A polarimetrically oriented X-ray stare at the accreting pulsar EXO 2030+375

Accreting X-ray pulsars (XRPs) are presumably ideal targets for polarization measurements, as their high magnetic field strength is expected to polarize the emission up to a polarization degree of ~80%. However, such expectations are being challenged by recent observations of XRPs with the Imaging X-ray Polarimeter Explorer (IXPE). Here we report on the results of yet another XRP, EXO 2030+375, observed with IXPE and contemporarily monitored with Insight-HXMT and SRG/ART-XC. In line with recent results obtained with IXPE for similar sources, analysis of the EXO 2030+375 data returns a low polarization degree of 0%-3% in the phase-averaged study and variation in the range 2%-7% in the phase-resolved study. Using the rotating vector model we constrain the geometry of the system and obtain a value for the magnetic obliquity of ~$60^{\circ}$. Considering also the estimated pulsar inclination of ~$130^{\circ}$, this indicates that the magnetic axis swings close to the observer line of sight. Our joint polarimetric, spectral and timing analysis hint to a complex accreting geometry where magnetic multipoles with asymmetric topology and gravitational light bending significantly affect the observed source behavior.Comment: A&A accepted. Proofs versio

L’ADERENZA ALLA TERAPIA IMMUNOSOPPRESSIVA POST-TRAPIANTO DI FEGATO: DAI MODELLI TEORICI ALLE STRATEGIE D’INTERVENTO

There are no easy challenges in current medical practice. This is due to the intricacy of human nature as well as to the complexity of medical interventions to be implemented for patients in need. Over the recent years, focus has been directed to the mechanisms of drug non-adherence across individuals and communities, in view of designing solutions to improve the results of therapeutic programs. Treatments are getting more complex, and may often challenge patients, their families, and the communities. The ever-increasing demand on the part of the patients is not only to be treated, but to get help irrespective of the outcome. Non-adherence may not only be a source of morbidity, but it is a request for help from those in need. Non adherers to treatment programs - even to a limited extent – are to be taken care of, due to the anticipated risk of treatment failure and because they may have not entirely understood the objectives of their therapeutic plan. The most appropriate approach to explore non-adherence is the ecological perspective. This latter mandates to explore all levels involved in delivering care for the individual and the communities: the micro-level between patients and their care providers; the meso-level of health care organizations, and the macro-level, that is, the socio-political environment. Based on such ecological perspective, the current work illustrates the research that has been carried out on patient adherence at the Liver transplant center of the University Hospital of Pisa. This work has been conducted in collaboration with colleague nurses, physicians, students, and trainees, and investigated the prevalence of non-adherence at the individual level, explored the level of organization of regional transplant centers, and illustrates the patient-centered educational program implemented at our center

Early switching to intramuscular anti-HBs Immunoglobulins (Igantibe™) after liver transplantation: feasibility, efficacy, and safety

We present the results of a single-center trial on early switching from i.v to i.m.anti HBs immunoglobulins (HBG) after liver transplantation

Screening for alcohol-induced liver injury by patient self-report after liver transplantation

Despite widespread concern about the magnitude of alcohol consumption and/or recidivism after liver transplantation (LT), no universal agreement exists regarding the tools to assess problem alcohol drinking. We performed a single-center, cross-sectional study to assess the performance of the CAGE questionnaire in discriminating between LT recipients with and without post-transplant alcohol-induced liver injury. A total of 316 adult, consenting, maintenance patients between 6 months and 5 years after LT received the CAGE (Cut down, Annoyed, Guilty, Eye-opener) screening questionnaire. Calculation of the sensitivity, specifi city, receiver operating characteristic (ROC) curve, and likelihood ratio for CAGE scores of 0 to 4 was performed using as gold standard the biopsy-proven evidence of alcohol-induced liver injury (BPAI). One-hundred-ninety-fi ve patients responded to the questionnaire, and among them 45 (23%) had a CAGE score ≥1 (mean 2.13 ± 0.9). Among patients with a CAGE score = 0 there were 11 (7.3%) cases of BPAI, as compared with 24 (53.3%) among patients with a CAGE score of ≥1 (p<0.0001). A CAGE score ≥1 was associated with a sensitivity and a specifi city of 68.5% and 86.8%, and an area under ROC curve of 0.79 (95% CI 0.70-0.87). The likelihood ratios for scores of 0 to 4 were 0.3, 5.2, 7.8, 9.9, and 100, respectively. These ratios were associated with posterior probabilities for BPAI of 7.3%, 53.3%, 63.3%, 87.5%, and 100%, respectively. Based on these data, transplant physicians can improve their ability to predict the probability for alcohol-related liver injury using likelihood ratios for CAGE scores, in the setting of either recurrent or de novo post-transplant alcohol disorder

Aging with a Liver Graft: Analysis of Very Long-Term Survivors after Liver Transplantation

