Hysterectomy prevention using the uterine hollow obliterations (HYUNHO) method for placenta previa

OBJECTIVE

We have invented a method of hysterectomy prevention called the uterine hollow obliteration (HYUNHO) method to preserve the uterus and fertility after treating placenta previa or accreta.

METHODS

Eighty patients underwent cesarean section because of placenta previa between January 2003 and December 2009. All patients eligible for the study were evaluated by followup and a telephone questionnaire about fertility, menstruation recovery, and complications.

RESULTS

The success rate on preserving the uterus with the HYUNHO method was 96.2%. Three cases required additional procedures, including a cesarean hysterectomy or uterine artery embolization (UAE), two cases underwent a cesarean hysterectomy after delivery, and one case underwent UAE.

CONCLUSION

The HYUNHO method is a safe, easy method for placenta previa, although it should be evaluated in a randomized controlled trial.

Expression of p53, p27 and Jab1 protein in epithelial ovarian tumors

OBJECTIVE

The study aimed to investigate expression of p53, p27 and Jun activation domain-binding protein 1 (Jab1) proteins in epithelial ovarian tumors and the values of these factors as discriminating markers for the transformation of borderline tumors to cancers.

METHODS

Forty-seven cases of paraffin-embedded tissues of epithelial ovarian tumors including 22 cases of benign ovarian tumors, nine cases of borderline tumors, and 16 cases of invasive cancers were used to evaluate expression of p53, p27 and Jab1 proteins by immunohistochemical methods.

RESULTS

p53 protein was expressed in 13.6% of the benign tumors, 44.4% of the borderline tumors and 62.5% of the malignant tumors and p27 protein was expressed in 95.5% of the benign tumors, 66.7% of the borderline tumors, and 37.5% of the malignant tumors. Expression of Jab1 protein was observed in 22.7% of the benign tumors, 77.8% of the borderline tumors and 62.5% of the malignant tumors. Expressions of p53, p27 and Jab1 proteins in malignant tumors were all higher than in benign tumors and the expression of p27 protein in malignant tumors was lower than in benign tumors (p < 0.05). Expression of Jab1 protein in borderline tumors was significantly higher than in benign tumors (p < 0.05).

CONCLUSIONS

Expression of p53, p27 and Jab1 proteins can be used to discriminate between benign and malignant tumors in epithelial ovarian tumors.

Robotic testing of proximal tibio-fibular joint kinematics for measuring instability following total knee arthroplasty

Pain secondary to instability in total knee arthroplasty (TKA) has been shown to be major cause of early failure. In this study, we focused on the effect of instability in TKA on the proximal tibio-fibular joint (PTFJ). We used a robotics model to compare the biomechanics of the PTFJ in the native knee, an appropriately balanced TKA, and an unbalanced TKA. The tibia (n = 5) was mounted to a six-degree-of-freedom force/torque sensor and the femur was moved by a robotic manipulator. Motion at the PTFJ was recorded with a high-resolution digital camera system. After establishing a neutral position, loading conditions were applied at varying flexion angles (0°, 30°, and 60°). These included: internal/external rotation (0 Nm, ±5 Nm), varus/valgus (0 Nm, ±10 Nm), compression (100 N, 700 N), and posterior drawer (0 N, 100 N). With respect to anterior displacement, external rotation had the largest effect (coefficient = 0.650; p < 0.0001). Polyethylene size as well as the interaction between polyethylene size and flexion consistently showed substantial anterior motion. Flexion and mid-flexion instability in TKA have been difficult to quantify. While tibio-femoral kinematics is the main aspect of TKA performance, the effects on adjacent tissues should not be overlooked. Our data show that PTFJ kinematics are affected by the balancing of the TKA.

Isolation, Complementation, and Initial Characterization of Temperature-Sensitive Mutants of the Baculovirus Autographa californica Nuclear Polyhedrosis Virus

Sixteen temperature-sensitive mutants of Autographa californica nuclear polyhedrosis virus were isolated. Several interesting phenotypes were observed. A large proportion of the mutants were unable to form polyhedral occlusion bodies (polyhedra) at the nonpermissive temperature (32.5 degrees C). At 32.5 degrees C, one mutant formed plaques in which the cells lacked polyhedra. Another mutant type was defective in the production of progeny extracellular nonoccluded virus and produced a "plaque" consisting of only a single cell containing polyhedra at 32.5 degrees C. One mutant was defective in plaque formation, progeny nonoccluded virus formation, and polyhedra formation at 32.5 degrees C. Several mutants produced nonoccluded virus but failed to produce plaques or polyhedra at 32.5 degrees C. Other phenotypes were also distinguished. Complementation analyses, performed by either measuring the increase in extracellular nonoccluded virus formation or by observing polyhedra formation in mixed infections at 32.5 degrees C, indicated the presence of 15 complementation groups. A high frequency of recombination was observed. Four of the mutants were found to be host dependent in their temperature sensitivity for polyhedra formation.

