection criteria to refer patients for OLT. However, continued follow-up and larger series are necessary to test this hypothesis in the long-term and to assess the role of posttransplantation chemotherapy.
Transplantation Proceedings 01/2009; 40(10):3821-2. · 1.00 Impact Factor
