Single-center experience of 253 portal vein thrombosis patients undergoing liver transplantation in China

OBJECTIVE

We sought to review the etiopathogenesis, diagnosis, and surgical options for 253 patients with portal vein thrombosis (PVT) undergoing orthotopic liver transplantation (OLT) to assess the the impact of PVT on outcomes.

METHODS

We retrospectively analyzed the data from 2508 adult patients undergoing 2614 OLTs in our center from September 1998 to July 2007. PVT was scored according to the operative findings and Yerdel grading of PVT. No prisoners were used as donors for this study.

RESULTS

Two hundred fifty-three patients were diagnosed with PVT (10.09%): there were 104 grade I; 114, grade II; 29, grade III; and 6, grade IV PVT. Sex and previous splenectomy increased the risk for PVT. In grade I and II cases, we performed simple thrombectomy, eversion thrombectomy, or improved eversion thrombectomy (IET, innovated by our center), producing smooth postoperative recoveries with a 0% in-hospitality mortality. In grade III cases, 18 underwent successful IET. Of 11 subjects who had eversion thrombectomy, six failed, and the distal superior mesentery vein or dilated splanchnic collateral tributary had to be used as the inflow vessel in four patients, and portal vein arterialization were performed in the other two patients, all of whom experienced a smooth postoperative recovery except one who died of hepatic failure and pulmonary infection 2 weeks after the operation. The in-hospitality mortality was 3.45%. In grade IV cases, three underwent successful IET, but another three cases failed, with two of them requiring a renal vein as the inflow vessel, and other one undergoing portocaval hemitransposition, with one postoperative death due to hepatic failure and another of cancer recurrence, an in-hospitality mortality rate of 33.33%. The transfusion requirement among PVT patients was significantly higher than that in non-PVT patients (9.32 +/- 3.12 U vs 6.02 +/- 2.40 U; P < .01). Blood loss in PVT patients who underwent the IET technique was significantly lower than that for an eversion thrombectomy (2800.36 +/- 930.52 mL vs 5700.21 +/- 162.50 mL P < .05). The overall actuarial 1-year survival rate in PVT patients was similar to the controls (86.56% vs 89.40%; P > .05).

CONCLUSION

OLT was successfully performed for PVT patients. The grade of PVT decided the surgical strategy. Similar 1-year survival rates were attained between PVT patients and controls undergoing OLT.

Prospective comparison of 3D FIESTA versus fat-suppressed 3D SPGR MRI in evaluating knee cartilage lesions

AIM

To prospectively compare the accuracy of three-dimensional fast imaging employing steady-state acquisition (3D FIESTA) sequences with that of fat-suppressed three-dimensional spoiled gradient-recalled (3D SPGR) in the diagnosis of knee articular cartilage lesions, using arthroscopy as the reference standard.

MATERIALS AND METHODS

Fifty-eight knees in 54 patients (age range 21-82 years; mean 36 years) were prospectively evaluated by using sagittal 3D FIESTA and sagittal fat-suppressed 3D SPGR sequences. Articular cartilage lesions were graded on MRI and during arthroscopy with a modified Noyes scoring system. Sensitivity, specificity, and accuracy were assessed. Interobserver agreement was determined with kappa statistics.

RESULTS

The performance of 3D FIESTA sequences (sensitivity, specificity, and accuracy were 80, 94, and 92%, respectively, for reader 1 and 76, 94, and 90%, respectively, for reader 2) was similar to that of fat-suppressed 3D SPGR sequences (sensitivity, specificity, and accuracy were 82, 92, and 90%, respectively, for reader 1 and 82, 90, and 88%, respectively, for reader 2) in the detection of knee articular cartilage lesions. The interobserver agreement varied from fair to good to excellent (kappa values from 0.43-0.83).

CONCLUSION

3D FIESTA has good diagnostic performance, comparable with fat-suppressed 3D SPGR in evaluating knee cartilage lesions, and it can be incorporated into routine knee MRI protocols due to the short acquisition time.