Increased prevalence of white matter hyperintensities in patients with panic disorder

The aim of the current study is to compare the prevalence, severity and location of cerebral white matter hyperintensities (WMH) between patients with panic disorder (PD) and healthy control subjects. Patients with PD (n = 24) and matched healthy control subjects (n = 24) were scanned using a 3.0 Tesla whole-body magnetic resonance scanner. Axial T2-weighted and fluid-attenuated inversion recovery images were acquired and evaluated for the prevalence, severity and location of WMH using the modified composite scale of Fazekas and Coffey and coded separately for deep and periventricular WMH. Logistic regression analyses were used to assess the association between WMH and the diagnosis of PD. A greater severity of total WMH was associated with a diagnosis of PD in a dose-dependent pattern (odds ratio [OR] = 8.8, P = 0.005 for mild WMH; OR = 27.7, P = 0.007 for moderate to severe WMH). Deep WMH, where most group differences originated, were predominantly located in the frontal region of the brain (n = 16 in PD, n = 1 in control). The current report is the first study to report an increased prevalence of WMH in patients with PD.

Validity of interferon-γ-release assays for the diagnosis of latent tuberculosis in haemodialysis patients

Haemodialysis patients are at higher risk of developing active tuberculosis (TB) infection. However, tuberculin skin tests (TST) have limitations and the diagnostic usefulness of interferon-γ-release assays (IGRAs) remains unclear in immunocompromised hosts including haemodialysis patients. Haemodialysis patients were enrolled from a dialysis centre in Korea, an intermediate TB-burden country with a high bacille Calmette-Guérin (BCG) vaccination rate. The QuantiFERON-Gold TB In tube test (QFT) and the T-SPOT TB test (TSPOT) were performed, along with the TST. We stratified patients to low- and high-risk groups, according to the risk factors for latent TB. Association between each of the three diagnostic tests and the risk of latent TB was analysed. One hundred and sixty-seven patients were enrolled. The positive rates for the TST, the QFT and TSPOT were 23.5, 45.9 and 60.4%, respectively. Previous BCG vaccination increased the TST-positive rate in the low-risk group (OR 4.438), whereas it affected neither QFT nor TSPOT. The positive QFT rates were 41.2 and 62.5% in the low- and high-risk groups, respectively. The QFT was associated with the high-risk group (OR 2.578), whereas the TST was not. The positive TSPOT rates were 58.9 and 65.7% in the low- and high-risk groups, respectively. The frequency of indeterminate results was higher for the QFT (12.6%) compared with the TSPOT (4.8%). In conclusion, the IGRAs can be useful for the diagnosis of latent TB infection in haemodialysis patients.

Pitfalls of internet-accessible diagnostic tests: inadequate performance of a CE-marked Chlamydia test for home use

OBJECTIVES

To evaluate the performance of a Conformitée Européenne (CE)-marked home test for Chlamydia trachomatis (CT) that is available over the internet.

METHODS

A total of 231 eligible women attending the Social Hygiene Clinic (SHC) or Obstetrics-Gynecology (OB-GYN) Clinic in Iloilo City, Philippines were recruited to an evaluation of the HandiLab-C Chlamydia home test (HandiLab-C). One vaginal swab was tested with HandiLab-C on-site and the second in Cambridge, UK with two nucleic acid amplification tests (NAAT), the Roche Amplicor and Abbott m2000. The organism load of NAAT-positive swabs was quantified.

