Does smoking habit affect dendritic cell expression in oral squamous cell carcinoma?

The aim of this study was to determine the presence of immature CD1a+ and mature CD83+ dendritic cells in oral squamous cell carcinoma, to compare immunoreactivity between smokers and nonsmokers, and to correlate the results with histopathological grading. In this observational study, twenty-eight paraffin-embedded biopsies of oral squamous cell carcinoma were retrospectively retrieved and submitted to immunohistochemistry for immature CD1a+ and mature CD83+. Descriptive and statistical analyses were performed. The sample consisted of 18 man (64.3%) and 10 women (35.7%), with a mean age of 64.6 years in the nonsmoker group and 53.2 years in the smoker group. The tongue (11 cases, 39.2%) was the most commonly affected anatomical site, followed by gingiva (6 cases, 21.4%). Histopathological grading revealed 7 low-grade and 7 high-grade malignancy cases in each group, and no correlation with the number of positive DCs. The number of immature CD1a+ was not significantly different between smoker and nonsmoker groups, while a lower number of mature CD83+ was detected in the smoker group (p = 0.001). Smoking changes the oral immune system and decreases the ability to activate and mature dendritic cells, which may influence the development and progression of oral squamous cell carcinoma.

Unlocking synchrotron sources for THz spectroscopy at sub-MHz resolution

Synchrotron radiation (SR) has proven to be an invaluable contributor to the field of molecular spectroscopy, particularly in the terahertz region (1-10 THz) where its bright and broadband properties are currently unmatched by laboratory sources. However, measurements using SR are currently limited to a resolution of around 30 MHz, due to the limits of Fourier-transform infrared spectroscopy. To push the resolution limit further, we have developed a spectrometer based on heterodyne mixing of SR with a newly available THz molecular laser, which can operate at frequencies ranging from 1 to 5.5 THz. This spectrometer can record at a resolution of 80 kHz, with 5 GHz of bandwidth around each molecular laser frequency, making it the first SR-based instrument capable of sub-MHz, Doppler-limited spectroscopy across this wide range. This allows closely spaced spectral features, such as the effects of internal dynamics and fine angular momentum couplings, to be observed. Furthermore, mixing of the molecular laser with a THz comb is demonstrated, which will enable extremely precise determinations of molecular transition frequencies.

Scabies in wildlife animals, pets and humans: a re-emerging zoonosis?

Background

Scabies or sarcoptic mange is an infestation of the skin caused by the mite Sarcoptes scabiei. Transmission from animals to humans occurs through close contact. The most common symptoms are papules, erythema, excoriations, hyperkeratosis, and hypotrichosis. In the province of Ferrara (Emilia Romagna, Italy) mange is endemic in wild animals, mostly in foxes, which can act as vectors for domestic animals and humans.

Methods

From 2012 to 2020, 564 foxes were surveyed within the Wildlife Health Surveillance Re-gional Program, including microscopic examination in cases of skin lesions referable to scabies. In 2018, a domestic dog (10-year border collie, male), frequenting an uncultivated area colonized by foxes and located in the outskirts of Ferrara, showed scabby lesions mainly on the nose, around the eyes and on the back.

Results

11 out of 564 foxes resulted positive (1,95%), 6 cases out of 38 being in 2018 (15,8%). The parasite was detected by skin biopsy and direct microscopic examination in the domestic dog. The parasite was transmitted by the dog to the owner and the other two family members.

Conclusions

The increased density of dogs and foxes in the Ferrara province, and the attitude of foxes to live near to human settlements, increase the risk of contacts between foxes, domestic animals and humans, even though stray dogs are uncommon. This case illustrates the interdependencies between animal health, human health and environment, a synergy that can enable exacerbation of diseases of zoonotic origin as highlighted by the One Health concept. It is therefore important to increase the investigation on paths as well as vectors of diseases and to find collaborative, multi-sectorial and transversal approaches to ensure quality health outcomes. The control of the disease requires an appropriate monitoring of dogs' health being skin lesions in both, humans and animals, very similar to allergic dermatitis, which can delay the proper diagnosis of the disease.

