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These guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of post-operative surgical site infections (SSIs) in solid organ transplantation. SSIs are a significant cause of morbidity and mortality in SOT recipients. Depending on the organ transplanted, SSIs occur in 3%-53% of patients, with the highest rates observed in small bowel/multivisceral, liver, and pancreas transplant recipients. These infections are classified by increasing invasiveness as superficial incisional, deep incisional, or organ/space SSIs. The spectrum of organisms implicated in SSIs in SOT recipients is more diverse than the general population due to other important factors such as the underlying end-stage organ failure, immunosuppression, prolonged hospitalizations, organ transportation/preservation, and previous exposures to antibiotics in donors and recipients that could predispose to infections with multidrug-resistant organisms. In this guideline, we describe the epidemiology, clinical presentation, differential diagnosis, potential pathogens, and management. We also provide recommendations for the selection, dosing, and duration of peri-operative antibiotic prophylaxis to minimize post-operative SSIs.

The aim of this study was to assess a model for the surface degradation kinetics of natural wood exposed to artificial weathering. The photochemical and physical processes of weathering result in simultaneous changes of both the wood matrix composition (i.e. lignin content, cellulose crystallinity index, cellulose polymerization degree) and wood’s appearance (i.e. colour, gloss, roughness). European larch, a popular cladding material, was used for experimental samples. Weathering was conducted in a QUV artificial weathering machine for 672 h according to the EN927-6 standard. The response of wood was assessed using multi-sensor measurements. Results revealed that changes in colour are evident already after 28 h of artificial weathering, with an increase in a*and b*, and a decrease in L*. That initial trend was reversed afterward, with the colour changing to grey. Due to the particular shape of the curves representing colour coordinates, it is difficult to use CIE L*a*b*parameters to model the weathering dose. However, the degradation curve established for selected near infrared bands was useful to build a dose–response model of wood surface degradation. In all cases, a clear trend of change in absorbance values that progressed along with the weathering dose was observed. These curves, unlike the CIE L*a*b* values, are monotonic, meaning that dose value corresponded with only one value of absorbance. Principal component analysis of the near infrared spectra allowed clustering of the spectra by different dose classes, with the main differentiation in the reference class and in the final class (maximum dose). It was found that the discrimination between spectra at diverse cumulative weathering doses was more evident for earlywood than for latewood. This confirms the hypothesis that degradation kinetics differ depending on the anatomical configuration of wood. This research is a first step for establishing dose–response model for natural weathering, where precise quantification of weathering parameters is more challenging.

Objectives A prospective cohort study was conducted in Italy in order to describe the microbiologic aspects of colonization/infection by carbapenemase-producing Enterobacteriaceae (CPE) in donors and recipients of lung and liver transplants and the possible CPE transmission from donors to recipients. Methods Between 15 January 2014 and 14 January 2015, all recipients of solid organ transplants (SOT) at ten lung and eight liver transplantation centres and the corresponding donors were enrolled. Screening cultures to detect CPE were performed in donors, and screening and clinical cultures in recipients with a 28-day microbiologic follow-up after receipt of SOT. Detection of carbapenemase genes by PCR, genotyping by multilocus sequence typing, and pulsed-field gel electrophoresis and whole-genome sequencing were performed. Results Of 588 screened donors, 3.4% were colonized with CPE. Of the liver first transplant recipients (n = 521), 2.5% were colonized before receipt of SOT and 5% acquired CPE during follow-up. CPE colonization was higher in lung first transplant recipients (n = 111, 2.7% before SOT and 14.4% after SOT). CPE infections occurred in 1.9% and 5.3% of liver or lung recipients, respectively. CPE isolates were mostly Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae belonging to CG258. Three events of donor–recipient CPE transmission, confirmed by whole-genome sequencing and/or pulsed-field gel electrophoresis, occurred in lung recipients: two involving K. pneumoniae sequence type 512 and one Verona integron-encoded metallo-β-lactamase (VIM)-producing Enterobacter aerogenes. Conclusions This study showed a low risk of donor–recipient CPE transmission, indicating that donor CPE colonization does not necessarily represent a contraindication for donation unless colonization regards the organ to be transplanted. Donor and recipient screening remains essential to prevent CPE transmission and cross-infection in transplantation centres.

Cytomegalovirus (CMV) remains a major cause of morbidity and mortality in allogeneic hematopoietic stem cell transplantation (allo-HSCT) and solid organ transplantation (SOT) recipients. In view of the uncertainties on the assessment and prevention of CMV infection in both transplant procedures, three Italian scientific societies for HSCT and SOT and for Clinical Microbiology appointed a panel of experts to compose a framework of recommendations. Recommendations were derived from a comprehensive analysis of the scientific literature and from a multidisciplinary consensus conference process. The lack of adequate clinical trials focused on certain diagnostic procedures, and antiviral intervention forced the panel to use the methods of consensus for shaping some recommendations. Recommendations concerning the two types of transplant were given for the following issues: assessment of pretransplant CMV serostatus, immunological monitoring after transplant, CMV prophylaxis with antivirals, CMV preemptive strategy, and CMV prophylaxis with immunoglobulin infusion and with adoptive immunotherapy. The questions raised by and the recommendations resulting from this consensus conference project may contribute to the improvement of certain crucial aspects of the management of CMV infections in allo-HSCT and in SOT populations.

