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N Rolando

Publications and source records attributed to N Rolando.

At least 19 recordsLinked to original sources
PubMed2005

Monitoring surgical and medical outcomes: the Bernoulli cumulative SUM chart. A novel application to assess clinical interventions.

BACKGROUND: Monitoring clinical interventions is an increasing requirement in current clinical practice. The standard CUSUM (cumulative sum) charts are used for this purpose. However, they are difficult to use in terms of identifying the point at which outcomes begin to be outside recommended limits. OBJECTIVE: To assess the Bernoulli CUSUM chart that permits not only a 100% inspection rate, but also the setting of average expected outcomes, maximum deviations from these, and false positive rates for the alarm signal to trigger. METHODS: As a working example this study used 674 consecutive first liver transplant recipients. The expected one year mortality set at 24% from the European Liver Transplant Registry average. A standard CUSUM was compared with Bernoulli CUSUM: the control value mortality was therefore 24%, maximum accepted mortality 30%, and average number of observations to signal was 500-that is, likelihood of false positive alarm was 1:500. RESULTS: The standard CUSUM showed an initial descending curve (nadir at patient 215) then progressively ascended indicating better performance. The Bernoulli CUSUM gave three alarm signals initially, with easily recognised breaks in the curve. There were no alarms signals after patient 143 indicating satisfactory performance within the criteria set. CONCLUSIONS: The Bernoulli CUSUM is more easily interpretable graphically and is more suitable for monitoring outcomes than the standard CUSUM chart. It only requires three parameters to be set to monitor any clinical. INTERVENTION: the average expected outcome, the maximum deviation from this, and the rate of false positive alarm triggers.

Adult↗
PubMed2005

Endoscopic biliary stenting facilitates safe and early removal of T-tube in liver transplant patients.

AIM: Duct to duct anastomosis in orthotopic liver transplant (OLT) patients have been traditionally performed with a t-tube in place for 3 to 6 months. Following removal of the t-tube a high incidence of biliary leakage has been reported. METHODS: Prospective study to evaluate the role of endoscopic biliary stenting to facilitate early and uncomplicated t-tube removal. All patients with duct to duct biliary anastomosis who had a t-tube in situ, from January 1998 to December 2002 were included in this study. RESULTS: There were 29 patients eligible for the study. Eight patients were not included due to early death. A protocol t-tube cholangiogram was performed in all patients, (median 12 days; range 4-47 days) followed by an endoscopic stent insertion (median 37 days; range 20-55 days). The stent was removed later (median 84 days; range 45-133 days). All complications related to the procedure were noted. Stent insertion was successful in all cases. In 2 patients a second endoscopic retrograde cholangiopancreatography (ERCP) was necessary, either because of failure to cannulate the papilla or to reposition the stent. There was a patient who presented a biliary leak due to stent displacement requiring a laparotomy. There were two further biliary leaks, one of them in an asymptomatic patient, which were managed conservatively. In addition 1 patient developed a mild case of postERCP pancreatitis. CONCLUSIONS: In liver transplants patients with an end-to-end choledochostomy with a t-tube, endoscopic biliary stenting allows an early removal of the T tube, with few complications.

Adult↗
PubMed2003

Timing and aetiology of bacterial infections in a liver intensive care unit.

We undertook a prospective study of 887 consecutive adult patients admitted over an 11 year period to a liver intensive care unit. One or more bacterial infections occurred in 335 (37.8%) patients. Gram-positive cocci predominated. In relation to the date of admission these infections occurred in a statistically significant sequence. Streptococci infections were earliest (median time to infection two days), followed by Staphylococcus aureus (three days), coagulase-negative staphylococci (six days) and enterococci (eight days). Escherichia coli infections occurred earlier than those due to klebsiella-enterobacter (two vs seven days; P = 0.0001) and, overall, Enterobacteriaceae earlier than non-fermentative Gram-negatives (four vs. eight days; P = 0.0081). This study contributes to the management of high-dependency patients by confirming statistically the timing and sequence of infecting bacteria in patients with acute liver failure.

Adult↗
PubMed2000

The systemic inflammatory response syndrome in acute liver failure.