Key messages

Sarcoptic mange is a zoonosis still present in Emilia Romagna, Italy. The One Health approach is key to control the cycle of the zoonotic sarcoptic mange.

Preliminary investigation of possible effects of mineral clay treatment applied to oils produced from olives: focus on moisture removal and compositional changes

In this preliminary study, two non-filtered virgin olive oils (one freshly produced VOO-N; one VOO-O stored for one year) were subjected to moisture removal with mineral clay (raw or activated) and analyses were performed to attest possible effects on the quality of the product. The results demonstrated that the treatment of oil with mineral clay at 36-38 °C had no negative effect on the basic quality parameters or on the volatile comound profile. On the other hand, a significant decrease in the water amount as well as in pigments was observed in the samples subjected to this kind of treatment, in particular with raw clay. Regarding the colour measurement, the lightness (L) as well as the consumers’ acceptability exhibited a marked increase when oils were treated with raw clay.

Evaluation of Norovirus contamination in bivalve molluscs harvested from Northern Adriatic Sea, Italy

Background

Norovirus (NoV) is the leading cause of acute gastroenteritis in developed countries. Transmission is through direct contact, unsanitary food handling or ingestion of contaminated water or food. Shellfish bioaccumulate NoV and current post-harvest depuration is not effective for its removal.

Materials and

Methods

A monitoring programme for NoV in bivalve shellfish harvested from Northern Adriatic Sea was initiated in 2016. From January 2016 to March 2019, 418 samples including 257 Manila clams, 73 mussels, 46 striped clams, and 42 oysters, were examined. Mollusc samples were tested for NoV genogroups I (NoV GI) and II (NoV GII) contamination by RealTime RT-PCR according to ISO 15216-2.

Results

Ninety-three out of 418 tested samples (22.2%) were contaminated by at least one NoV genogroup, the simultaneous presence of the two genogroups was detected in 19/418 of the cases. Positive samples were distributed among the tested species as follow: 29/73 (39.7%) mussels, 51/257 (19.5%) Manila clams, 8/42 (19.0%) oysters, 5/46 (10.9%) striped clam. In 2016 (n = 135), 2017 (n = 122), 2018 (n = 132) and in the first trimester of 2019 (n = 12), prevalence of NoV was 6.7%, 24.6%, 31.8% and 41.4%, respectively. NoV GII was largely predominant being detected, alone or in association with GI, in 98.9% of the contaminated samples. On the other hand, GI prevalence increased from 1.5% (2016) to 12.1% in 2018, maybe reflecting a higher circulation of this genogroup in production environments.

The vast majority of positive samples (91.4%) were detected during the cold season (November to March).

Conclusions

Overall positive samples have increased over the years (from 6.7% in 2016 to 31.8% in 2018). NoV GII was the most frequently detected genogroup, but NoV GI prevalence significantly raised in 2018. The routine application of quantitative RT-PCR (ISO 15216-1) to determine the viral load in bivalve molluscs would expand knowledge on potential for foodborne transmission.

Key messages

Overall positive samples have increased over the years. The routine application of quantitative PCR to determine the viral load in bivalve molluscs would expand knowledge on potential for foodborne transmission.

INNOVATIVE SOLUTIONS FOR PERSONAL RADIATION SHIELDING IN SPACE

Personal radiation shielding is likely to play an important role in the strategy for radiation protection of future manned interplanetary missions. There is potential for the successful adoption of wearable shielding devices, readily available in case of accidental exposures or used for emergency operations in low-shielded areas of the habitat, particularly in case of solar particle events (SPEs). Based on optimization of available resources, conceptual models for radiation protection spacesuits have been proposed, with elements made of different materials, and the first prototype of a water-fillable garment was designed and manufactured in the framework of the PERSEO project, funded by the Italian Space Agency, leading to the successful test of such prototype for ease of use and wearability on-board the International Space Station. We present results of Monte Carlo calculations offering a proof-of-principle validation of the shielding efficacy of such prototype in different SPE environments and shielding conditions.