Phaeohyphomycosis is a diverse group of uncommon mycotic infections caused by dematiaceous fungi which appears to be increasing in incidence, particularly in transplant recipients. Alternaria is the most frequent isolated genus. Subcutaneous, pulmonary and disseminated disease are the most common sites of Alternaria infection in solid organ transplant recipients. We report the first case, to our knowledge, of a kidney transplant recipient with Alternaria alternata subcutaneous infection who was successfully treated with isavuconazole.

INTRODUCTION Carbapenem-resistant enterobacteriaceae (CRE) infections are difficult to treat and pose a serious threat to solid organ transplant (SOT) recipients. At our institute we observed an infection burden in 2012. METHODS In order to contain the spread of CRE infections, we established a taskforce to implement guidelines suggested by the Centers for Disease Control and Prevention (CDC) for this type of outbreak. Here, we describe the epidemiology of the outbreak in our SOT population, and the effectiveness of such interventions, by comparing levels of CRE hospital-acquired infection (HAI) pre- and post-task force intervention (from January 2009 to December 2012, and from September 2013 to December 2016, respectively) through a linear regression model. RESULTS In this study, we included 933 patients who underwent a total of 1017 SOT procedures, 286 of whom had a CRE-positive culture (28.8%), of which 65 (22.7% of CRE positive) developed infection. One-year mortality post-SOT was significantly higher in patients with CRE infection. After the taskforce intervention, the CRE HAI rate in SOT showed a significant inverse trend (event rate: -1.28, CI -1.70 to 0.86; P

Despite advances in the field of solid organ transplantation (SOT), multidrug-resistant (MDR) bacterial infections are responsible for significant morbidity and mortality worldwide. The most common MDR Gram-positive bacteria include methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE). Therapeutic options exist for both MRSA and VRE infections, and MRSA infections appear to be declining. However, infections with MDR Gram-negative bacteria, specifically with Enterobacteriaceae, Pseudomonas, and Acinetobacter, continue to pose a significant threat to SOT recipients. Increasing attention should be focused on prevention and optimal management of infections with these organisms. Although several new therapeutic options exist, the importance of source control, infection prevention, and antimicrobial stewardship should always be emphasized.

Ergot alkaloids in endophyte-infected grasses inhibit prolactin (PRL) secretion and may reduce milk production of cows consuming these grasses. We investigated the effects of consuming endophyte-infected fescue seed during late lactation and the dry period on mammary growth, differentiation, and milk production. Twenty-four multiparous Holstein cows were randomly assigned to 3 treatment groups. Starting at 90±4 d prepartum, cows were fed endophyte-free fescue seed (control; CON), endophyte-free fescue seed plus 3×/wk subcutaneous injections of bromocriptine (0.1mg/kg of body weight, positive control; BROMO), or endophyte-infected fescue seed (INF) as 10% of the diet on an as fed basis. Although milk yield of groups did not differ before treatment, at dry off (-60 d prepartum) INF and BROMO cows produced less milk than CON. Throughout the treatment period, basal concentrations of PRL and the prepartum increase in plasma PRL were reduced in INF and BROMO cows compared with CON cows. Three weeks after the end of treatment, circulating concentrations of PRL were equivalent across groups. In the subsequent lactation milk yield was not decreased; in fact, BROMO cows exhibited a 9% increase in milk yield relative to CON. Evaluation of mammary tissue during the dry period and the subsequent lactation, by quantitative histology and immunohistochemical analysis of proliferation markers and putative mammary stem or progenitor cell markers, indicated that feeding endophyte-infected fescue seed did not significantly affect mammary growth and development. Feeding endophyte-infected grasses during the dry period may permit effective utilization of feed resources without compromising milk production in the next lactation.

Shahid Husain, MD, MS, Amparo Sole, MD, PhD, Barbara D. Alexander, MD, MHS, Saima Aslam, MD, MS, Robin Avery, MD, Christian Benden, MD, Eliane M. Billaud, PharmD, PhD, Daniel Chambers, MBBS, MD, Lara Danziger-Isakov, MD, Savitri Fedson, MD, Kate Gould, MD, Aric Gregson, MD, Paolo Grossi, MD, PhD, Denis Hadjiliadis, MD, Peter Hopkins, MD, Me-Linh Luong, MD, Debbie J.E. Marriott, MD, Victor Monforte, MD, Patricia Munoz, MD, PhD, Alessandro C. Pasqualotto, MD, PhD, Antonio Roman, MD, Fernanda P. Silveira, MD, Jeffrey Teuteberg, MD, MS, Stephen Weigt, MD, Aimee K. Zaas, MD, MHS, Andreas Zuckerman, MD, and Orla Morrissey, MD, PhD