A phase II trial of gefitinib and pegylated interferon alfa 2b (PEG-IFN) in previously-treated renal cell carcinoma (RCC)

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Background: Modulation of the epidermal growth factor receptor (EGFR) pathway is relevant to IFN activity in RCC. Cell lines sensitive to IFN's antiproliferative effects downregulate EGFR, while IFN treatment of resistant cells precludes such an effect. (Eisenkraft et al, Cancer Res. 1991) Lack of EGFR down-regulation may thus be responsible in part for IFN resistance. To explore this hypothesis, we conducted a trial of the EGFR tyrosine kinase inhibitor gefitinib plus PEG-IFN in RCC patients (pts). Methods: Unresectable or metastatic RCC pts (no limit on prior therapies; performance status 0–2, and adequate end-organ function) were eligible. Prior IFN was allowed. Dose schedule: PEG-IFN SQ weekly (6μg/kg/week or 4 μg/kg/week) × 12 weeks and gefitinib 250 mg po daily until progression. A 6-month progression free survival (PFS) rate of 50% was considered promising (vs. 30%) in a two-stage design incorporating the Green-Dahlberg rule. We accrued 21 patients in the first-stage of accrual. Results: Pt characteristics: Males -16; median age - 56 years; Prior nephrectomy - 12. All had > 1 prior systemic therapy . Accrual slowed with increased use of small molecule kinase inhibitors, bevacizumab, and temsirolimus for RCC. At 6 months, PFS was 26% (95% CI: 9%, 49%); 20% (4 pts) had died. Best responses by RECIST: complete (1), partial (4), stable (8); progression (4). Response duration: CR (35+ months) and PR (3, 5, 5, 38+ months). Median time to treatment failure was 18.4 weeks (95%CI: 7.4, 24.9). Median PFS and overall survival were 23 and 53 weeks, respectively. Most common treatment-related toxicities were leucopenia, thrombocytopenia, rash, nausea, diarrhea, and hyperglycemia. Conclusions: Although gefitinib plus PEG-IFN did not meet the pre-specified 6-month PFS of 50%, it appears to have activity similar to other first-line therapies even in this previously-treated setting. (Supported by Astra Zeneca)

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Design of a phase 0 microdosing trial for correlation of platinum-induced DNA damage to chemotherapy outcomes

2543

Background: DNA damage is the critical step in cancer cell response to platinum (Pt) chemotherapy. We hypothesize that low levels of Pt-induced DNA damage are predictive of chemoresistance. Accelerator mass spectrometry (AMS), an ultrasensitive method for measuring radiocarbon, can detect [14C]carboplatin bound to the DNA of cancer cells from cell culture, mice bearing tumor xenografts and patients receiving subtoxic microdoses of compound. Methods: Cancer cells and mice bearing tumor xenografts were treated with one microdose (1/100th of the therapeutic dose) or one therapeutic dose of [14C]carboplatin. Relevant parameters such as drug influx/efflux, intracellular drug inactivation, DNA damage and repair, were measured and correlated with response to chemotherapy. A Phase 0 microdosing trial has been designed to study patients with non-small cell lung or bladder transitional cell cancers who are planning to receive Pt-based chemotherapy. One microdose of [14C]carboplatin is administered to these patients 4 hours before biopsy. Pt-induced DNA damage and repair in tumor biopsy specimens and other relevant parameters will be measured and correlated with the response and toxicity of chemotherapy. Results: Preclinical studies showed that AMS can detect Pt-DNA damage when cancer cells and mice with tumor xenografts are exposed to one microdose of [14C]carboplatin. The levels of microdose-induced DNA damage are directly proportional to the damage caused by a therapeutic drug dose (p<0.001); and these levels of DNA damage correlate with chemoresistance as measured by MTT assay. Measuring drug uptake/efflux and intracellular inactivation allows insights into resistance mechanisms. These data support the conclusion that the levels of DNA damage induced by microdosing can potentially predict chemoresistance in patients. Consequently, a Phase 0 microdosing trial is in progress. Conclusions: These results support a phase 0 microdosing trial employing AMS to identify chemoresistance and determine the underlying chemoresistant mechanisms for personalized therapy before patients receive cytotoxic chemotherapy.