RESULTS

Concordance between the NAATs was high (kappa agreement: 0.984). Using the Abbott assay as the gold standard, the sensitivity and specificity of the Roche assay were 97.4% and 100%, respectively. CT prevalence by Abbott was 8.0% (8/100) in the OB-GYN Clinic and 23.7% (31/131) at SHC. The sensitivity of HandiLab-C was 12.5% (1/8) and 19.4% (6/31) in OB-GYN and SHC respectively, with specificities of 93.5% (86/92) and 88% (88/100) respectively. Overall positive and negative predictive values of HandiLab-C were 28% and 84.5% respectively. No correlation between HandiLab-C performance and organism load (range: 1.3 x 10(2) to 1.4 x 10(7) bacteria/swab) was observed.

CONCLUSIONS

The performance of HandiLab-C is very poor, with the test yielding more false-positive (18/193) than true-positive (7/38) results. It remains accessible via the internet under various brand names and has retained its CE mark. This situation raises serious concerns about the regulation of diagnostic products available via the internet and the standards of certain Notified Bodies that issue the CE mark.

High-strength nitrogenous wastewater treatment in biofilm and granule anammox processes

Biofilm and granule reactors were employed to remove nitrogen via an anammox reaction applying synthetic nitrogen wastewater, whose concentration was in the range of 20 to 1,400 mg N/L as total nitrogen. A biofilm reactor was packed with non-woven fabric and a granule reactor was filled with anaerobic granular sludge taken from the brewery wastewater treatment plant. Both reactors were seeded with Planctomycetes KSU-1 and operated for 450 days. The biofilm reactor showed high NH(4) (+)-N and NO(2) (-)-N removal efficiencies of over 88% and 94%, respectively, until total nitrogen concentration was reached at 800 mg N/L. However, the biofilm reactor showed severe inhibition at over 1,000 mg N/L of total nitrogen due to nitrogen overloading. The granule reactor revealed better nitrogen removal performance than the biofilm reactor, showing high NH(4) (+)-N and NO(2) (-)-N removal efficiencies of over 90%, even at a total nitrogen concentration of 1,400 mg N/L. However, aggregation of anammox bacteria grown in the sludge bed after long-term operation resulted in the deterioration of nitrogen. The removal ratio of NH(4) (+)-N and NO(2) (-)-N was close to 1:1, suggesting other reactions related to ammonium oxidation could occur simultaneously. Free ammonia inhibition as well as NO(2) (-)-N could be significant when high-strength nitrogenous wastewater was applied.

Comparative efficacies of albendazole and the Chinese herbal medicine long-dan-xie-gan-tan, used alone or in combination, in the treatment of experimental eosinophilic meningitis induced by Angiostrongylus cantonensis

Angiostrongylus cantonensis, the rat lungworm, is the principal cause of human eosinophilic meningitis or meningoencephalitis world-wide. In the present study, the efficacies of early-stage treatment with the Chinese herbal medicine long-dan-xie-gan-tan (LDXGT) and albendazole, used alone or in combination, were evaluated in BALB/c mice with A. cantonensis-induced dysfunction of the blood-central-nervous-system barrier and eosinophilic meningo-encephalitis. Indicators of the therapeutic effect included worm recovery, histopathological scores for the meningitis, assays of tissue-type plasminogen activator (PA), urokinase-type PA and matrix metalloproteinase-9 (MMP-9) in the brain, the ratio between albumin concentrations in the cerebrospinal fluid (CSF) and serum, and counts of eosinophils in the CSF. Combined treatment with albendazole and LDXGT gave better results than monotherapy based on either drug, apparently inhibiting eosinophilic meningitis via antagonists of the PA/MMP-9 system. LDXGT may have a therapeutic role in reducing inflammatory reaction in the subarachnoid space. Monotherapy with such an anti-inflammatory drug may relieve the symptoms of mild infection and the host's immune responses to A. cantonensis larvae. In severe infection, however, co-therapy with an anthelmintic (to kill the larvae) and an anti-inflammatory agent (to provide symptomatic relief) is probably a better approach. The therapeutic strategy should be tailored to the severity of the illness and the numbers of eosinophils in the CSF.

Ezrin is a key element in the human vagina

OBJECTIVE

The vagina is a complex tubular structure that has reproductive, support and barrier functions. These depend on the cytoarchitecture of the vaginal cells, which is controlled by key proteins. Cytoskeletal proteins determine cell polarity and membrane specializations by integrating the actin cytoskeleton with cell membranes. This integration is the domain of cytoskeletal proteins including the MERM protein family (moesin-ezrin-radixin-Merlin). Nothing is known about the cyto-localization of the MERM's in the vaginal epithelium or how it influences the cytoarchitecture of the vaginal epithelium and stroma.