Introduction According to current estimates, there are about 540,000 patients who are infected with HIV in Western Europe, of which about 3100 are potential candidates for organ transplantation. In Italy, there are currently 85 HIV patients on the transplant list. Methods Organ transplantation activity in HIV recipients from 2002 to December 2014 was assessed from the database provided by the Transplant Center of Modena until the year 2011. For the years 2012 to 2014, data are from the Transplant Information System (SIT). The follow-up data have been extracted from the function “Quality” of the SIT. Results The transplant centers on Italian territory that meet the requirements according to national protocol are in total 29: 11 for the liver, 9 for the kidney including 1 pediatric, 3 for the heart, 3 for the lungs, and for 3 for the combined kidney–pancreas. Since 2002, 257 organ transplantations were carried out, including 185 liver, 59 kidney, 5 combined liver–kidney, 5 combined kidney–pancreas, 2 heart, and 1 double lung. The first cause of death is represented by co–hepatitis C virus infection, in particular in 26 liver recipients (37%) and in 3 kidney recipients (20%). Conclusions The analysis showed that transplantation activity in HIV is on the rise, especially in the last 2 years, with an outcome similar to that reported in the literature.

This paper describes the main outcomes of a shake table test on a full-scale light-timber framed building carried out within the framework of the SERIES project at National Laboratory of Civil Engineering (Lisbon, Portugal) in coordination with the University of Trento (Trento, Italy). The specimen was a single family house with a 7 × 5 m2 footprint and a maximum height of 7.65 m. The walls were sheathed only with gypsum-fibre boards (GFB). The seismic tests were performed by scaling a natural earthquake from 0.07 g up to 0.66 g in two different stages. In the first stage, the building was characterized by its design geometry, whereas in the latter stage, the sheathing panels of five external walls at ground level were removed in order to reduce the racking capacity of the building. Precious and interesting data were found from the experimental results to investigate the seismic capacity of light-frame buildings sheathed with GFB. A comparison between the un-weakened and weakened specimen was also performed.

The paper presents the outcome of a research on the in-plane behaviour of two different log house construction systems when subjected to lateral loading. Such systems, identified by the way the logs are joined together are: the Standard half lapped joint (ST) system and Tirolerschloss joint (TR) system. Two stages of experimental testing were carried out at the laboratory of the University of Trento. In the first stage the focus was on the corner joints and on a possible wall reinforcement system (22 monotonic and 5 cyclic tests were performed). In the second stage full-scale wall specimens were tested (5 monotonic and 5 cyclic tests). Several layouts were investigated: 4.2 m long walls with thin (TR and ST) or thick logs (ST); “short” walls (2.75 m long); walls with openings. The test results highlighted some critical aspects in the in-plane behaviour of the walls. The lateral load carrying capacity of the wall appeared to be influenced by two main phenomena: friction and corner-joint interlocking. Due to mounting tolerance a large displacement was required to fully engage the corner joint resistance. A large horizontal plateau characterized the post friction part of the load displacement curve (wide plateau) both for ultimate limit state (ULS) and serviceability limit state (SLS). The cyclic tests showed a high level of energy dissipation that was attributed to the “inter-log friction”. In order to have a better insight into such aspects, a simplified rheological/analytical model was developed by using the experimental data as input parameters. A good agreement between the model output and the experimental behaviour was obtained.

O presente texto trata-se do discurso proferido em razão da conferência inaugural do primeiro Congresso da Sociedade Espanhola de História do Direito. Seu objetivo é contextualizar e caracterizar os dois momentos distintos de florescimento jurídico na península italiana, a saber: a modernidade herdada da Revolução Francesa e a pós-modernidade do entreguerras. Para tanto, aborda essa modernidade jurídica italiana como o império do estatismo e do legalismo, período em que a burguesia pretendia controlar toda realidade social por meio do monopólio da produção jurídica e seu consequente afastamento do povo, isto é, uma busca por um Direito codificado abstrato e pretensamente claro, coerente e seguro. Em seguida, em contraste com esse absolutismo jurídico, surge o Direito pós-moderno italiano, nascente durante a 1ª Guerra Mundial e concretizado na Constituição pós-guerra de 1948, cujas peculiaridades são suas facticidade e pluralidade, ou seja, é uma arte jurídica espontânea que germina e autoorganiza-se a partir da própria sociedade em que está inserida, culminando com os direitos sociais. O discurso conclui que os direitos pós-modernos têm, cada vez mais, tornando-se valores inderrogáveis e fundamentais tanto da República quando do Estado italiano.

