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Acute calculus cholecystitis (ACC) is increasing in frequency within an ageing population, in which biliary tract infection, including cholecystitis and cholangitis, is the second most common cause of sepsis, with higher morbidity and mortality rates. Patient's critical conditions, such as septic shock or anaesthesiology contraindication, may be reasons to avoid laparoscopic cholecystectomy-the first-line treatment of ACC-preferring gallbladder drainage. It can aid in patient's stabilization with also the benefit of identifying the causative organism to establish a targeted antibiotic therapy, especially in patients at high risk for antimicrobial resistance such as healthcare-associated infection. Nevertheless, a recent randomized clinical trial showed that laparoscopic cholecystectomy can reduce the rate of major complications compared with percutaneous catheter drainage in critically ill patients too. On the other hand, among the possibilities to control biliary sepsis in non-operative management of ACC, according to recent meta-analysis, endoscopic gallbladder drainage showed better clinical success rate, and it is gaining popularity because of the potential advantage of allowing gallstones clearance to reduce recurrences of ACC. However, complications that may arise, although rare, can worsen an already weak clinical condition, as happened to the high surgical-risk elderly patient taken into account in our case report.

Background: An immune function assay shows promise for identifying solid organ recipients at risk for infection or rejection. The following randomized prospective study was designed to assess the clinical benefits of adjusting immunosuppressive therapy in liver recipients based on immune function assay results., Methods: Adult liver recipients were randomized to standard practice (control group; n = 102) or serial immune function testing (interventional group; n = 100) performed with a commercially available in vitro diagnostic assay (ImmuKnow; Viracor-IBT Laboratories, Lee's Summit, MO) before transplantation, immediately after surgery and at day 1, weeks 1 to 4, 6, and 8, and months 3 to 6, 9, and 12. The assay was repeated within 7 days of suspected/confirmed rejection/infection and within 1 week after event resolution., Results: Based on immune function values, tacrolimus doses were reduced 25% when values were less than 130 ng/mL adenosine triphosphate (low immune cell response) and increased 25% when values were greater than 450 ng/mL adenosine triphosphate (strong immune cell response). The 1-year patient survival was significantly higher in the interventional arm (95% vs 82%; P < 0.01) and the incidence of infections longer than 14 days after transplantation was significantly lower among patients in the interventional arm (42.0% vs. 54.9%, P < 0.05). The difference in infection rates was because of lower bacterial (32% vs 46%; P < 0.05) and fungal infection (2% vs 11%; P < 0.05). Among recipients without adverse events, the study group had lower tacrolimus dosages and blood levels., Conclusions: Immune function testing provided additional data which helped optimize immunosuppression and improve patient outcomes.

Background: Statistical cure is achieved when a patient population has the same mortality as cancer-free individuals; however, data regarding the probability of cure after hepatectomy of colorectal liver metastases (CLM) have never been provided. We aimed to assess the probability of being statistically cured from CLM by hepatic resection., Methods: Data from 1,012 consecutive patients undergoing curative resection for CLM (2001-2012) were used to fit a nonmixture cure model to compare mortality after surgery to that expected for the general population matched by sex and age., Results: The 5- and 10-year disease-free survival was 18.9 and 15.8 %; the corresponding overall survival was 44.3 and 32.7 %. In the entire study population, the probability of being cured from CLM was 20 % (95 % confidence interval 16.5-23.5). After the first year, the mortality excess of resected patients, in comparison to the general population, starts to decline until it approaches zero 6 years after surgery. After 6.48 years, patients alive without tumor recurrence can be considered cured with 99 % certainty. Multivariate analysis showed that cure probabilities range from 40.9 % in patients with node-negative primary tumors and metachronous presentation of a single lesion <3 cm, to 1.5 % in patients with node positivity, and synchronous presentation of multiple, large CLMs. A model for the calculation of a cure fraction for each possible clinical scenario is provided., Conclusions: Using a cure model, the present results indicate that statistical cure of CLM is possible after hepatectomy; providing this information can help clinicians give more precise answer to patients' questions.

