Usefulness of Sequential Aspergillus galactomannan Antigen Detection Combined With Early Radiologic Evaluation for Diagnosis of Invasive Pulmonary Aspergillosis in Patients Undergoing Allogeneic Stem Cell Transplantation

Background: Early diagnosis of invasive pulmonary aspergillosis (IPA) is important as prompt treatment with antifungal drugs may increase patient survival. Our study investigated the efficiency of routine testing of the Aspergillus galactomannan antigen (AGA) test in combination with chest CT scans for IPA diagnosis. Patients and Methods: From February 2002 to June 2004, 74 hemato-oncologic patients undergoing allogeneic stem cell transplantation were prospectively studied with serum AGA twice weekly from admission until death or discharge and weekly afterward when possible. Chest CT scans were performed when fever of unknown origin had lasted beyond 3 days of antibacterial therapy. Results: Seven patients were classified with possible IPA and two patients, proven IPA. Fourteen patients showed positive results for AGA (OD index ≥ 1.0 on two subsequent sera). The sensitivity and specificity of the test were 100% and 93%, respectively; the positive and negative predictive values were 64% and 100%, respectively. All patients with possible/proven IPA showed abnormal CT signs; in four cases, imaging signs followed AGA positivity (median 5 days), whereas in five cases they preceded serologic positivity (median, 8 days). In the nine patients with IPA, antifungal therapy was promptly instituted, including lipid formulations of amphotericin B (n = 5) or caspofungin (n = 4). In only two of the nine patients (22%) with IPA, the primary cause of death was fungal infection. Conclusions: The combination of AGA detection and early chest CT scans might be considered useful tools to detect minimal changes of IPA. Based on these findings, aggressive antifungal therapy should be initiated. © 2006 Elsevier Inc. All rights reserved

Pulmonary Hypertension in Chronic Obstructive Pulmonary Disease and Pulmonary Fibrosis: Prevalence and Hemodynamic Differences in Lung Transplant Recipients at Transplant Center's Referral Time

Introduction Single or bilateral lung transplantation is a therapeutic procedure for end-stage lung diseases. In particular, in cases of chronic obstructive pulmonary disease (COPD) and pulmonary fibrosis, patients can be referred to the transplant center late and with important comorbilities. Pulmonary hypertension (PH) associated with lung diseases not only is an index of poor outcome but also is an indication for bilateral procedure. Methods We conducted a retrospective observational study. We analyzed right heart catheterization in a consecutive series of patients who underwent lung transplantation from 2006 to 2014 for end-stage COPD and pulmonary fibrosis. Results We included in the study 73 patients (35 with fibrosis and 38 with COPD); prevalence of PH was higher in the COPD group (84.3% vs 31.4%), and with worse hemodynamic parameters (mean pulmonary artery pressure [30.3 mm Hg vs 24.1 mm Hg]). The majority of COPD patients presented mild or moderate PH, and fibrosis patients showed normal pulmonary arterial pressures. Conclusions COPD patients are referred to the Transplant Center with a higher prevalence of PH because of an echocardiographic screening or a late referral, but many patients survive on the waiting list and undergo the procedure. On the other hand, patients transplanted with interstitial diseases have a lower prevalence of PH; this can be explained by an earlier referral or a higher mortality on the waiting list and a more aggressive and rapidly progressing disease

Posttransplantation chronic renal damage in nonrenal transplant recipients

Background. The growing problem of relentless deterioration of renal function in patients who undergo transplantation of nonrenal solid organs is bound to have an increasingly important impact as it may not only worsen patient morbidity and mortality but also increase transplantation costs. Methods. We reviewed the literature in order to provide a sumof the most important data on the incidence, clinical picture, renal pathology pattern, damage mechanisms, and risk factors, along with strategies for prevention and treatment of chronic renal damage following nonrenal solid organ transplantation. Results. Literature data report that 10% to 80% of transplanted patients have some degree of renal dysfunction and that they share a common clinical picture characterized by relentless asymptomatic progression, frequent hypertension, mild urinary abnormalities, and pathology features of vascular, glomerular, tubular, and interstitial involvement. These changes are very similar to those reported for chronic nephrotoxicity from calcineurin inhibitors. The occurrence of end-stage renal disease (ESRD) requiring chronic dialysis has been reported in up to 20%of nonrenal transplant recipients. Although there are some organ-specific differences, a group of common risk factors has been recognized, including the use of calcineurin inhibitors as immunosuppressive agents, age, pretransplantation renal function, intraoperative/perioperative factors, concomitant use of other nephrotoxic drugs, infections, and posttransplantation acute renal failure. Conclusion. Calcineurin inhibitor\u2013induced nephrotoxicity is a growing problem and, as the age of recipients of nonrenal organs is increasing, this problem is destined to increase. It would therefore be advisable for nephrologists to share their experiences in immunomodulation with other specialties, so as tofavor the cautious extension of calcineurin inhibitor\u2013sparing protocols to the area of life-saving transplants