The paper examines the way jurists, since the glosses, until Jacques Cujas, analyzed the definition of feud within the interpretation of common law, in the light of the Oberto dell’Orto’s writings. By this perspective, this author reviews aspects of the feudary real situation as an useful domain, grounding the usufruct’s technical inadequacy to express it, as well as analyzing the fiefs’ later characterization as quasi-dominium, found mainly in legal thought of sixteenth and seventeenth centuries’ jurists O texto examina o modo como os juristas, dos glosadores a Jacques Cujas, analisaram a definição de feudo na interpretação do direito comum à luz dos escritos de Oberto dell’Orto. Nessa perspectiva, o autor revê aspectos da situação real do feudatário como domínio útil, afirmando a inadequação técnica do usufruto para expressá-la, analisa a posterior caracterização dos feudos como quase-dominium, presente, sobretudo, em alguns juristas entre os séculos XVI e XVII.

The overall goal of this work was to develop a prototype expert system assisting quality control and traceability of particleboard panels on the production floor. Four different types of particleboards manufactured at the laboratory scale and in industrial plants were evaluated. The material differed in terms of panel type, composition, and adhesive system. NIR spectroscopy was employed as a pioneer tool for the development of a two-level expert system suitable for classification and traceability of investigated samples. A portable, commercially available NIR spectrometer was used for nondestructive measurements of particleboard panels. Twenty-five batches of particleboards, each containing at least three independent replicas, was used for the original system development and assessment of its performance. Four alternative chemometric methods (PLS-DA, kNN, SIMCA, and SVM) were used for spectroscopic data classification. The models were developed for panel recognition at two levels differing in terms of their generality. In the first stage, four among twenty-four tested combinations resulted in 100% correct classification. Discrimination precision with PLS-DA and SVMC was high (>99%), even without any spectra preprocessing. SNV preprocessed spectra and SVMC algorithm were used at the second stage for panel batch classification. Panels manufactured by two producers were 100% correctly classified, industrial panels produced by different manufacturing plants were classified with 98.9% success, and the experimental panels manufactured in the laboratory were classified with 63.7% success. Implementation of NIR spectroscopy for wood-based product traceability and quality control may have a great impact due to the high versatility of the production and wide range of particleboards utilization.

Background The present review is part of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Infections in Compromised Hosts (ESGICH) Consensus Document on the safety of targeted and biologic therapies. Aims To review, from an infectious diseases perspective, the safety profile of therapies targeting different intracellular signaling pathways and to suggest preventive recommendations. Sources Computer-based Medline searches with MeSH terms pertaining to each agent or therapeutic family. Content Although BCR-ABL tyrosine kinase inhibitors modestly increase the overall risk of infection, dasatinib has been associated with cytomegalovirus and hepatitis B virus reactivation. BRAF/MEK kinase inhibitors do not significantly affect infection susceptibility. The effect of Bruton tyrosine kinase inhibitors (ibrutinib) among patients with B-cell malignancies is difficult to distinguish from that of previous immunosuppression. However, cases of Pneumocystis jirovecii pneumonia (PCP), invasive fungal infection and progressive multifocal leukoencephalopathy have been occasionally reported. Because phosphatidylinositol-3-kinase inhibitors (idelalisib) may predispose to opportunistic infections, anti-Pneumocystis prophylaxis and prevention strategies for cytomegalovirus are recommended. No increased rates of infection have been observed with venetoclax (antiapoptotic protein Bcl-2 inhibitor). Therapy with Janus kinase inhibitors markedly increases the incidence of infection. Pretreatment screening for chronic hepatitis B virus and latent tuberculosis infection must be performed, and anti-Pneumocystis prophylaxis should be considered for patients with additional risk factors. Cancer patients receiving mTOR inhibitors face an increased incidence of overall infection, especially those with additional risk factors (prior therapies or delayed wound healing). Implications Specific preventive approaches are warranted in view of the increased risk of infection associated with some of the reviewed agents.

This report summarizes the clinical features and the indications for treating HCV infection in immunocompromised and transplanted patients in the Direct Acting Antiviral drugs era.

Background Dual therapy (DT) with boosted protease inhibitors (bPIs) plus lamivudine has been shown to be superior to bPI monotherapy in virologically suppressed patients despite previous selection of the lamivudine resistance M184V mutation. We compared the virological efficacy of lamivudine-based DT in patients with and without a history of M184V detection. Methods We retrospectively analyzed patients with HIV-RNA ≤50 copies/mL switching to DT with at least 1 previous resistance genotype in the ARCA database. Time to virological failure (VF; HIV-RNA ≥200 copies/mL or 2 consecutive HIV-RNA >50 copies/mL) and to treatment discontinuation (TD) was analyzed by survival analysis. Results Four hundred thirty-six patients switching to lamivudine plus bPIs (70%) or integrase inhibitors (30%) were included. Patients with M184V (n = 87) were older, had lower nadir CD4+ cell count, longer duration of antiretroviral therapy and of virologic suppression, and higher rate of hepatitis C virus infection compared with patients without M184V. The 3-year probability of remaining free from VF was 91.9% (95% confidence interval [CI], 86.6–97.2) without M184V and 87.8% (95% CI, 78.4–97.2) with M184V (P = .323). The time to TD did not differ between groups. Multivariate analysis adjusting for baseline variables differing between groups also did not detect M184V as being associated with VF or TD; however, the 3-year probability of remaining free of viral blips (isolated HIV-RNA 51–199 copies/mL) was 79.8% (95% CI, 67.8%–91.8%) with M184V vs 90.1% (95% CI, 84.0%–96.2%) without M184V (P = .016). Conclusions Previous selection of M184V did not increase the risk of VF or TD with lamivudine-based DT but was associated with a higher probability of viral blips.