Objective: To optimize the results of low-volume (LV) centers for hepatopancreaticobiliary (HPB) surgery., Background: High-volume (HV) centers for HPB surgery have lower mortality than LV. Strategies for collaboration between HV and LV centers are not well investigated., Methods: Postoperative outcomes of patients undergoing curative HPB resection were evaluated at an LV hospital before (2006-2008) and during the collaboration (2009-2012) and at 2 hospitals with HV for either liver or pancreatic resection (2009-2012). Itinerant tutor surgeons from the HV centers were involved in the pre-, intra- and postoperative course of HPB patients at the LV hospital., Results: HPB cases at the LV center increased from 18 to 40 patients per year from 2006 to 2012, whereas 6-month postoperative mortality decreased from 17.8% (2006-2008) to 6% (2009-2012), P<0.05 (liver: 10.3% vs 4.7% and pancreas: 29.4% vs 7.9%). During the collaborative study period, outcomes for hepatectomy were similar for LV and HV (85 vs 507 cases): postoperative Clavien-Dindo scores 4 and 5 were 2% and 0.2% for HV versus 2.4% and 1.2% for LV, respectively. Outcomes for pancreatic procedures (LV 63 vs HV 269 cases) showed better postoperative Clavien-Dindo scores 4 and 5 in the HV (0.7% score 4 and 1.5% score 5 for HV vs 3.2% and 6.3%, respectively, for LV) but the difference disappeared in the last 2 years (2011-2012) and matching the cases., Conclusions: Our partnership model helped improve postoperative outcomes at the LV center. Results at the LV hospital were comparable with the HV centers, although 2 years of partnership were required to achieve this in pancreatic surgery.

Improvements in the medical and pharmacological management of liver transplantation (LT) recipients have led to a better long-term outcome and extension of the indications for this procedure. Liver tumors are relevant to LT; however, the use of LT to treat malignancies remains a debated issue because the high risk of recurrence. In this review we considered LT for hepatocellular carcinoma (HCC), cholangiocarcinoma (CCA), liver metastases (LM) and other rare tumors. We reviewed the literature, focusing on the past 10 years. The highly selected Milan criteria of LT for HCC (single nodule < 5 cm or up to 3 nodules < 3 cm) have been recently extended by a group from the University of S. Francisco (1 lesion < 6.5 cm or up to 3 lesions < 4.5 cm) with satisfying results in terms of recurrence-free survival and the "up-to-seven criteria". Moreover, using these criteria, other transplant groups have recently developed downstaging protocols, including surgical or loco-regional treatments of HCC, which have increased the post-operative survival of recipients. CCA may be treated by LT in patients who cannot undergo liver resection because of underlying liver disease or for anatomical technical challenges. A well-defined protocol of chemoirradiation and staging laparotomy before LT has been developed by the Mayo Clinic, which has resulted in long term disease-free survival comparable to other indications. LT for LM has also been investigated by multicenter studies. It offers a real benefit for metastases from neuroendocrine tumors that are well differentiated and when a major extrahepatic resection is not required. If LT is an option in these selected cases, liver metastases from colorectal cancer is still a borderline indication because data concerning the disease-free survival are still lacking. Hepatoblastoma and hemangioendothelioma represent rare primary tumors for which LT is often the only possible and effective cure because of the frequent multifocal, intrahepatic nature of the disease. LT is a very promising procedure for both primary and secondary liver malignancies; however, it needs an accurate evaluation of the costs and benefits for each indication to balance the chances of cure with actual organ availability.

The association between exposure to urban air pollution and cardiac or respiratory impairments in susceptible subjects was evaluated in a panel study including 11 patients with chronic obstructive pulmonary disease (COPD), 7 with ischemic heart disease (IHD), and 11 asthmatics resident in Rome (Italy). Patients underwent repeated 24 h Holter EKG monitoring, 12 h pulse oximetry at night and spirometry examinations during 1999 summer and winter. Multiple linear regression models for repeated individual measures (fixed-effect) were used to analyse the relationship between average daily concentrations of pollutants (PM10-2.5, PM2.5 NO2 and O3) and outcome variables, controlling for meteorological conditions, survey period, and week-ends. In the BPCO panel, increasing ambient PM2.5 levels were associated with increased heart rate and decreased respiratory function. In the asthmatic panel, inverse associations between pulmonary function and both NO2 and PM10-2.5 concentrations were observed, as well as direct association between ambient NO2 concentrations and NO in exhaled breath. In the IHD panel an increase of hearth rate variability associated with increasing concentration of PM2.5 was observed.