DESIGN

Full-thickness human vaginal fornix samples were obtained from 20 normal human specimens obtained at surgery for pelvic relaxation. Light- and electron microscopical immunohistochemistry (IHC) were used to identify and study activation and cellular localization of immuno-reactive-ezrin (ir-ezrin), a prototypical MERM.

RESULTS

Ir-ezrin was identified in the stratified squamous vaginal epithelium and connective tissue (fibroblasts, blood vessels and leucocytes). "H" scoring indicated that ir-ezrin staining is denser in the vaginal epithelium than in other layers, that the ir-ezrin staining was associated with increased keratinization and with the size of the tight junctions (p<0.01). Both the amounts and localization of ir-ezrin were associated with high levels of estrogen, identified by the menstrual history and keratinization of the superficial vaginal epithelium. The density of stromal ir-ezrin was increased in the presence of dense epithelial keratinization. Immuno-reactive-ezrin staining was most pronounced near the cell membranes of both keratinized and non-keratinized epithelium, indicating that ezrin activation (unfolding and movement to the membrane) had occurred. Ultra-structural examination of the epithelium showed intra-cellular ir-ezrin to be localized to junctional complexes that have been associated with decreased mucosal penetration by microorganisms. Ir-ezrin was widely distributed throughout stromal fibro-muscular cell, vessels and immunocytes.

CONCLUSIONS

MERM's, represented by ezrin, are widely present in the vaginal wall. This has implications for the strength and resilience of this tubular structure and may be the case in other internal genital tissues. Ezrin's localization and association with cell specializations indicate that in the vagina, as in other tissues, ezrin likely modulates vaginal cell-cell interactions including the changing vaginal cellular interface with the external environment, the regulation of the elasticity of the vagina, and the regulation of microbial and chemical traffic that determine the pH and microbial environment of the vagina. In other work we have shown that ezrin expression is induced by estradiol. The increase of ir-ezrin staining during the appearance of keratinization and maturation of the vaginal cytology indicates that estrogen may regulate vaginal ezrin and thereby the properties of the vaginal wall and epithelium.

Efficacy of curcumin therapy against Angiostrongylus cantonensis-induced eosinophilic meningitis

Angiostrongylus cantonensis can invade the central nervous system, leading to human eosinophilic meningitis or eosinophilic meningoencephalitis. Curcumin is a natural product which has the effects of anti-inflammation, anti-oxidation and anti-carcinogensis, while the administration of curcumin has been reported to possibly relieve the symptoms of meningitis. The present study tested the potential efficacy of curcumin in A. cantonensis-induced eosinophilic meningitis of BALB/c mice. Assay indicators for the therapeutic effect included the larvicidal effect, eosinophil counts and matrix metalloproteinase-9 (MMP-9) activity in angiostrongyliasis. Eosinophils were mildly reduced in treatment groups compared with infected-untreated mice. However, there were no significant differences in larvicidal effects or MMP-9 activity. This study suggests that anti-inflammatory treatment with curcumin alone has low efficacy, but the treatment does not interfere with MMP-9 expression and is not useful for larvicidal effects. The possible reasons include low curcumin across the blood-brain barrier and also those larvae that survive stimulate MMP-9 production, which promotes blood-brain barrier damage, with leukocytes then crossing the blood-brain barrier to cause meningitis. Further studies will be required to test these possibilities.

Tau overexpression in transgenic mice induces glycogen synthase kinase 3β and β-catenin phosphorylation

The abnormal phosphorylations of tau, GSK3beta, and beta-catenin have been shown to perform a crucial function in the neuropathology of Alzheimer's disease (AD). The primary objective of the current study was to determine the manner in which overexpressed htau23 interacts and regulates the behavior and phosphorylation characteristics of tau, GSK3beta, and beta-catenin. In order to accomplish this, transgenic mice expressing neuron-specific enolase (NSE)-controlled human wild-type tau (NSE/htau23) were created. Transgenic mice evidenced the following: (i) tendency toward memory impairments at later stages, (ii) dramatic overexpression of the tau transgene, coupled with increased tau phosphorylation and paired helical filaments (PHFs), (iii) high levels of GSK3beta phosphorylation with advanced age, resulting in increases in the phosphorylations of tau and beta-catenin, (iv) an inhibitory effect of lithium on the phosphorylations of tau, GSK3beta, and beta-catenin, but not in the non-transgenic littermate group. Therefore, the overexpression of NSE/htau23 in the brains of transgenic mice induces abnormal phosphorylations of tau, GSK3beta, and beta-catenin, which are ultimately linked to neuronal degeneration in cases of AD. These transgenic mice are expected to prove useful for the development of new drugs for the treatment of AD.