A COMPARISON BETWEEN X-RAY AND CARBON ION IRRADIATION IN HUMAN NEURAL STEM CELLS

Glioblastoma multiforme (GBM) is characterized by a poor prognosis and a median survival of ~12-18 months. GBM is usually managed by neurosurgery followed by both chemotherapy and radiotherapy. Since GBM develops resistance to conventional therapies, treatment with C-ions is promising to completely eradicate the tumoural mass. During cranial irradiation, exposure of healthy tissues is inevitable. Because of the presence of neural stem cells, a deep investigation on the effects of C-ion irradiation with respect to X-ray induced damage is mandatory to allow a better definition of treatments. In this work, the comparison of X-rays and C-ion irradiation-induced effects on human neural stem cell, focusing on multiple endpoints, such as cell viability, cytokine secretion and spheroid formation is presented. Results show different temporal and dose responses of human neural stem cells to the different radiation qualities, suggesting different underpinning mechanisms of radiation-induced damages.

WHAT ROLES FOR TRACK-STRUCTURE AND MICRODOSIMETRY IN THE ERA OF -omics AND SYSTEMS BIOLOGY?

Ionizing radiation is a peculiar perturbation when it comes to damage to biological systems: it proceeds through discrete energy depositions, over a short temporal scale and a spatial scale critical for subcellular targets as DNA, whose damage complexity determines the outcome of the exposure. This lies at the basis of the success of track structure (and nanodosimetry) and microdosimetry in radiation biology. However, such reductionist approaches cannot account for the complex network of interactions regulating the overall response of the system to radiation, particularly when effects are manifest at the supracellular level and involve long times. Systems radiation biology is increasingly gaining ground, but the gap between reductionist and holistic approaches is becoming larger. This paper presents considerations on what roles track structure and microdosimetry can have in the attempt to fill this gap, and on how they can be further exploited to interpret radiobiological data and inform systemic approaches.

Flavored olive oils: focus on their acceptability and thermal stability

The presence of flavored olive oils (FOO) on the market represents an answer to an increasing consumer demand for novel and healthy food. This work aims to compare the sensory acceptability and the thermal stability of FOO prepared by mixing different flavors (lemon, onion, garlic, paprika) to an extra virgin olive oil (EVOO) also used as the control sample. 96 Tunisian citizens were involved in a consumer test and the lemon flavored oil was the most liked whereas the least liked was the oil with onion. Samples were subjected to different heat treatments (60 °C, 100 °C, 200 °C for 1, 2, 4, 8 hours) and the flavor addition did not influence the EVOO stability when samples were heated at 60 °C, whereas at 200 °C the FOO with onion and garlic showed higher oxidative stability. The thermo-oxidation process at 60 °C and at 100 °C of the FOOs was not detrimental for the volatile compound markers but the effect was noticeable for all these markers at 200 °C.

Peri-lead edema after deep brain stimulation surgery for Parkinson's disease: a prospective magnetic resonance imaging study

BACKGROUND AND PURPOSE

The aim of this study was to define the prevalence and characteristics of peri-electrode edema in a prospective cohort of patients undergoing deep brain stimulation (DBS) surgery and to correlate it with clinical findings.

METHODS

We performed brain magnetic resonance imaging (MRI) between 7 and 20 days after surgery in 19 consecutive patients undergoing DBS surgery for Parkinson's disease. The T2-weighted hyperintensity surrounding DBS leads was characterized and quantified. Any evidence of bleeding around the leads was also evaluated. Clinical and follow-up data were recorded. In a subgroup of patients, a follow-up MRI was performed 3-6 weeks after surgery. We also retrospectively reviewed the post-operative computed tomography scans of patients who underwent DBS at our center since 2013.

RESULTS

Magnetic resonance imaging showed a peri-lead edematous reaction in all (100%) patients, which was unilateral in three patients (15.8%). In six patients (31.6%), we detected minor peri-lead hemorrhage. Edema completely resolved in eight out of 11 patients with a follow-up MRI and was markedly reduced in the others. Most patients were asymptomatic but six (31.6%) manifested various degrees of confusional state without motor symptoms. We found no significant correlation between edema volume, distribution and any clinical feature, including new post-operative neurological symptoms. The retrospective computed tomography analysis showed that peri-electrode hypodensity consistent with edema is absent at early post-operative imaging but is common at scans performed >3 days after surgery.