Ergot alkaloids in endophyte-infected grasses inhibit prolactin secretion and reduce milk production in lactating cows. However, we previously showed that prepartum consumption of infected seed throughout the dry period did not inhibit subsequent milk production and prior exposure to bromocriptine (ergot peptide) actually increased production in the next lactation. To identify changes in the transcriptome and molecular pathways mediating the mammary gland's response to ergot alkaloids in the diet, RNA sequencing (RNA-seq) was performed on mammary tissues obtained from 22 multiparous Holstein cows exposed to 1 of 3 treatments. Starting at 90 ± 4 d prepartum, cows were fed endophyte-free fescue seed (control; CON), endophyte-free fescue seed plus 3×/wk subcutaneous injections of bromocriptine (BROMO; 0.1 mg/kg of BW), or endophyte-infected fescue seed (INF) as 10% of the diet. Cows were dried off 60 ± 2 d prepartum. Mammary biopsies from 4 (BROMO, INF) or 5 (CON) cows/treatment at each of the 3 phases were obtained: 7 d before dry off during the initial lactation (L1), mid-dry period (D), and 10 d postpartum (L2). Although tissue from the same cow was preferentially used at 3 phases (L1, D, L2), tissue from additional cows were used to as necessary to provide RNA of sufficient quality. Individual samples were used to generate individual RNA-seq libraries. Normalized reads of the RNA-seq data were organized into technical and biological replicates before processing with the RSEM software package. Each lactation phase was processed separately and genes that differed between any of 3 treatments were identified. A large proportion of genes differentially expressed in at least 1 treatment (n = 866) were found to be similarly expressed in BROMO and INF treatments, but differentially expressed from CON (n = 575, total for 3 phases). Of genes differentially expressed compared with CON, 104 genes were common to the L1 and L2 phases. Consistent with the production findings, networks most affected by treatments in L1 and L2 included lipid metabolism, small molecule biochemistry, and molecular transport, whereas networks related more to developmental and cellular functions and maintenance were evident during D phase. Similar patterns of expression in BROMO and INF during late and early lactation suggest involvement of similar cell signaling pathways or mechanisms of action for BROMO and INF and the importance of prolactin messaging pathways.

To explore the attitudes of European physicians on adherence and how treatment modalities impact adherence in complicated forms of soft skin and skin structure infections, now referred as acute bacterial skin and skin structures infections (ABSSSI). After literature review, a questionnaire was prepared. Topics focused on (1) the importance of adherence, (2) the importance of administration regimen on adherence, (3) the importance of drug selection on adherence, (4) the importance of complexity on choice of drug for treatment, (5) the role of adherence in drug resistance, and (6) the role of adherence in administration of long-acting antibiotics (ABs). The questionnaire was administered to 323 European infectious diseases specialists, of whom 74% responded. A modified Delphi method was used to obtain the highest consensus. Results varied by countries. We found a high degree of agreement of the importance of adherence in ABSSSI treatment. Experts agreed that complexity of patient’s conditions, drug selection, drug resistance, the type of regimen, and the number of infusions impact adherence. Two items linking oral switching and adherence did not reach consensus. Adherence for ABSSSI therapies appears a crucial factor for therapeutic management and reduces the risk of AB resistance. Among new treatment opportunities, long-acting agents, with their characteristics, may represent an interesting options.

The objective of this study was to investigate predisposing factors and outcomes of infective endocarditis (IE) caused by non-HACEK Gram-negative bacilli (GNB) in a contemporary multicenter cohort. Patients with IE due to GNB, prospectively observed in 26 Italian centers from 2004 to 2011, were analyzed. Using a case-control design, each case was compared to three age- and sex-matched controls with IE due to other etiologies. Logistic regression was performed to identify risk factors for IE due to GNB. Factors associated with early and late mortality were assessed by Cox regression analysis. The study group comprised 58 patients with IE due to GNB. We found that Escherichia coli was the most common pathogen, followed by Pseudomonas aeruginosa and Klebsiella pneumoniae . The genitourinary tract as a source of infection (odds ratio [OR], 13.59; 95% confidence interval [CI], 4.63 to 39.93; P < 0.001), immunosuppression (OR, 5.16; 95% CI, 1.60 to 16.24; P = 0.006), and the presence of a cardiac implantable electronic device (CIED) (OR, 3.57; 95% CI, 1.55 to 8.20; P = 0.003) were factors independently associated with IE due to GNB. In-hospital mortality was 13.8%, and mortality rose to 30.6% at 1 year. A multidrug-resistant (MDR) etiology was associated with in-hospital mortality (hazard ratio [HR], 21.849; 95% CI, 2.672 to 178.683; P = 0.004) and 1-year mortality (HR, 4.408; 95% CI, 1.581 to 12.287; P = 0.005). We conclude that the presence of a genitourinary focus, immunosuppressive therapy, and an indwelling CIED are factors associated with IE due to GNB. MDR etiology is the major determinant of in-hospital and long-term mortality.