The systemic inflammatory response syndrome (SIRS) in acute liver failure (ALF), in which infection is common, has not been studied. In this study, SIRS components were recorded on admission and during episodes of infection, in 887 ALF patients admitted to a single center during an 11-year period. Overall, 504 (56.8%) patients manifested a SIRS during their illness, with a maximum of 1, 2, and 3 concurrent SIRS components in 166, 238, and 100 patients, respectively. In 353 (39.8%) patients who did not become infected, a SIRS on admission was associated with a more critical illness, subsequent worsening of encephalopathy, and death. Infected patients more often developed a SIRS and one of greater magnitude. The magnitude of the SIRS in 273 patients with bacterial infection correlated with mortality, being 16.7%, 28.4%, 41.2%, and 64.7% in patients with 0, 1, 2, and 3 maximum concurrent SIRS components, respectively. Similar correlations with mortality were seen for SIRS associated with fungal infection, bacteremia, and bacterial chest infection. Fifty-nine percent of patients with severe sepsis died, as did 98% of those with septic shock. A significant association was found between progressive encephalopathy and infection. Infected patients with progressive encephalopathy manifested more SIRS components than other infected patients. For patients with a SIRS, the proportions of infected and noninfected patients manifesting worsening encephalopathy were similar. In ALF, the SIRS, whether or not precipitated by infection, appears to be implicated in the progression of encephalopathy, reducing the chances of transplantation and conferring a poorer prognosis.

Acetaminophen↗
PubMed2000

Granulocyte colony-stimulating factor improves function of neutrophils from patients with acute liver failure.

OBJECTIVE: To evaluate the in vitro effects of granulocyte colony-stimulating factor (G-CSF) on function of neutrophils in acute liver failure (ALF). METHODS: Neutrophil functions (superoxide and hydrogen peroxide production; phagocytosis and killing; complement receptor expression) were determined simultaneously in 23 patients with ALF due to paracetamol overdose and compared with 23 healthy control subjects. RESULTS: Phagocytosis was reduced in neutrophils from ALF patients compared to controls (P< 0.005) and was significantly increased by incubation with 1,000 or 5,000 IU/ ml G-CSF (P< 0.05). This correlated with increased expression of CD11b (r= 0.93) and CD18 (r= 0.98) after incubation with 5,000 IU/ml G-CSF (P< 0.05). Killing was reduced in ALF neutrophils compared to controls (P< 0.005) and was similarly restored by G-CSF (P< 0.005). An increase in killing correlated with increases in production of superoxide (r = 0.96) and hydrogen peroxide (r= 0.97) by ALF neutrophils after incubation with 1,000 and 5,000 IU/ml of G-CSF when formylmethionylleucylphenylalanine (fMLP) was the stimulant. G-CSF at 5,000 IU/ml increased the production of hydrogen peroxide (P< 0.01) when zymosan was the stimulant. CONCLUSIONS: G-CSF improves the neutrophil dysfunction of ALF.

Adolescent↗
PubMed2000

Administering granulocyte colony-stimulating factor to acute liver failure patients corrects neutrophil defects.

OBJECTIVES: Neutrophil function is defective in acute liver failure (ALF) and the in vitro ability of granulocyte colony-stimulating factor (G-CSF) to reverse these defects has been reported. The effects of administering G-CSF to ALF patients are presented in this study. DESIGN: This was a prospective, phase I/II, open label, study. SETTING: The liver intensive therapy unit at King's College Hospital, London. PARTICIPANTS: Sequential patients admitted with acute liver failure due to acetaminophen overdose. INTERVENTIONS: G-CSF was given to four groups (each n = 6) of ALF patients as a daily infusion at 25, 50, 100 or 150 microg/m2. A control group of eight patients did not receive G-CSF. MAIN OUTCOME MEASURES: Neutrophil phagocytosis and killing of Staphylococcus aureus and superoxide release before G-CSF administration and at 24 and 96 h thereafter. RESULTS: Neutrophils from patients receiving 50, 100 or 150 microg/m2 G-CSF, but not from control patients or those receiving 25 microg/m2, showed significantly increased phagocytosis and killing at 96 h. Doses of 50 or 150 microg/m2 G-CSF resulted in increased superoxide production at 96 h. No patients discontinued treatment as a consequence of side effects related to G-CSF administration. CONCLUSIONS: G-CSF administration is a safe and effective means of reversing the neutrophil defects of ALF, and may have a role in the prevention and treatment of infection in these patients. A dose of 50 microg/m2/day is as effective as higher doses and was associated with fewer side effects.