Tailored cytomegalovirus management in lung transplant recipient: A single-center experience

Introduction Among solid organ recipients lung transplant recipients are at highest risk to be affected by cytomegalovirus infection (CMV) or to die from CMV disease. Two strategies are usually adopted in the clinical management of transplant recipients: antiviral prophylaxis and pre-emptive therapy. Methods In our center we adopted from 2007 a combined prophylaxis with anti-CMV immunoglobulins in the first post-transplant year and antiviral therapy (gancyclovir or valgancyclovir) from post-transplant day 15 for 3 weeks and in case of CMV bronchoalveolar lavage specimen positivity (polymerase chain reaction or shell vial). Moreover, we studied specific cellular immune response by an Elispot assay to define responder patients by the number of spot forming units (<5 nonresponders, 5-20 weeks, 20-100 good, >100 very good responders). Results We reduced acute rejections (from 17% to 6%, odds ratio 3.25), lymphocytic bronchitis bronchiolitis (from 11% to 2%), and first-year CMV pneumonia after the first post-transplant month (from 6.4% to 1%). We showed in nonresponders an earlier onset (68 vs 204 post-transplant days) and a longer duration (>14 days vs <14 days) of infection (P <.05 for all referred data). Discussion The morbility reduction has been obtained by antiviral therapy, increasing costs and risk of side effects. Our more recent studies show a population with a good immune response that probably doesn't need a pharmacological intervention but just a strict follow-up. Conclusion Our proposed strategy is now tailoring the therapy on immune response clinical application, limiting to the specimen positivity in nonresponders. \ua9 2013 by Elsevier Inc. All rights reserved

Implants survival rate in regenerated sites with innovative graft biomaterials: 1 year follow-up

In thirteen different dental clinics in Singapore, Spain, Czech Republic and Italy, 504 patients were selected, and 483 dental implants were placed in maxillary sites after alveolar socket preservation (ASP) procedures with an autologous demineralized tooth extracted as graft material from an innovative Tooth Transformer device was obtained. All procedures used were reported in n◦638 Ethical Committee surgical protocol of University of Chieti and approved. After 4 months, at dental implant placing, bone biopsies were performed to evaluate the histologic outcomes, and 12 months after implant loading, global implant survival rate, failure percentage and peri-implant bone loss were detected. After ASP, only 27 post-operative complications were observed and after 4 months, bone biopsy histomorphometric analysis showed a high percentage of bone volume (BV) 43.58 (±12.09), and vital new bone (NB) 32.38 (±17.15) with an absence of inflammation or necrosis areas. Twelve months after loading, only 10 dental implants failed (2.3%), with a 98.2% overall implant survival rate, nine cases showed mucositis (1.8%) and eight showed peri-implantitis (1.6%). At mesial sites, 0.43 mm (±0.83) of bone loss around the implants was detected and 0.23 mm (±0.38) at the distal sites with an average value of 0.37 mm (±0.68) (p > 0.568). Several studies with a longer follow-up will be necessary to confirm the preliminary data observed. However, clinical results seem to suggest that the post-extraction socket preservation procedure using innovative demineralized autologous tooth-derived biomaterial may be a predictable procedure to produce new vital bone able to support dental implant rehabilitation of maxilla edentulous sites

High incidence of type 1 diabetes among children of North African migrants in Emilia-Romagna Region, Italy

In the last few decades, many studies have reported an increasing global incidence of Type 1 Diabetes (T1D), especially in younger children. The differences between different ethnic and age groups have underlined both the importance of environmental and genetic factors in the development of the pathology, as studies on migrant populations have already demonstrated. Objectives: Evaluate the incidence of T1D and DKA prevalence in North African vs Italian children aged 0 to 14 years from 1st January 2015 to 31st December 2018, in Emilia Romagna Region, Italy. Methods: Clinical and epidemiological data about childhood onset T1D in E-R region were retrospectively collected and matched using 3 different data sources (Clinical registries, hospital discharge records and regional lists of exemptions for pathology). T1D cumulative incidence was calculated basing on the number of inhabitants in the region as a whole and subdividing the Italian and North African groups. Results: 365 new T1D onset were diagnosed (M 50.1%). DKA was present in 33% of cases (severe DKA 10.4%). Median age at T1D onset was 8.2 ± 3.7 yrs. Total cumulative incidence was 15.4/100.000/year and no increasing trend was recorded in the incidence of diabetes in the study period. In particular, North African cases were 52 with a cumulative incidence of 62.2/100.000/year, statistically significant compared to cumulative incidence of the Italian cases alone 13.1/100.000/year (p value <0.001). The annual incidence did not differ in the 4 years for both groups. No difference as for DKA cases and median age at T1D onset between the groups. Conclusions: The incidence of T1D in the pediatric age was significantly higher in the North African population than in the Italian one. Surprisingly, the incidence was much higher than not only that of the host country, but also of the country of origin, suggesting an explosive mix of genetic and environmental factors causing the increase in newly diagnosed cases