The purpose of this study was to assess the safety and the clinical outcome associated with organ transplantation from increased infectious risk donors (IRD). We retrospectively identified all adult deceased IRD referred to the Nord Italia Transplant program coordinating center from November 2006 to November 2011. All potential donors were screened for social risk factors that may increase the risk of donor-derived infection with human immunodeficiency (HIV), hepatitis B virus (HBV), or hepatitis C virus (HCV). All recipients were followed monthly for the first 6 months post-transplant. A total of 86 potential IRD were identified during the study period. Three hundred and seventy-nine organs from IRD were offered to the transplant centers, but only 185 (48.8%) were used for transplantation. Organs from IRD were transplanted into 174 recipients. The complete follow-up data were available for 152 of 174 (87.3%) recipients. During a mean follow-up of 11.7 months (median 12; range 2.4-12), no transmission of HIV, HBV, or syphilis was documented by serology and nucleic acid testing (NAT) testing. Two patients transplanted with organs from HCV-RNA-positive donors, as expected, developed post-transplant HCV infection. In conclusion, the use of organs from IRD was associated with a safe increase in the transplant procedures in our country.

Purpose of review Donor-derived transmission of infectious diseases is a well-recognized complication of solid organ transplantation (SOT). Most donor-derived disease transmissions are expected. Although uncommon, unexpected donor-derived infections can be associated with significant morbidity and mortality, and as the volume of patients undergoing SOT increases, the number of infections transmitted through organ donation can also be expected to rise. The growing gap between the number of patients waiting for transplantation and available organs continue in fact to be the number one issue facing the transplant community. As a consequence the major focus in organ transplantation has been developing strategies to increase the available organs, including the use of organs from donors with infections or risky behaviors that have disqualified them from the donation in the past. Recent findings In addition to the commonly reported donor-derived transmissions, an increasing number of studies have reported unusual infections transmitted by SOT. Summary Transplant surgeons and physicians should increase their awareness toward uncommon donor-derived infections including them in the differential diagnosis of unusual clinical pictures in their recipients.

A 39-year-old Ethiopian HIV-positive man with peripheral T-cell lymphoma developed Strongyloides stercoralis hyperinfection. The patient was initially treated with oral ivermectin for three weeks without response, most likely due to malabsorption because of concomitant paralytic ileus. Given the persistence of larvae in the body fluids, the worsening respiratory status and clinical malabsorption, veterinary parenteral formulation of ivermectin was administered. The very high plasma concentration of ivermectin achieved in the patient after parenteral administration led to a rapid improvement in his clinical condition and rapid disappearance of the parasite from biological samples, without any adverse reaction.

This study evaluated the independent contribution of voriconazole to the development of squamous cell carcinoma (SCC) in lung transplant recipients, by attempting to account for important confounding factors, particularly immunosuppression. This international, multicenter, retrospective, cohort study included adult patients who underwent lung transplantation during 2005-2008. Cox regression analysis was used to assess the effects of voriconazole and other azoles, analyzed as time-dependent variables, on the risk of developing biopsy-confirmed SCC. Nine hundred lung transplant recipients were included. Median follow-up time from transplantation to end of follow-up was 3.51 years. In a Cox regression model, exposure to voriconazole alone (adjusted hazard ratio 2.39, 95% confidence interval 1.31-4.37) and exposure to voriconazole and other azole(s) (adjusted hazard ratio 3.45, 95% confidence interval 1.07-11.06) were associated with SCC compared with those unexposed after controlling for important confounders including immunosuppressants. Exposure to voriconazole was associated with increased risk of SCC of the skin in lung transplant recipients. Residual confounding could not be ruled out because of the use of proxy variables to control for some confounders. Benefits of voriconazole use when prescribed to lung transplant recipients should be carefully weighed versus the potential risk of SCC. EU PAS registration number: EUPAS5269.