Reversible renal vasoconstriction in a patient with acute renal failure after exercise

Acute renal failure (ARF) with severe loin pain induced by anaerobic exercise is a rare condition that is accompanied by wedge-shaped contrast enhancement seen on computerized tomographic (CT) scan without evidence of rhabdomyolysis. An 18-year-old Korean male was transferred to our hospital for evaluation of mild azotemia, that developed after anaerobic exercise. The laboratory tests revealed that the serum creatinine was 2.1 mg/dl and the serum uric acid level was 1.6 mg/dl without any elevation of the serum myoglobin or creatine phosphokinase. Under the impression of exercise-induced ARF, we tried to determine the relationship between the occurrence of clinical symptoms, renal dysfunction and the characteristic CT findings by observing those changes prospectively before and after anaerobic exercise. After obtaining a written consent, the patient underwent a strenuous period of anaerobic exercise to induce the clinical symptoms. Before exercise, he was completely asymptomatic; his serum creatinine level was 0.9 mg/dl and CT scan of the kidneys showed no abnormalities. Loin pain developed 2 hours after exercise, and the serum creatinine level increased to 1.2 mg/dl 18 hours after the exercise. CT scan 18 hours after exercise showed multiple perfusion defects, and a 24-hour delayed CT scan showed multiple areas of wedge-shaped enhancement on both kidneys. These changes were completely resolved on the follow-up CT scan obtained 13 days after exercise with the return of a normal serum creatinine level. We conclude that reversible renal vasoconstriction is probably the main pathophysiologic mechanism of acute renal failure induced by anaerobic exercise.

An integrated healthcare enterprise information portal and healthcare information system framework

The paper presents an integrated, distributed Healthcare Enterprise Information Portal (HEIP) and Hospital Information Systems (HIS) framework over wireless/wired infrastructure at National Taiwan University Hospital (NTUH). A single sign-on solution for the hospital customer relationship management (CRM) in HEIP has been established. The outcomes of the newly developed Outpatient Information Systems (OIS) in HIS are discussed. The future HEIP blueprints with CRM oriented features: e-Learning, Remote Consultation and Diagnosis (RCD), as well as on-Line Vaccination Services are addressed. Finally, the integrated HEIP and HIS architectures based on the middleware technologies are proposed along with the feasible approaches. The preliminary performance of multi-media, time-based data exchanges over the wireless HEIP side is collected to evaluate the efficiency of the architecture.

Enhanced terahertz-wave parametric generation and oscillation in lithium niobate waveguides at terahertz frequencies

We observed parametric-generation efficiency of 1.61% from 1064 to 1071 nm and at 162 microm in a 0.5 mm thick, 45 mm long z-cut congruent lithium niobate waveguide with a pump energy of 2.2 mJ and a pump pulse width of 5.8 ns. We also measured an ultralow-threshold intensity of 70 MW/cm2 for a 1064 nm pumped parametric oscillator resonating at 1071 nm and emitting at 162 microm with a 1 mm thick, 45 mm long lithium niobate waveguide.

Genotypic resistance of hepatitis B virus to lamivudine in renal transplant recipients

Renal recipients with hepatitis B virus (HBV) should be treated with prolonged lamivudine. However, lamivudine resistance usually results after YMDD mutation within the HBV polymerase gene. Thereupon, the aim of this study was to investigate the genotypic resistance to lamivudine among renal transplant recipients to identify its effect on the clinical course of HBV in these patients. Between March 1997 and September 2003, eight of 17 renal transplant patients with hepatitis B virus were enrolled into this study and treated with 100 mg of lamivudine once each day. We amplified a selected region of the polymerase gene of HBV in order to confirm mutations in the YMDD motif. Mutations of YMDD region were observed in five of eight patients (62.5%). Out of five patients positive for HBV DNA, three (60%) showed genotypic resistance (YMDD mutation) with a normal ALT level. Two patients converted to HBV DNA negative. But, they were not associated with HBeAg seroconversion. Out of three patients who were pretransplant HBV DNA negative, genotypic resistance was observed in two patients (67%) revealing both positivity of HBe antibody and negativity of HBV DNA. In conclusion, although a normal ALT level and HBV DNA negative are maintained, the mutation of the YMDD locus may develop. Accordingly, we suggest that if the YMDD mutation is not involved in the progression of hepatitis B, lamivudine therapy should be continued despite genotypic resistance.