Background: In Italy, data on long-term survivors after liver transplantation are lacking. Materials and Methods: We conducted a hybrid design study on a cohort of 359 adult recipients who received transplants between 1996 and 2002 to identify predictors of survival and the prevalence of co-morbidities among long-term survivors. Results: The actuarial (95% CI) patient survival was 96% (94.6–98.3%), 69% (64.2–73.6%), 55% (49.8–59.9%), 42.8% (37.6–47.8%), and 34% (29.2–38.9%) at 1, 5, 10, 15, and 20 years, respectively. The leading causes of death were hepatitis C virus recurrence (24.6%), extrahepatic malignancies (16.9%), infection (14.4%), and hepatocellular carcinoma recurrence (14.4%). The factors associated with the survival probability were younger donor and recipient ages (p = 0.001 and 0.004, respectively), female recipient sex (p p p = 0.001), and absence of diabetes mellitus at one year (p < 0.01). At the latest follow-up, the leading comorbidities were hypertension (53.6%), obesity (18.7%), diabetes mellitus (17.1%), hyperlipidemia (14.7%), chronic kidney dysfunction (14.7%), and extrahepatic malignancies (13.8%), with 73.9% of patients having more than one complication. Conclusions: Aging with a liver graft is associated with an increased risk of complications and requires ongoing care to reduce the long-term attrition rate resulting from chronic immunosuppression

Immunosuppression for older liver transplant recipients

Older liver transplant recipients have a lower risk of acute rejection than younger patients (9% for patients aged ≥65 years versus 23% for those aged 18–34 years) and are more vulnerable to immunosuppression-related complications. The number of liver transplant recipients ≥65 years has risen to 22% in Europe and the US, but limited information is available on the optimal immunosuppressive regimen for these patients. In this review, we discuss the appropriate management of immunosuppressive agents in older adults to minimize adverse events while avoiding acute rejection. The way the body processes drugs greatly depends on age. In the case of calcineurin inhibitor drugs, aging reduces hepatic metabolism, leading to changes in their pharmacokinetics. Corticosteroids also show decreased clearance as the patient ages. In severe cases of hypoalbuminemia, dose adjustment of mycophenolate acid derivatives may be necessary. However, the pharmacokinetic profiles of the mammalian target of rapamycin inhibitors, basiliximab, and rabbit anti-thymocyte globulin remain unaffected by age. Furthermore, age-related frailty may impact drug metabolism and require tailored interventions and closer follow-up. Although there is limited research, elderly liver transplant recipients require less immunosuppression with double or triple-agent regimens, lower exposure to calcineurin inhibitors, and a shorter course of corticosteroids. The usage of mammalian target of rapamycin inhibitors in older transplant populations has not been specifically investigated, and thus their usage should align with indications for younger patient groups

The impact of socioeconomic deprivation on liver transplantation

Despite global expansion, social disparities impact all phases of liver transplantation, from patient referral to post-transplant care. In pediatric populations, socioeconomic deprivation is associated with delayed referral, higher waitlist mortality, and reduced access to living donor transplantation. Children from socially deprived communities are twice as much less adherent to immunosuppression and have up to a 32% increased incidence of graft failure. Similarly, adult patients from deprived areas and racial minorities have a higher risk of not initiating the transplant evaluation, lower rates of waitlisting, and a 6% higher risk of not being transplanted. Social deprivation is racially segregated, and Black recipients have an increased risk of post-transplant mortality by up to 21%. The mechanisms linking social deprivation to inferior outcomes are not entirely elucidated, and powered studies are still lacking. We offer a review of the most recent evidence linking social deprivation and post-liver transplant outcomes in pediatric and adult populations, as well as a literature-derived theoretical background model for future research on this topic

COVID-19 infection requires strengthening of the chronic care model: the impact on liver transplant practice at a high-volume center in Italy

Spreading of SARS-CoV-2 infection in Italy has challenged the practice of liver transplantation in an unprecedented way. We report on the initiatives implemented at a high-volume transplant center to handle an anticipated increase in waiting list time, deferral of pre-transplant care and temporary postponement of routine post-transplant follow up. In March 2020 liver transplant procedures decreased by 57% over the previous month, however with no change in laboratory MELD or outcome. No waitlist mortality was observed. Three patients declined transplantation for fear of COVID-19. Two liver transplant recipients were diagnosed with SARS-CoV-2 infection, and 2 waitlist candidates tested positive. Our outpatient program was switched to a remote, e-assistance model, with 517 e-mail contacts from transplant patients (i.e. 59.1% increase) and 712 patient laboratory tests faxed (45.0% increase). No health care worker was diagnosed with COVID-19 thanks to implementation of social distancing and routine use of individual safety devices. All of the strategies we implemented were derived from the chronic care model and based on productive interaction across healthcare professionals, communities, authorities and patients