Introduction: Ceftolozane/tazobactam (C/T) is a new antibiotic resulting from the combination of a novel cephalosporin, structurally similar to ceftazidime, with tazobactam, a well-known beta-lactamase inhibitor. C/T remains active against extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae and multi-drug resistant (MDR) P. aeruginosa, and has been recently approved for the treatment of complicated intra-abdominal infections (cIAI) and complicated urinary tract infections (cUTI). A trial on hospital-acquired pneumonia is ongoing. Areas covered: The place in therapy of C/T is delineated by addressing the following main topics: (i) antimicrobial properties; (ii) pharmacological properties; (iii) results of clinical studies. Expert commentary: C/T is approved for cIAI and cUTI. However, the drug has a special value for clinicians in any kind of infectious localization for two main reasons. The first is that C/T is especially valuable in suspected or documented severe infections due to MDR P. aeruginosa, which is not a rare occurrence in many countries. The second is that C/T may provide an alternative to carbapenems for the treatment of infections caused by ESBL-producers, thus allowing a carbapenem-sparing strategy. Reporting of off-label use is mandatory to increase the body of evidence and the clinicians’ confidence in using it for indications other than cIAI and cUTI.

Staphylococcus aureus is still an important problem in clinical and therapeutic area, worldwide. In Italy, in recent years, methicillin resistance remained stable, yet considerably high, the percentage of strains of MRSA being around 40%. It was deemed interesting and timely to carry out a consensus conference using the RAND/UCLA method to collect the opinion of a group of experts in infectious diseases on the role of glycopeptides in the management of MRSA infections within several clinical scenarios and namely in pneumonia, bacteremia and endocarditis, joint replacement infections, skin and soft tissue infections, diabetic foot, abdominal infections and central nervous system infections. The scenarios proposed by the Scientific Committee have been validated by a group of experts in infectious diseases and then voted in three meetings of infectious disease specialists. The results obtained on each individual condition were analyzed and therapeutic recommendations on each of these were released.

Since December 2013, chikungunya virus (CHIKV) spread in many countries of the Western Hemisphere, and during the last year some cases of infected European travelers, coming back from the Caribbean, have been reported. The risk of acquiring severe travel-related illness is higher in immunocompromised subjects, such as patients with human immunodeficiency virus (HIV) infection or solid organ transplant recipients. We reported the first case, to our knowledge, of CHIKV infection in an HIV-infected kidney transplant recipient.

The mechanical behaviour of timber frame shear walls subjected to in-plane forces has been investigated through full-scale tests. Eleven monotonic and 11 cyclic tests were performed on full-scale shear walls, each 2·5 m high by 2·5 m long. Some variables were changed during the tests as follows; different vertical loads were applied, various angle brackets and hold-downs were used, and different sheathing panels were connected to the timber frame. Also, the influence of openings was investigated. Furthermore two walls with non-structural finishing were tested in order to correlate the inter-storey drift with the level of damage. In part 1 of the paper, the test procedure and test results are presented. A detailed discussion of the test apparatus and how the boundary conditions influence the results are also reported. The theoretical approach used to predict the mechanical behaviour of the presented system is explained.

The mechanical behaviour of timber frame shear walls subjected to in-plane forces has been investigated through full-scale tests. Eleven monotonic and 11 cyclic tests were performed on full-scale shear walls, each 2·5 m high and 2·5 m long. Different variables were changed during the tests as follows. Different vertical loads were applied, different angle brackets and hold-downs were used and different sheathing panels were connected to the timber frame. Also, the influence of openings was investigated. Furthermore, two walls with non-structural finishing were tested in order to correlate the inter-storey drift with the level of damage. This paper (part 2) reports on a comparison between different test results, permitting evaluation of the influence of each variable on the stiffness and the resistance of the walls. Moreover, the theoretical formulae presented in a companion paper (part 1) were compared with the outcome of the tests, and good agreement was found. The racking resistance predicted by Eurocode 5 was also checked using the data obtained from the tests.

Background and Aims In patients with hepatitis C virus (HCV), recurrence of infection after liver transplant (LT) is universal and associated with worst survival. We present the results of an Italian cohort to compare the 3-year outcome of HCV-Ab-positive and HCV-Ab-negative LT recipients and to assess the potential interaction between HCV-Ab sero-status and other risk factors for LT failure. Methods The study is a multicentre cohort including a sample of liver transplant centres. Participant's information was collected at the local level. The best functional form of variables was decided according to the objective methods based on information theory. Association between transplant failure and potential risk factors was assessed in univariate and multivariate Poisson regression model with random intercept. Results Between June 2007 and May 2009, 1164 LT recipients were enrolled in 16 Italian transplant centres, of them 275 (23.63%) experienced LT failure. Incidence rates of LT failure was 0.32 and 0.23 per 1000 person-days in HCV-Ab-positive and HCV-Ab-negative recipients respectively (P = 0.003). Inferential models according to Akaike information criterion indicated that donor–recipient age difference and donor–recipient sex matching were more informative to predict LT failure than the age and the sex as separate variables. Multivariate analysis provided evidence that HCV-Ab sero-status, time after LT, donor–recipient age difference, donor–recipient sex matching and recipient's MELD score were significantly associated with LT failure. Moreover, the effect of HCV-Ab sero-status on LT failure was modified by the simultaneous action of time after LT and donor–recipient age difference. No interaction was found between recipient's HCV-Ab sero-status and either recipient's MELD or donor–recipient sex matching. Conclusion In view of the imminent introduction of new anti-HCV therapies, our study provides information to assess which LT recipients should be prioritized for receiving these highly effective, but expensive, new treatments. This is particularly relevant for those clinical settings where healthcare prioritization is endorsed by national authorities.