Adolescent↗
PubMed1998

The significance of aerobic gram-negative bacilli in clinical specimens following orthotopic liver transplantation.

In a prospective study of 284 liver transplant patients, we sought associations between aerobic gram-negative bacillus acquisition or infection and 35 preoperative, perioperative, and postoperative variables. Although the 128 (45%) who acquired aerobic gram-negative bacilli had longer admissions (P = 0.0001), no associations were found with pretransplant variables. Fifty-three (41%) of the 128 acquired coliforms (e.g., Escherichia coli, Klebsiella spp., or Enterobacter spp.), 50 (39%) acquired nonfermentative bacilli (e.g., Acinetobacter spp., Pseudomonas spp., or Stenotrophomonas maltophilia), and a further 25 (20%) acquired both. Acquisition progressed to infection in 58% of patients who acquired coliforms but in only 18% of patients who acquired nonfermentative bacilli (P = 0.005). Acinetobacter spp. were isolated from more patients than other bacilli but rarely caused infection. The positive predictive values for infection of acquiring coliforms or nonfermentative bacilli in clinical material were 42% and 17%, respectively. This study allowed us to determine for each clinical site the positive predictive values for infection of acquisition of different aerobic gram-negative bacilli. Our results should contribute to the rationalization of antimicrobial prescribing for this patient group.

Adolescent↗
PubMed1997

Clinical characteristics affecting the outcome of liver retransplantation.

BACKGROUND: The outcome of retransplantation remains unsatisfactory when compared with primary transplantation of the liver. The aim of the present study was to determine which preoperative clinical and laboratory risk variables are implicated in the poorer outcome. METHODS: The preoperative status of 70 retransplanted patients was compared with a group of 303 time-matched recipients receiving their first graft. RESULTS: Survival at 1 year was reduced in the retransplant versus the primary transplant group (50% vs. 80%, P<0.001). Preoperatively older age, high United Network of Organ Sharing score, inpatient status, elevated bilirubin, and creatinine levels were associated with increased mortality after a second transplant. Preoperatively, the retransplant group had higher encephalopathy grades, were more likely to be inpatients, and had higher serum creatinine, bilirubin, and white cell levels than the primary recipients (P<0.05 in all cases). The median length of inpatient stay was longer after the second transplant (25 vs. 19 days, P<0.001). CONCLUSIONS: These factors assist in the stratification of patients awaiting retransplantation; however, the outcome of this procedure is only likely to be improved with an earlier identification of the patients who require it, along with an increased priority in organ allocation.

Adolescent↗
PubMed1997

Randomised placebo-controlled trial of granulocyte-colony stimulating factor in diabetic foot infection.

BACKGROUND: Diabetic foot infections cause substantial morbidity and mortality. Neutrophil superoxide generation, a crucial part of neutrophil bactericidal activity, is impaired in diabetes. Granulocyte-colony stimulating factor (G-CSF) increases the release of neutrophils from the bone marrow and improves neutrophil function. We assessed G-CSF as adjuvant therapy for the treatment of severe foot infections in diabetic patients. METHODS: 40 diabetic patients with foot infections were enrolled in a double-blind placebo-controlled study. On admission, patients were randomly assigned G-CSF (filgrastim) therapy (n = 20) or placebo (n = 20) for 7 days. Both groups received similar antibiotic and insulin treatment. Neutrophils from the peripheral blood of these participants and from healthy controls were stimulated with opsonised zymosan, and superoxide production was measured by a spectrophotometric assay (reduction of ferricytochrome C). FINDINGS: G-CSF therapy was associated with earlier eradication of pathogens from the infected ulcer (median 4 [range 2-10] vs 8 [2-79] days in the placebo group; p = 0.02), quicker resolution of cellulitis (7 [5-20] vs 12 [5-93] days; p = 0.03), shorter hospital stay (10 [7-31] vs 17.5 [9-100] days; p = 0.02), and a shorter duration of intravenous antibiotic treatment (8.5 [5-30] vs 14.5 [8-63] days; p = 0.02). No G-CSF-treated patient needed surgery, whereas two placebo recipients underwent to amputation and two had extensive debridement under anaesthesia. After 7 days' treatment, neutrophil superoxide production was significantly higher in the G-CSF group than in the placebo group (16.1 [4.2-24.2] vs 7.3 [2.1-11.5] nmol per 10(6) neutrophils in 30 min; p < 0.0001). G-CSF therapy was generally well tolerated. INTERPRETATION: G-CSF treatment was associated with improved clinical outcome of foot infection in diabetic patients. This improvement may be related to an increase in neutrophil superoxide production.