CONCLUSIONS

Peri-electrode edema is a common, transient reaction to DBS lead placement and a convincing relation between edema and post-operative clinical status is lacking.

A New Standard DNA Damage (SDD) Data Format

Our understanding of radiation-induced cellular damage has greatly improved over the past few decades. Despite this progress, there are still many obstacles to fully understand how radiation interacts with biologically relevant cellular components, such as DNA, to cause observable end points such as cell killing. Damage in DNA is identified as a major route of cell killing. One hurdle when modeling biological effects is the difficulty in directly comparing results generated by members of different research groups. Multiple Monte Carlo codes have been developed to simulate damage induction at the DNA scale, while at the same time various groups have developed models that describe DNA repair processes with varying levels of detail. These repair models are intrinsically linked to the damage model employed in their development, making it difficult to disentangle systematic effects in either part of the modeling chain. These modeling chains typically consist of track-structure Monte Carlo simulations of the physical interactions creating direct damages to DNA, followed by simulations of the production and initial reactions of chemical species causing so-called "indirect" damages. After the induction of DNA damage, DNA repair models combine the simulated damage patterns with biological models to determine the biological consequences of the damage. To date, the effect of the environment, such as molecular oxygen (normoxic vs. hypoxic), has been poorly considered. We propose a new standard DNA damage (SDD) data format to unify the interface between the simulation of damage induction in DNA and the biological modeling of DNA repair processes, and introduce the effect of the environment (molecular oxygen or other compounds) as a flexible parameter. Such a standard greatly facilitates inter-model comparisons, providing an ideal environment to tease out model assumptions and identify persistent, underlying mechanisms. Through inter-model comparisons, this unified standard has the potential to greatly advance our understanding of the underlying mechanisms of radiation-induced DNA damage and the resulting observable biological effects when radiation parameters and/or environmental conditions change.

Neurophysiology of the pelvic floor in clinical practice: a systematic literature review

Neurophysiological testing of the pelvic floor is recognized as an essential tool to identify pathophysiological mechanisms of pelvic floor disorders, support clinical diagnosis, and aid in therapeutic decisions. Nevertheless, the diagnostic value of these tests in specific neurological diseases of the pelvic floor is not completely clarified. Seeking to fill this gap, the members of the Neurophysiology of the Pelvic Floor Study Group of the Italian Clinical Neurophysiology Society performed a systematic review of the literature to gather available evidence for and against the utility of neurophysiological tests. Our findings confirm the utility of some tests in specific clinical conditions [e.g. concentric needle electromyography, evaluation of sacral reflexes and of pudendal somatosensory evoked potentials (pSEPs) in cauda equina and conus medullaris lesions, and evaluation of pSEPs and perineal sympathetic skin response in spinal cord lesions], and support their use in clinical practice. Other tests, particularly those not currently supported by high-level evidence, when employed in individual patients, should be evaluated in the overall clinical context, or otherwise used for research purposes.

A water-filled garment to protect astronauts during interplanetary missions tested on board the ISS

As manned spaceflights beyond low Earth orbit are in the agenda of Space Agencies, the concerns related to space radiation exposure of the crew are still without conclusive solutions. The risk of long-term detrimental health effects needs to be kept below acceptable limits, and emergency countermeasures must be planned to avoid the short-term consequences of exposure to high particle fluxes during hardly predictable solar events. Space habitat shielding cannot be the ultimate solution: the increasing complexity of future missions will require astronauts to protect themselves in low-shielded areas, e.g. during emergency operations. Personal radiation shielding is promising, particularly if using available resources for multi-functional shielding devices. In this work we report on all steps from the conception, design, manufacturing, to the final test on board the International Space Station (ISS) of the first prototype of a water-filled garment for emergency radiation shielding against solar particle events. The garment has a good shielding potential and comfort level. On-board water is used for filling and then recycled without waste. The successful outcome of this experiment represents an important breakthrough in space radiation shielding, opening to the development of similarly conceived devices and their use in interplanetary missions as the one to Mars.