This paper reports on a shaking table test conducted on a timber-framed building sheathed with oriented strand board within the framework of the European Series project at the National Laboratory of Civil Engineering in Lisbon, Portugal. The test structure was a full-scale, three-storey, 7 m × 5 m plan building. The aim of the tests was to assess the integrity of the structural members and the non-structural components during a seismic event. The structural design was carried out in accordance with European standards. The input signals comprised ‘accelerograms’, which were scaled versions of those recorded during the Montenegro (1979) and Tohoku (2011) earthquakes. The outcome of the tests showed excellent seismic behaviour, as demonstrated by the fact that the structure frequency did not change until the last step of the procedure. Moreover, after 17 simulations, no visible damage was detected.

Use of organs from donors testing positive for hepatitis B virus (HBV) may safely expand the donor pool. The American Society of Transplantation convened a multidisciplinary expert panel that reviewed the existing literature and developed consensus recommendations for recipient management following the use of organs from HBV positive donors. Transmission risk is highest with liver donors and significantly lower with non-liver (kidney and thoracic) donors. Antiviral prophylaxis significantly reduces the rate of transmission to liver recipients from isolated HBV core antibody positive (anti-HBc+) donors. Organs from anti-HBc+ donors should be considered for all adult transplant candidates after an individualized assessment of the risks and benefits and appropriate patient consent. Indefinite antiviral prophylaxis is recommended in liver recipients with no immunity or vaccine immunity but not in liver recipients with natural immunity. Antiviral prophylaxis may be considered for up to 1 year in susceptible non-liver recipients but is not recommended in immune non-liver recipients. Although no longer the treatment of choice in patients with chronic HBV, lamivudine remains the most cost-effective choice for prophylaxis in this setting. Hepatitis B immunoglobulin is not recommended.

Organ transplantation is considered the therapy of choice for end-stage organ failure. However, the growing gap between the number of patients waiting for transplantation and available organs continue to be the number one issue facing the transplant community. As a consequence the major focus in liver transplantation has been developing strategies to increase available donors, including the use of live donor liver segments, splitting deceased donor grafts for two patients and the use of organs procured from donors after circulatory death (DCD). In addition several groups continue to explore ways in which outcomes can be improved utilizing organs from “extended criteria” donors, including donors with infections or malignancies [1-2]. This article is protected by copyright. All rights reserved.

Bacteria are the pathogens most frequently transmitted through substances of human origin (SoHO). The European Centre for Disease Prevention and Control (ECDC) organized an expert consultation, with the objective of developing a priority list of bacterial pathogens transmissible via SoHO. The list will be used to further assess risks and determine appropriate preventive measures.The 14 most frequently SoHO-transmitted bacteria identified through a scoping literature review were then prioritized during an expert workshop through a methodology based on multicriteria decision analysis. The selection of the prioritization method was based upon an ECDC framework for best practices in conducting risk-ranking exercises. Three transmission pathways, blood and blood components, tissues and cells, and organs, were considered in the ranking exercise.According to the ranking score (RS), bacteria were organized within each SoHO pathway into one of four risk tiers: Tier 1 (RS ≥ 0.70), Tier 2 (RS = 0.60-0.69), Tier 3 (RS = 0.40-0.59), or Tier 4 (RS 0.40). The most consistently identified pathogens in the highest risk Tiers 1 and 2 of all three pathways were: Staphylococcus aureus, Klebsiella spp., Escherichia coli, β-hemolytic streptococci, Pseudomonas spp., and Acinetobacter spp.Six bacteria were defined as being of the highest priority in respect of the threat to the safety of SoHO and will be the subject of subsequent in-depth risk assessments to be conducted by ECDC to identify measures to mitigate the risk posed by these bacteria.

Regional anesthesia: the best is yet to come

Skin and soft-tissue infections (SSTIs) are among the most common bacterial infections, posing considerable diagnostic and therapeutic challenges. Fourteen members of the Italian Society of Infectious Diseases, after a careful review of the most recent literature using Medline database and their own clinical experience, updated a previous paper published in 2011 by preparing a draught manuscript of the statements. The manuscript was successively reviewed by all members and ultimately re-formulated the present manuscript during a full day consensus meeting. The microbiological and clinical aspects together with diagnostic features were considered for necrotizing and not necrotizing SSTIs in the light of the most recent guidelines and evidences published in the last five years. The antimicrobial therapy was considered as well - both empirical and targeted to methicillin-resistant Staphylococcus aureus and/or other pathogens, also taking into account the epidemiological and bacterial resistance data and the availability of new antibacterial agents.