Matrix metalloproteinases activity demonstrated in the infective stage of the nematodes, Angiostrongylus cantonensis

Ingestion of the larval nematode Angiostrongylus cantonensis can cause the human eosinophilic meningitis known as angiostrongyliasis. Analysis of the extracts and excretory-secretory (ES) products of A. cantonensis larvae and adult stages on gelatin substrate zymography demonstrated the presence of distinct gelatinolytic enzymes. In worm extracts, inhibitor studies showed that the metalloproteinases revealed in L(1) (23 kDa), L(3) (66, 42 and 30 kDa), young adult worm (72 and 94 kDa) and adult worm (72 and 94 kDa). In ES products, the L(1) revealed one low (42 kDa) and two high (105 and 94 kDa) molecular weight proteolytic bands that degraded gelatin in substrate gels. The L(3) revealed three low (66, 50, and 30 kDa) and one high (105 kDa) molecular weight proteolytic bands. Inhibitor studies confirmed that the 105 and 94 proteolytic bands of the L(1), and the 50 and 30 kDa proteolytic bands of the L(3) classification were metalloproteinases. These metalloproteinases secreted in the infective larvae may be associated with the parasite dissemination or pathogenesis.

"Shave" biopsy of the optic nerve in isolated neurosarcoidosis

We report a case of isolated central nervous system sarcoidosis, limited to the optic nerve, characterized by negative systemic work up and neuroradiological features consistent with both optic sheath meningioma and optic nerve glioma. A magnetic resonance imaging examination revealed a dural tail sign associated with a diffuse enhancement and enlargement of the optic nerve. Both positive laboratory findings and systemic manifestation of sarcoidosis or autoimmune diseases were absent. Because of progressive visual loss, tissue confirmation was sought and the optic nerve itself biopsied after non-diagnostic dural samplings. The approach to this was to perform a "shave" biopsy of the optic nerve within its intracranial compartment. This procedure spared the central macular fibers and was not associated with loss of vision. The use of the fiber-sparing "shave" biopsy provided diagnostic samples containing non-caseating granulomas, without compromising the patient's preoperative central visual field. The authors advocate the use of this simple and safe technique when a definitive diagnosis among optic nerve meningioma, optic nerve glioma and isolated neurosarcoidosis cannot be reached by means of less invasive procedures.

Can we expand the Milan criteria for hepatocellular carcinoma in living donor liver transplantation?

INTRODUCTION

The Milan criteria, namely, tumors 5 cm or less in diameter in patients with single hepatocellular carcinoma (HCC), no more than 3 tumor nodules, and each 3 cm or less in diameter in patients with multiple tumors, are accepted for cadaveric liver allocation. However, in living donor liver transplantation (LDLT), graft donation may only depend on the donor's intention. The aim of this study was to elucidate the feasibility of Milan criteria in LDLT.

MATERIALS AND METHODS

From January 2001 to December 2002, 46 cases of liver transplantation (LT) for HCC included 5 hospital mortalities and 3 cadaveric transplantations, all of which were excluded. We classified the patients into Group I cases that met the Milan criteria and Group II cases that did not meet the Milan criteria. The analyses examined tumor-related risk factors affecting recurrence and survival, such as tumor size, number of tumor nodules, and presence of microvascular and macrovascular invasion.

RESULTS

Twenty-one cases belonged to Group I and 17 to Group II. There was no significant difference in the recurrence or survival rates between Groups I and II. The risk factors affecting recurrence were macrovascular invasion and tumor size (5 cm). The number of tumor nodules and microvascular invasion did not appear to affect recurrence. The risk factor affecting survival was macrovascular invasion.

CONCLUSION

We suggest that in selected cases the Milan criteria could be extended to increase the number of tumor nodules as long as the HCC were small and did not macrovascular invasion.

