Don Burke's Global Health Blog: Palermo, Italy, ISMETT visit

Early AM, 7 January 2008

We arrived in Palermo on schedule on Thursday morning. Accompanying me on this leg of my trip is Chuck Rinaldo, Chairman of Infectious Diseases and Microbiology at GSPH. I invited Chuck for his expertise in viral infections in transplantation.

My purpose here is to explore collaborative research and training opportunities between the University of Pittsburgh and ISMETT, the Italian acronym for the Mediterranean Institute for Transplantation and Specialized Therapies. ISMETT is an exciting joint venture between UPMC and the Italian and Sicilian governments to create a state-of-the-art transplant hospital in Palermo. In years past Sicilian patients requiring transplants were typically sent to centers outside Italy, at great expense to the government. The idea was to create a joint public-private (with UPMC) center of transplantation excellence that would build up local Sicilian medical and scientific infrastructure and at the same time keep money in the country. By most measures the ISMETT experiment is a runaway success. ISMETT has rapidly become a leading Italian center, both in number of transplants performed and the vitality of the scientific program. ISMETT emphasizes liver transplants, but also performs a large number heart, lung, and other organ transplants.

Although transplantation is the central procedure, for every transplant patient ISMETT provides the medical care for dozens of other severely ill patients who are awaiting transplantation. Because of this, ISMETT is essentially a full-service hospital, with more than 70 full time physicians, 300 nurses, and a large staff.

ISMETT is directed by Dr. Bruno Gridelli, a transplant surgeon whose youthful appearance and soft spoken manner conceal ferocious drive, energy, and intelligence. Originally from the North of Italy, Bruno trained in Pittsburgh and has strong Pitt/UPMC connections. He met his charming American wife Melanie in Pittsburgh, where she worked at Mellon bank.

Dr. Gridelli arranged a full schedule for us to meet with ISMETT physicians and scientists, ranging from transplant surgeons to cardiologists to infectious disease specialists to regulatory compliance experts. Most spoke English well, only a few required translators. We also toured the facility.

The main ISMETT building, constructed only four years ago, is a surprisingly large, completely modern hospital with a state of the art ICU, sophisticated radiology and imaging, comfortable patient areas, and an efficient staff. Implementation of a new comprehensive Electronic Medical Record is essentially complete for all patient-related data.

Now that the clinical program is successfully launched, attention at ISMETT is turning toward developing a research program, with a strong emphasis on transplantation. A second major public–private partnership with UPMC has recently been announced, this one aiming to create a research institute in Palermo, and to train post doctoral research scientists who will return to Palermo to staff the institute. The new research institute will be physically and administratively distinct from ISMETT, but closely linked scientifically. Based on my initial discussions, I can foresee a wealth of opportunities where Pitt and ISMETT could develop important and productive collaborations.

Most ISMETT liver transplants are done for liver failure or liver cancer caused by hepatitis C virus, a common infection in Sicily as it is throughout the Mediterranean region. Because some virus remains in patients’ bodies after transplantation with a new liver, the virus infects the new liver and causes recurrence of hepatitis and destruction of the new liver. Methods are needed to prevent this terrible but very common occurrence. Would it be possible to cure a patient of hepatitis C at the time of transplant? Chuck Rinaldo is already working on defining T-lymphocyte activity against hepatitis C virus infected cells. One possible project would be to grow large quantities of anti-hepatitis C lymphocytes in the new ISMETT GMP “cell factory” facility and infuse these cells into a patient at the time of transplant. The large bulk of hepatitis C virus will be removed with the diseased liver, and such immunotherapy could contain or even eliminate residual virus. Alternatively, anti-hepatitis C drugs might be added to lymphocyte infusions, in an all-out effort to cure the patient.

Another chronic virus that causes transplant problems is the Human Herpes Virus Type 8 (HHV-8), also known as the Kaposi’s Sarcoma Herpes Virus (KSHV). Prevalences of this virus are about 7% in ISMETT transplant patients and donors, and recurrent or acute KSHV infections are a serious problem in transplant recipients here. Pat Moore and Yuan Chang, the discoverers of KSHV are professors at Pitt (UPCI). Pat and Yuan could provide outstanding expertise in research into improved diagnostics and therapeutics for KSHV. I plan to ask them to visit ISMETT soon.

ISMETT has growing training needs. For example, transplant patients require unusually intensive and complex nursing care, but trained nurses are in short supply in Sicily. The University of Palermo has a solid three-year nurses training program, yet an additional training period beyond three years is necessary for most ISMETT nurses. This would seem to be a good area of opportunity for the Pitt School of Nursing and ISMETT. Another need is in health administration, where a program could be developed through the Pitt Health Policy and Management Department at the School of Public Health.

One exciting opportunity would be to create a Mediterranean center of health research excellence, headquartered in Palermo. Located smack in the center of the Mediterranean Sea, only a short distance from Northern Africa, Sicily serves as a bridge between Arab and European cultures. These dual influences permeate every aspect of Sicilian life, from art and religion to language and food. Nowhere is this fusion of cultures more evident than in the spectacular Monreal Cathedral here just outside Palermo. Within this Norman Christian Church the life of Jesus is shown in spectacular mosaic tiled murals, bordered with classic interwoven Arabian patterns. The nearby cloisters are similarly decorated with an Arabian flair. ISMETT has already struck agreements on transplantation with Tunisia, Libya, and Egypt. This could provide a creative opportunity for the USA to mend its dangerously frayed relationships with the Islamic world! ISMETT could become a lead partner in growing cooperation on health research with the moderate north African Islamic states. Tempting as such grand visions may be, we of course will want to proceed stepwise. Perhaps we could start by co-sponsoring a small multi-country conference at ISMETT.

I’ve been up for a couple of hours now, and its time for breakfast. Another full day at ISMETT today, then off to Doha, Qatar, tomorrow morning.