AT THE PHYSICS-BIOLOGY INTERFACE: THE NEUTRON AFFAIR

We present predictions of neutron relative biological effectiveness (RBE) for cell irradiations with neutron beams at PTB-Braunschweig. A neutron RBE model is adopted to evaluate initial DNA damage induction given the neutron-induced charged particle field. RBE values are predicted for cell exposures to quasi-monoenergetic beams (0.56 MeV, 1.2 MeV) and to a broad energy distribution neutron field with dose-averaged energy of 5.75 MeV. Results are compared to what obtained with our RBE predictions for neutrons at similar energies, when a 30-cm sphere is irradiated in an isotropic neutron field. RBE values for experimental conditions are higher for the lowest neutron energies, because, as expected, target geometry determines the weight of the low-effectiveness photon component of the neutron dose. These results highlight the importance of characterizing neutron fields in terms of physical interactions, to fully understand neutron-induced biological effects, contributing to risk estimation and to the improvement of radiation protection standards.

Perioperative benefit and outcome of thoracic epidural in esophageal surgery: a clinical review

Surgery for esophageal cancer is a highly stressful and painful procedure, and a significant amount of analgesics may be required to eliminate perioperative pain and blunt the stress response to surgery. Proper management of postoperative pain has invariably been shown to reduce the incidence of postoperative complications and accelerate recovery. Neuraxial analgesic techniques after major thoracic and upper abdominal surgery have long been established to reduce respiratory, cardiovascular, metabolic, inflammatory, and neurohormonal complications.The aim of this review is to evaluate and discuss the relevant clinical benefits and outcome, as well as the possibilities and limits of thoracic epidural anesthesia/analgesia (TEA) in the setting of esophageal resections. A comprehensive search of original articles was conducted investigating relevant literature on MEDLINE, Cochrane reviews, Google Scholar, PubMed, and EMBASE from 1985 to July2017. The relationship between TEA and important endpoints such as the quality of postoperative pain control, postoperative respiratory complications, surgical stress-induced immunosuppression, the overall postoperative morbidity, length of hospital stay, and major outcomes has been explored and reported. TEA has proven to enable patients to mobilize faster, cooperate comfortably with respiratory physiotherapists and achieve satisfactory postoperative lung functions more rapidly. The superior analgesia provided by thoracic epidurals compared to that from parenteral opioids may decrease the incidence of ineffective cough, atelectasis and pulmonary infections, while the associated sympathetic block has been shown to enhance bowel blood flow, prevent reductions in gastric conduit perfusion, and reduce the duration of ileus. Epidural anesthesia/analgesia is still commonly used for major 'open' esophageal surgery, and the recognized advantages in this setting are soundly established, in particular as regards the early recovery from anesthesia, the quality of postoperative pain control, and the significantly shorter duration of postoperative mechanical ventilation. However, this technique requires specific technical skills for an optimal conduction and is not devoid of risks, complications, and failures.

Dynamics of a broad-band quantum cascade laser: from chaos to coherent dynamics and mode-locking

The dynamics of a multimode quantum cascade laser, are studied in a model based on effective semiconductor Maxwell-Bloch equations, encompassing key features for the radiation-medium interaction such as an asymmetric frequency dependent gain and refractive index as well as the phase-amplitude coupling provided by the linewidth enhancement factor. By considering its role and that of the free spectral range, we find the conditions in which the traveling wave emitted by the laser at the threshold can be destabilized by adjacent modes, thus leading the laser emission towards chaotic or regular multimode dynamics. In the latter case our simulations show that the field oscillations are associated to self-confined structures which travel along the laser cavity, bridging mode-locking and solitary wave propagation. In addition, we show how a RF modulation of the bias current leads to active mode-locking yielding high-contrast, picosecond pulses. Our results compare well with recent experiments on broad-band THz-QCLs and may help in the understanding of the conditions for the generation of ultrashort pulses and comb operation in mid-IR and THz spectral regions.