Factors affecting graft survival after living donor liver transplantation

Living donor liver transplantation (LDLT) has been considered as an alternative option to resolve the shortage of cadaveric donor organs, despite the ethical aspects of the donor procedure. The objective of this study was to analyze the risk factors affecting graft survival in LDLT. From June 1996 to December 2002, 141 patients who underwent LDLT were retrospectively analyzed. Graft survival rates were 82.5%, 80%, 77.3%, and 77.3% at 6 months, 1 year, 3 years, and 5 years, respectively. The factors influencing graft survival in univariate analysis were graft-to-recipient body weight ratio (GRWR) less than 0.8% (P = .0009), intraoperative transfusion of more than six packed RBC units in addition to the use of cell saver amounts (P = .0001), left lobe grafts in adults causing small-for-size situations (P = .0135), and donor age (P = .0472). The multivariate analysis demonstrated that GRWR less than 0.8% (P = .002) and intraoperative transfusion of more than six packed RBC units (P = .014) were independent factors that decreased graft survival rates. The graft selection of greater than 0.8% of GRWR and reduction of intraoperative RBC transfusion improve graft survival.

Posttransplantation lymphoproliferative disorder in pediatric liver transplantation

INTRODUCTION

The aim of this study was to evaluate the clinical features of risk factors for posttransplantation lymphoproliferative disorder (PTLD) in pediatric liver transplantation.

MATERIALS AND METHODS

Between June 1996 and June 2002, among 41 pediatric patients who underwent liver transplantation, 7 died in the postoperative period. Thirty-five patients, including 1 patient who died of PTLD, were reviewed. Based on the serology results, patients were divided into a high-risk group (EBV-naive recipients of EBV-positive grafts) and a low-risk group (patients other than those in the high-risk group).

RESULTS

Five of 41 patients (12.2%) developed PTLD. All of them belonged to the high-risk group. The incidence of PTLD in the high-risk group was 31.3% (5 of 16). The mean duration between operation and diagnosis for PTLD was 9.8 months. Primary EBV infection developed at a median of 6 months after transplantation. Three of 5 patients developed rejection before the diagnosis of PTLD. One patient was diagnosed with laryngeal and gastrointestinal PTLD, whereas the other 4 had gastrointestinal PTLD. They experienced the following symptoms and signs: anemia (100%), hypoalbuminemia (100%), fever (80%), diarrhea (80%), gastrointestinal bleeding (80%), and anorexia (60%).

CONCLUSION

The common features of PTLD development were as follows: (1) EBV-positive donors placed into EBV-naive recipients, (2) primary EBV infection approximately 6 months after transplantation, (3) young age, 1 year old at operation, and (4) requirement for intensive posttransplantation immunosuppression.

Adenovirus-mediated CTLA4 immunoglobulin G gene therapy in cardiac xenotransplantation

BACKGROUND

CTLA4 immunoglobulin (CTLA4 Ig), which binds with high affinity to B7-1 and B7-2, interrupts T-cell activation by inhibiting the costimulatory signal. CTLA4Ig has been used to achieve antigen-specific tolerance induction in cardiac allografts. On the other hand, we have shown that short-term administration of deoxyspergualin (DSG) and daily cyclosporine (CsA) induces long-term survival of cardiac xenotransplants. We hypothesized that the combination therapy of DSG and adenovirus-mediated CTLA4IgG might induce long-term, survival or tolerance in cardiac xenotransplantation.

OBJECTIVES

Syrian hamster hearts were transplanted heterotopically into Lewis rats. We compared the survival time and immunopathology of the following five groups: (1) no treatment; (2) DSG (5 mg/kg per day intramuscularly [IM], days -1 to +7) alone; (3) CsA (15 mg/kg per day IM, day 0 to rejection) plus DSG; (4) AdexLacZ (LacZ-adenovirus 1 x 10(9) (PFU intravenously [IV], day -7) plus DSG; and (5) AdexCTLA4IgG (CTLA4IgG-adenovirus 1 x 10(9) PFU IV, day -7) plus DSG.

RESULTS

The survival times were: (1) no treatment, 3.7 days; (2) DSG alone, 12.4 days; (3) CyA plus DSG, >100 days; (4) AdexLacZ plus DSG, 11.0 days; and (5) AdexCTLA4IgG plus DSG, 23.6 days. Adenovirus-mediated CTLA4IgG therapy with DSG prolonged survival time significantly compared with DSG alone or AdexLacZ plus DSG, but CTLA4IgG therapy was not as effective as CsA. Immunopathology showed the deposition of C3 and IgM on the endothelium in the AdexCTLA4IgG plus DSG group.