The concentration of airborne particulate matter (PM2.5 and PM10) was assessed over 12 months (1999-2000) both outdoor and indoor (workplaces and homes without major PM sources) through a manual gravimetric method. Mean concentration values outdoors were moderately lower than indoor concentrations in summer, but higher in winter. The correlations between outdoor and indoor values are statistically significant, especially for PM2.5 in winter. The position of indoor sites with respect to street level was immaterial as far as mean values is concerned, whilst maximum values presented some differences accordingly. Day-to-day variability was higher outside than inside, especially in winter. The PM2.5/PM10 ratio was higher indoors, probably owing to the higher sedimentation speed of the coarse fraction.

Size distributions of trace metals of specific health concern (Pb, Cd, Cr, Ni, Cd, V, Zn and Fe) in the fine (PM2.5) and coarse (PM2.5-10) fractions of suspended particulate matter were evaluated. Samples were collected through a year in three sites (traffic oriented and urban background in the urban area of Rome, and remote, in the Regional Park of Simbruini Mountains). Mean concentrations never exceeded the values recommended by WHO and EU. During winter season, levels of Cr, Cd, Pb and Zn resulted higher than in summer, in both fine and coarse fractions. The series of Pb, Cd, and V concentrations clearly showed a predominant fine-particle distribution, whereas Cr, Mn and Ni were more equally distributed between the coarse and fine fractions. Fe prevailed in the coarse mode at the urban sites. At the urban sites mean concentrations of the different metals were from 4 to 22 times higher than at the remote site. For various metals the distribution mode, as well as the seasonal trends of the concentrations, showed significant differences between urban and remote site. In busy and densely populated urban areas, without relevant industrial emissions, anthropogenic sources of metallic species seem still to give a contribution to air pollution, though a trend downwards, compared to previous surveys, was observed, particularly for Pb.

Recent studies have shown that an increased concentration of environmental particulate matter (PM(10)) is related to many respiratory diseases. One major issue is whether the toxicity of the particles resides in some particular fraction as defined by chemical composition and size. The overall purpose of this study was to compare the in vitro toxicity of coarse (PM(2.5-10)) and fine (PM(2.5)) particulate matter, collected in an urban area of Rome, in relation to their physicochemical composition as assessed by analytic electron microscopy and atomic absorption spectroscopy. In particular, our aim was to evaluate the importance of particle physicochemical components in the induced toxicity. The in vitro toxicity assays used included human red blood cell hemolysis, cell viability, and nitric oxide (NO) release in the RAW 264.7 macrophage cell line. The hemolytic potential has been widely used as an in vitro toxicity screen and as a useful indicator of oxidative damage to biomembranes. We found that human erythrocytes underwent dose-dependent hemolysis when they were incubated with varying concentrations of fine and coarse particles. The hemolytic potential was greater for the fine particles than for the coarse particles in equal mass concentration. However, when data were expressed in terms of PM surface per volume unit of suspension, the two fractions did not show any significant hemolytic differences. This result suggested that the oxidative stress induced by PM on the cell membranes could be due mainly to the interaction between the particle surfaces and the cell membranes. RAW 264.7 macrophage cells challenged with particles showed decreased viability and an increased release of NO, a key inflammatory mediator, and both effects were not dose dependent in the tested concentration range. The fine particles were the most effective and the differences between the two size fractions in inducing these biological effects remained unchanged when the basis of comparison was changed from weight to surface measures. It seemed therefore that these differences relied on the different physicochemical nature of the particles. The main chemical difference between the two fractions resided in a greater abundance of C-rich particles with S traces in the fine fraction. Therefore, we cautiously suggest a role for these particles in the induction of toxicity., (Copyright 2001 Academic Press.)

Starting from 1993, various monitoring campaigns were carried out in Rome to determine PM10 and PM2.5. Their results are presented here cumulatively, with the aim of obtaining preliminary information on relationships among these size fractions, in various seasonal periods and in two sites with different characteristics (a road site and an urban background site in a public park). Particles were collected on filter and gravimetrically determined. Both PM10 and PM2.5 concentrations show temporal fluctuations with higher values during winter months. Background concentrations are lower than those contemporaneously measured at the road site only to a limited extent (10-17%). The contribution of PM2.5 to PM10 during the winter semester is higher than during the summer one (67 vs. 52%), with no substantial intersite differences.