Exploring innovative radiation shielding approaches in space: A material and design study for a wearable radiation protection spacesuit

We present a design study for a wearable radiation-shielding spacesuit, designed to protect astronauts' most radiosensitive organs. The suit could be used in an emergency, to perform necessary interventions outside a radiation shelter in the space habitat in case of a Solar Proton Event (SPE). A wearable shielding system of the kind we propose has the potential to prevent the onset of acute radiation effects in this scenario. In this work, selection of materials for the spacesuit elements is performed based on the results of dedicated GRAS/Geant4 1-dimensional Monte Carlo simulations, and after a trade-off analysis between shielding performance and availability of resources in the space habitat. Water is the first choice material, but also organic compounds compatible with a human space habitat are considered (such as fatty acids, gels and liquid organic wastes). Different designs and material combinations are proposed for the spacesuits. To quantify shielding performance we use GRAS/Geant4 simulations of an anthropomorphic phantom in an average SPE environment, with and without the spacesuit, and we compare results for the dose to Blood Forming Organs (BFO) in Gy-Eq, i.e. physical absorbed dose multiplied by the proton Relative Biological Effectiveness (RBE) for non-cancer effects. In case of SPE occurrence for Intra-Vehicular Activities (IVA) outside a radiation shelter, dose reductions to BFO in the range of 44-57% are demonstrated to be achievable with the spacesuit designs made only of water elements, or of multi-layer protection elements (with a thin layer of a high density material covering the water filled volume). Suit elements have a thickness in the range 2-6 cm and the total mass for the garment sums up to 35-43 kg depending on model and material combination. Dose reduction is converted into time gain, i.e. the increase of time interval between the occurrence of a SPE and the moment the dose limit to the BFO for acute effects is reached. Wearing a radiation shielding spacesuit of the kind we propose, the astronaut could have up to more than the double the time (e.g. almost 6 instead of 2.5 h) to perform necessary interventions outside a radiation shelter during a SPE, his/her exposure remaining within dose limits. An indicative mass saving thanks to the shielding provided by the suits is also derived, calculating the amount of mass needed in addition to the 1.5 cm thick Al module considered for the IVA scenario to provide the same additional shielding given by the spacesuit. For an average 50% dose reduction to BFO this is equal to about 2.5 tons of Al. Overall, our results offer a proof-of-principle validation of a complementary personal shielding strategy in emergency situations in case of a SPE event. Such results pave the way for the design and realization of a prototype of a water-filled garment to be tested on board the International Space Station for wearability. A successful outcome will possibly lead to the further refining of the design of radiation protection spacesuits and their possible adoption in future long-duration manned missions in deep space.

Comprehensive track-structure based evaluation of DNA damage by light ions from radiotherapy-relevant energies down to stopping

Track structures and resulting DNA damage in human cells have been simulated for hydrogen, helium, carbon, nitrogen, oxygen and neon ions with 0.25–256 MeV/u energy. The needed ion interaction cross sections have been scaled from those of hydrogen; Barkas scaling formula has been refined, extending its applicability down to about 10 keV/u, and validated against established stopping power data. Linear energy transfer (LET) has been scored from energy deposits in a cell nucleus; for very low-energy ions, it has been defined locally within thin slabs. The simulations show that protons and helium ions induce more DNA damage than heavier ions do at the same LET. With increasing LET, less DNA strand breaks are formed per unit dose, but due to their clustering the yields of double-strand breaks (DSB) increase, up to saturation around 300 keV/μm. Also individual DSB tend to cluster; DSB clusters peak around 500 keV/μm, while DSB multiplicities per cluster steadily increase with LET. Remarkably similar to patterns known from cell survival studies, LET-dependencies with pronounced maxima around 100–200 keV/μm occur on nanometre scale for sites that contain one or more DSB, and on micrometre scale for megabasepair-sized DNA fragments.

