Few cases of combined heart and liver transplantation (CHLT) for familial amyloidotic polyneuropathy have been reported, and the technique for the operation is far from being consolidated. Three patients with amyloidogenic transthyretin (ATTR)-related (variant Glu89Gln to ATTR Glu89Gln) cardiomyopathy underwent CHLT at our institution. Patient 1 had no serious involvement of other organs, whereas patients 2 and 3 had evident peripheral neuropathy and gastrointestinal motility alterations. Patient 3 also had high-grade orthostatic hypotension. All three patients underwent cardiac and sequential hepatic transplantation using the piggyback technique with organs procured from the same donor. Venovenous bypass (VVB) was used only in patient 1, with an uncomplicated procedure. After CHLT, his cardiac performance remained normal, and no progression of amyloidosis was observed. Patient 2 had no intraoperative complications, but experienced postoperative bleeding, renal failure, sepsis, and heart failure and eventually died of multiorgan failure 2 months after transplantation. In patient 3, right hemicolectomy was required intraoperatively because of intestinal ischemia without significant hemodynamic perturbations, whereas extracardiac symptoms of amyloidosis gradually worsened postoperatively. Two patients (no. 1 and 3) currently are alive after 38 and 18 months, respectively. CHLT for ATTR Glu89Gln can be performed successfully, even in patients with advanced disease. However, the most compromised patients are more exposed to intraoperative risks, postoperative complications, and worsening of extracardiac and extrahepatic symptoms. The need for VVB remains to be evaluated. (Liver Transpl 2003;9:986-992.)

The purpose of this study was to determine whether lysostaphin would enhance its anti-staphylococcal efficacy in combination with lysozyme. Minimum inhibitory concentrations (MICs) of lysostaphin and lysozyme were separately determined for 41 strains belonging to 10 different species of human staphylococci. Lysozyme was virtually inactive and showed MICs of 15 mg/ml. On the contrary, all strains were susceptible to lysostaphin and showed MICs ranging from 2.5 to 60 jig/ml for the different Staphylococcus species. When the MIC of lysostaphin was determined in media containing submultiples of the MIC of lysozyme, the values obtained were much lower. The reduction of the lysostaphin MIC ranged from 16-to 200-fold in the different species tested. In Staphylococcus aureus, in particular, the combination of lysostaphin with 1.5 mg of lysozyme per ml reduced the MIC of lysostaphin by 25-fold. The activities of two combinations of the two enzymes were evaluated: one combination was expected to be active on S. aureus only, and the other combination was expected to inhibit all Staphylococcus strains. The first combination (0.5 ,ug of lysostaphin plus 0.5 mg of lysozyme per ml) was inhibitory to all of the 84 S. aureus strains tested, whereas 137 of 151 strains of other Staphylococcus species were unaffected. On the contrary, all of the 235 Staphylococcus strains tested were inhibited by the second combination (4

Liver transplantation with preservation of the recipient vena cava (the "piggy-back'' technique) has been proposed as an alternative to the traditional method. We performed a randomized study on 39 cirrhotic patients, 20 who underwent the piggy-back technique (group 1) and 19 the traditional method using venovenous bypass (group 2) to evaluate the feasibility and true advantages of the piggyback technique compared to the traditional method. Two patients were switched to the conventional technique due to the presence of a caudate lobe embracing the vena cava in one patient and a caval lesion in the other. Statistically significant differences between the two groups were only found for the warm ischemia time (48.5 f 13 min for piggy-back vs 60 _+ 12 min for the conventional method) and for renal failure (zero cases in group 1 vs four cases in group 2). We therefore believe that liver transplantation with the piggy-back technique can easily be performed in almost all cases, and that only a few, specific situations, such as a very enlarged caudate lobe, do not justify its routine use.

SUMMARY A new test for the detection of bacterial phosphatase activity has been devised. The test is performed using agar media containing both methyl green (MG) and phenolphthalein diphosphate (PDP); in these media phosphatase-producing strains grow deep-green-stained colonies whereas non-producing strains do not. A total of 739 different strains were tested, including 593 staphylococci, 95 micrococci, 11 streptococci, 10 corynebacteria, 14 enterobacteria, and 16 candidae. All strains found phosphatase-positive according to the conventional phosphatase test displayed deep-greenstained colonies on MG-PDP media, whereas all phosphatase-negative strains showed unstained colonies on the same media. The main advantages of the present phosphatase test as compared with other conventional ones are that it is more simple to perform, it can reveal the phosphatase activity of colonies grown in deep agar, and can be incorporated into commercial multitest kits.The production of phosphatase is acknowledged as a key-test for both classification and routine identification of the Micrococcaceae (Baird-Parker, 1963;Schleifer and Kloos, 1975; Subcommittee on the Taxonomy of Staphylococci and Micrococcci, 1976; Oeding and Digranes, 1977). Phosphatase production has also been studied in many other microorganisms, including streptococci (Taketo and Taketo, 1974), corynebacteria (Bray and King, 1943), enterobacteria (Bayliss et al., 1948;Wolf et al., 1972;Bhatti and Done, 1974), anaerobic bacteria (Porschen and Spaulding, 1974), and yeasts (Bayliss et al., 1948;Smith et al., 1973).In routine clinical microbiology phosphatase activity is generally tested by procedures that require a further step after the inoculation of the medium.

The bacteriolytic activity of Staphylococcus aureus and Staphylococcus albus strains was tested with various media. Whereas S. aureus strains were found to be active under all conditions, the percentage of active S. albus strains was significantly influenced by the composition of the medium. Ionic strength and concentration of the organic nitrogen source were found to be the main factors affecting the expression of bacteriolytic activity of straphylococci. Virtually all of 318 S. aureus and 603 S. albus strains were active on a medium containing 3% peptone, 0.3% glucose, 0.2% yeast extract, 0.1% disodium phosphate, 2.2% sodium chloride and 0.9% agar. The optimal conditions for the bacteriolytic activity of S. aureus strains were different from those of most S. albus strains. Within S. albus, optimal conditions differed also from strain to strain. It is suggested that further studies on this subject may prove useful for the identification and taxonomy of staphylococci. A possible relationship between the production of extracellular bacteriolytic enzymes and pathogenic properties of staphylococci is also considered.