Aged↗
PubMed1997

Urinary tract infections in primary biliary cirrhosis and other chronic liver diseases.

In a study to determine the prevalence of urinary tract infections (UTI) in primary biliary cirrhosis, midstream specimens of urine from 97 females with primary biliary cirrhosis and 85 females with other chronic liver diseases were investigated prospectively for urinary pathogens and Mycobacterium gordonae. No significant differences between primary biliary cirrhosis and the two groups were observed in the prevalence of significant bacteriuria (11.3% vs. 7.1%), the prevalence of Escherichia coli UTI (9.3% vs. 7.1%) or the colony morphology of Escherichia coli. No mycobacterial species were grown from any sample. In both groups, the prevalence of UTI was higher in patients with cirrhosis (20% in both) than in those without.

Adult↗
PubMed1997

Neutrophil superoxide and hydrogen peroxide production in patients with acute liver failure.

Defects in superoxide and hydrogen peroxide production may be implicated in the high incidence of bacterial infections in patients with acute liver failure (ALF). In the present study, oxygen radical production in patients with ALF due to paracetamol overdose was compared with that of healthy volunteers. Neutrophils from 14 ALF patients were stimulated via the complement receptors using zymosan opsonized with ALF or control serum. Superoxide and hydrogen peroxide production by ALF neutrophils stimulated with zymosan opsonized with ALF serum was significantly reduced compared with the control subjects (P < 0.01). This defect persisted when zymosan opsonized by control serum was used (P < 0.05). Superoxide and hydrogen peroxide production in neutrophils stimulated with formyl-methionyl-leucyl-phenylalanine (fMLP) from a further 18 ALF patients was unaffected compared with control neutrophils. Serum C3 complement levels were significantly reduced in ALF patients compared with control subjects (P < 0.0005). These results demonstrate a neutrophil defect in ALF due to paracetamol overdose, that is complement dependent but independent of serum complement, possibly connected to the complement receptor.

Acetaminophen↗
PubMed1996

Prospective study comparing the efficacy of prophylactic parenteral antimicrobials, with or without enteral decontamination, in patients with acute liver failure.

The efficacy of prophylactic parenteral antibacterials, with or without selective decontamination of the digestive tract, was compared in patients with acute liver failure (ALF) or severe acetaminophen hepatotoxicity. One hundred eight patients were randomized on admission to receive intravenous ceftazidime and flucloxacillin, plus either oral and enteral decontamination with colistin, tobramycin, and amphotericin B (group 1), or enteral amphotericin B alone (group 2). The two groups were comparable with respect to age, gender, etiology, coma grade on admission, international normalization ratio, presence of renal failure, Acute Physiology and Chronic Health Evaluation II score, and indicators of poor prognosis. Patients were monitored for clinical and microbiological evidence of infection. There were 15 episodes of infection in 10 of 47 patients (21%) in group 1 and 17 episodes in 12 of 61 patients (20%) in group 2. No differences in incidence, site, and causative organisms of infection were observed between the two groups. Overall, the incidence of infection was significantly higher in patients who developed encephalopathy than in those who did not. In patients who on arrival were not encephalopathic, the development of infection was associated with progression to coma. Duration of Liver Intensive Care Unit (LICU) stay was an independent risk factor for the development of infection. Parenteral antibiotics are effective at reducing the risk of infection in patients with ALF; enteral decontamination provided no additional benefit.

Adolescent↗
PubMed1996

Bacterial and fungal infection in acute liver failure.