The origin of neutron biological effectiveness as a function of energy

The understanding of the impact of radiation quality in early and late responses of biological targets to ionizing radiation exposure necessarily grounds on the results of mechanistic studies starting from physical interactions. This is particularly true when, already at the physical stage, the radiation field is mixed, as it is the case for neutron exposure. Neutron Relative Biological Effectiveness (RBE) is energy dependent, maximal for energies ~1 MeV, varying significantly among different experiments. The aim of this work is to shed light on neutron biological effectiveness as a function of field characteristics, with a comprehensive modeling approach: this brings together transport calculations of neutrons through matter (with the code PHITS) and the predictive power of the biophysical track structure code PARTRAC in terms of DNA damage evaluation. Two different energy dependent neutron RBE models are proposed: the first is phenomenological and based only on the characterization of linear energy transfer on a microscopic scale; the second is purely ab-initio and based on the induction of complex DNA damage. Results for the two models are compared and found in good qualitative agreement with current standards for radiation protection factors, which are agreed upon on the basis of RBE data.

Pain control after liver transplantation surgery

BACKGROUND

Although post-liver transplantation pain is not as severe as expected from the size of the surgical incision, optimal pain control becomes crucial to aid compliance with the ventilator, improve respiratory function, and facilitate an early weaning from mechanical ventilation.

METHODS

Because the majority of analgesics are primarily metabolized and excreted by the hepatobiliary system, a poor recovery of graft function will result in a decrease in clearance and reduced elimination of the drug. On the other hand, if the liver is working well, the metabolism of analgesics improves significantly with minimal accumulation. Morphine-based analgesia has been associated with a higher risk of sedation and respiratory depression compared with major abdominal surgical procedures. Fentanyl and sufentanil in continuous intravenous infusion may be preferred in the presence of hemodynamic instability or bronchospasm. Sufentanil produces shorter-lasting respiratory depression and long-lasting analgesia than does fentanyl.

RESULTS

The provision of potent continuous analgesia, independent of the duration of infusion, and the unique pharmacokinetics, not significantly affected by the functional status of the graft, make remifentanil appropriate for the majority of liver-transplanted patients. Unlike for patients with very severe pain after major abdominal surgery, liver transplant recipients usually benefit from tramadol, either in repeated intravenous boluses or continuous intravenous infusion. Paracetamol has been included as adjuvant (or sole agent, rarely) in the analgesic treatment of mild to moderate postoperative pain. The combination treatment (paracetamol plus tramadol) is a reasonable, safe option with improved analgesia and concurrent reduction in the incidence of some opioid-related side effects.

CONCLUSIONS

Frequent review of the patient's response is mandatory when potent opioids are used because dose-dependent respiratory depression is a serious and potentially life-threatening adverse effect. The benefits provided by epidural analgesia in this particular setting should be weighed against the risks because in the presence of markedly deranged perioperative blood clotting, the development of epidural hematoma represents a disastrous complication.

Hemodynamic profile of portopulmonary hypertension

Portopulmonary hypertension (PPHTN) refers to the development of pulmonary arterial hypertension in the setting of portal hypertension with or without chronic hepatic failure. This syndrome is characterized by marked alternations of pulmonary vascular tone and obstruction of pulmonary arterial blood flow. An increased pulmonary blood flow, which is a hallmark of the hyperdynamic circulation of cirrhotic patients, seems to be present in almost all patients who develop PPHTN. The elevations of pulmonary artery pressure (PAP) and pulmonary vascular resistance (PVR) along with the transpulmonary gradient (TPG) have been considered in diagnosing PPHTN. Only a high TPG reflects the severity of obstruction to pulmonary blood flow and differentiates an elevated PAP with concomitant elevated PVR from the situation where the increase in PAP is due only to the hyperdynamic flow and elevated volume. A considerable risk for cardiovascular death arises when PAP increases significantly; this may occur in rapidly evolving syndromes, in very advanced disease, or during a complicated liver transplantation. The distinction between PPHTN and elevated PAP in the context of a hyperdynamic state is of great importance; a PAP increase of hyperkinetic origin, as opposed to PPHTN, is apparently not associated with a high risk for adverse effects during and following liver transplantation.