CONCLUSIONS

We showed that the effectiveness of adenovirus-mediated CTLA4IgG gene therapy in cardiac xenotransplantation in less than that of CsA. Combination therapy with inhibition of the B7/CD28 constimulatory signal and DSG administration might not be sufficient for long-term survival or tolerance in cardiac xenotransplantation.

Small-for-size graft in adult living-donor liver transplantation

In the era of living donor liver transplantation (LDLT), graft size is related to recipient prognosis. This study was performed to compare the clinical outcomes according to the graft-to-recipient weight ratio (GRWR) in adult LDLT. Seventy-nine adult patients who had undergone LDLT between June 1997 and June 2002 were retrospectively analyzed. The patients were divided into two groups according to the GRWR (group I, GRWR < 0.8%, n = 11; group II, GRWR > or = 0.8%, n = 68). The mean follow-up period was 19.4 (range 1 to 48) months. The recipients were 62 men (78.5%) and 17 women (21.5%) of mean age 45.2 (range 18 to 63) years. The overall patient survival rates were 74.7% at 1 year and 70.7% at 2 years. The patient survival rate in group I was 54.6% at 1 year and 40.9% at 2 years, whereas that in group II was 77.9% at 1 year and 75.3% at 2 years, showing a significant difference (P = .03). There were no significant differences in postoperative total bilirubin, transaminase enzyme level, prothrombin time (INR), portal vein flow on Doppler sonography, amount of ascites through the drain, complications, or acute rejection rates between the two groups. In conclusion, the minimum acceptable graft size in an adult-to-adult LDLT is GRWR of 0.8%. This study suggests that careful postoperative management and/or technical modifications during surgery are necessary, because small-for-size grafts (GRWR < 0.8%) result in lower patient survival rates.

Clinicopathological features of incidental hepatocellular carcinoma in liver transplantation

The incidence of detecting hepatocellular carcinoma (HCC) in a removed recipient liver after a liver transplant is not rare. The clinical features are expected to be different from the preoperatively diagnosed HCC. The aim of this study was to evaluate the clinicopathological features of incidental HCC. This study retrospectively analyzed five cases of incidental HCC among 51 liver transplant cases of HCC operated from September 1996 to February 2002. The proportion of an incidental HCC was 9.8%. The mean age was 46.2 years with a higher prevalence in may (80%, four cases). The alpha-fetoprotein level was normal or mildly elevated. HBsAg was positive in all cases. Imaging studies revealed regenerative or dysplastic nodules, or no specific lesion. The pathological findings demonstrated a mean size of 1.16 cm, multiplicity in three cases (60%), no microvascular invasion, and Edmonson grade I (60%) and II (40%). There was no recurrence of the HCC. However, two patients died due to an intracranial hemorrhage and a graft failure, respectively. In conclusion, incidentally found HCC showed less invasive pathological features and a better prognosis.

Ultrastructural localization of matrix metalloproteinase-9 in eosinophils from the cerebrospinal fluid of mice with eosinophilic meningitis caused by Angiostrongylus cantonensis

Matrix metalloproteinase-9 (MMP-9) has been implicated in the pathogenesis of eosinophilic meningitis caused by Angiostrongylus cantonensis. In the present study, such meningitis in mice was found to be associated with elevated expression of MMP-9 mRNA, elevated MMP-9 concentrations and enhanced MMP-9 activity in the cerebrospinal fluid (CSF). Immunocytochemistry showed that an anti-MMP-9 antibody reacted with macrophages, neutrophils and eosinophils from the CSF. As eosinophils are generally considered to be effector cells in host defence against A. cantonensis infection, high-resolution immuno-electron microscopy was then used to confirm the localization of MMP-9 in the eosinophils from the CSF. The method used, which was based on immunogold, indicated that the eosinophilic MMP-9 was mostly localized in the 'small' granules in the cytoplasm and along the cell membrane, and not in the crystalloid-containing secretory granules observed. It therefore appears that MMP-9 is synthesised and/or stored in the small granules of the eosinophils, and is released into the subarachnoid space of the host's brain by secretion or cell rupture.