Patients with acute liver failure (ALF) have increased susceptibility to infections, principally as a result of impaired phagocytic function, reduced complement levels, and the need for invasive procedures. Bacteriologically proven infection is recorded in up to 80% of these patients and fungal infection (predominantly candidiasis) in 32%. Clinical signs such as high temperature and high WBC are absent in 30% of the cases. Pneumonia accounts for 50% of infective episodes, and bacteremia and urinary tract infection a further 20 to 25% each, at a median 5, 3, and 2 days, respectively, after the onset of ALF. Selective parenteral and enteral antisepsis regimens (SPEAR) were evaluated in prospective controlled studies, but early systemic antibiotics alone are as effective as SPEAR. With early antibiotics, the incidence of infective episodes is reduced to 20% and the overall mortality to 44%, with a reduction in progression to encephalopathy and an increased opportunity for transplantation.

Bacterial Infections↗
PubMed1995

IgG donor-specific crossmatches are not associated with graft rejection or poor graft survival after liver transplantation. An assessment by cytotoxicity and flow cytometry.

Early studies in liver transplantation suggested that there was no association between graft outcome or rejection and the presence of alloantibodies before transplantation. More recent reports have suggested lower graft survival rates and a higher incidence of chronic rejection in patients with IgG warm-T crossmatches. In the present study, panel reactive antibody, direct crossmatch testing, and flow cytometry were used to detect preformed antibodies in sera from 158 consecutive adult recipients of first hepatic grafts. The relationship between preformed antidonor antibodies and liver allograft survival and rejection was determined. Twenty-six (17%) patients were panel reactive antibody (PRA)-positive before transplantation, 22 (15%) had positive donor-specific crossmatches, and 14 (9%) were positive by IgG-specific flow cytometry. Cumulative survival distribution and multivariate analysis failed to reveal any significant associations between overall graft survival and antibody status. Graft survival in patients with PRA-positive sera was 81% compared with 77% for those with PRA-negative sera, 68% for those with positive donor-specific crossmatches compared with 80% for those who were donor-specific crossmatch negative, and 79% for those who were antibody positive by flow cytometric analysis compared with 78% for those who were antibody negative. Subgroup analysis also failed to reveal any significant associations. In addition, Cox proportional hazards regression analysis failed to reveal a relationship between acute or chronic graft rejection with the presence or absence of preformed antibodies, irrespective of immunoglobulin class, cell type (T or non-T), specificity, or technique used for antibody detection. In conclusion, there appears to be no association between either donor-specific or "third-party" alloreactive IgG or IgM antibodies and liver transplant survival or rejection. These data do not indicate a need for prospective crossmatching of liver transplant recipients.

Adolescent↗
PubMed1995

Bacterial and fungal infections after liver transplantation: an analysis of 284 patients.

A prospective study of bacterial and fungal infections after liver transplantation in 284 adults was undertaken. One hundred seventy-five (62%) became infected; bacterial or fungal infections occurred in 159 (56%) and 36 (13%) patients, respectively. Gram-positive cocci, in particular Staphylococcus aureus and Enterococcus faecium, were the commonest bacterial pathogens, and bacteremia and wound infection were the most frequent bacterial infections. Acute rejection and prolonged admission were independent risk factors for bacterial infection; pretransplantation antibacterials had a protective effect. Fungal infection most frequently involved the urinary tract and chest; Candida albicans was the most common pathogen. Four independent variables predicted fungal infection: low pretransplantation hemoglobin, high pretransplantation bilirubin, return to surgery, and prolonged therapy with ciprofloxacin. Patients with acute liver failure were more prone to bacterial, but not fungal, infection. No associations were found between infections and duration of surgery. Bacterial, and to a lesser extent, fungal infections are important complications of liver transplantation. However, liver transplantation surgery per se may not be the major determinant of infection.

Abscess↗
PubMed1995

Serious infections caused by multiply-resistant Enterococcus faecium.

Three liver transplant patients developed serious intraabdominal infections and recurrent bacteremias due to strains of Enterococcus faecium with high-level resistance to vancomycin. The enterococci were also resistant to all other antibacterials except pristinamycin, which, given orally, proved ineffective. One strain was sensitive to tetracycline. Increasingly, clinicians are likely to encounter infections caused by multiply-resistant enterococci, and these cases illustrate the seriousness of such infections in compromised patients.

Abdomen↗