[Table: see text]

Preoperative chemoradiation and postoperative adjuvant tetrathiomolybdate for patients with resectable esophageal cancer

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Background: Tetrathiomolybdate (TM) is an oral copper chelator. Copper is necessary for blood vessel growth, and so TM functions as an antiangiogenic agent. Methods: Pts with resectable esophageal cancer were treated at the University of Michigan with chemoradiation followed by surgery, and then 2 years of TM. Chemoradiation was cisplatin 60 mg/m2 on days #1 and 22, paclitaxel 60 mg/m2 on days #1, 8, 15, and 22, and radiation 1.5 Gy fractions b.i.d. x 3 weeks to a total of 45 Gy. Transhiatal esophagectomy was performed on approximately day #50. TM 20 mg p.o. q.d. was started approximately 4 weeks post-op, and continued for 2 years. Doses were adjusted to maintain the ceruloplasmin level between 5 and 15. Results: Between 1/23/02 and 1/24/06, 69 pts were enrolled. Pt characteristics: males - 62 (90%), females - 7 (10%); median age - 60 (range 42–74); adenocarcinoma - 56 (81%), squamous cell carcinoma 13 (19%). The chemoradiation was well tolerated: grade 3 leukopenia in 15 pts (22%), and 17 pts (25%) required feeding tubes. 66 pts went to surgery. 61 pts had a complete resection; 4 pts had metastases discovered at surgery, and 1 pt had extensive positive margins. Histologic complete response rate was 10%. 21 pts never received TM because of metastases noted in the peri-operative period, long post-op recovery time, or pt refusal. 48 pts started TM after surgery and it was well tolerated. Grade 3 toxicities were diarrhea -2 (3%), nausea - 2 (3%), dizziness - 2 (3%). 13 pts completed the full 24 mos of treatment, 12 completed 10–23 mos, 15 completed 2–8 mos, and 8 completed only 1 month or less. 27 pts have had disease recurrence, the majority (23 of the 27) of which was distant. Current status of pts with median follow-up time of 55 months: 25 alive and disease-free, 1 alive with disease, and 43 have died. 3-year survival probability is 47% (95% CI 35%-58.6%). 3-year recurrence-free probability is 51% (95% CI 38%- 62.7%). Conclusions: TM is an antiangiogenic agent which is fairly well tolerated. Prolonged adjuvant treatment over 2 years is difficult but not impossible to complete. Disease-free survival and overall survival are promising when compared to historical controls treated with a very similar chemoradiation regimen without TM in the past at the University of Michigan.

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Assessment of mitral valve volume by quantitative three-dimensional echocardiography in patients with rheumatic mitral valve stenosis

BACKGROUND

Thickening of mitral leaflets in rheumatic mitral valve stenosis is well described in necropsy studies; however, volume computation of the thickening mitral leaflets has not been attempted. 4trial fibrillation is one of the complications of rheumatic mitral stenosis. Quantitative assessment of thickened mitral valve and its relation to clinical complications is clinically desirable.

HYPOTHESIS

The study was undertaken to compare measurement of mitral valve volume in normal subjects and in patients with rheumatic mitral valve stenosis.

METHODS

An HP Sonos 2500 echocardiographic system with 5 MHz multiplane transesophageal transducer was used for data acquisition, and TomTec Echoscan computer setup was used to off-line volume computation. Study subjects included 10 normal subjects (mean age 44.8 years) and 36 patients with rheumatic mitral valve stenosis (22 female, 14 male) with an age range of 25 to 69 years (mean age 47 +/- 9.6 years). Mitral valve volumes were compared between the normal subjects and patients with mitral valve stenosis, and further comparison was made between the sinus rhythm (SR) and atrial fibrillation (AF) groups in patients with mitral valve stenosis. In all study subjects, the mitral valve area (MVA) was determined by two-dimensional echocardiography.

RESULTS

Quantitative three-dimensional (3-D) echocardiography showed that mitral valve volume was significantly larger in patients with mitral valve stenosis than in normal subjects (9.0 +/- 2.2 and 4.5 +/- 0.7 ml, respectively, p < 0.001). When patients with mitral valve stenosis were divided into the SR and AF groups, mitral valve volume was found to be significantly larger in the AF group than in the SR group (9.76 +/- 2.2 ml. and 7.72 +/- 1.5 ml, respectively, p < 0.01) and patients in the AF group tended to be older (p < 0.05) with larger left atrial diameter (LAD) (p < 0.01). However, MVA between the two groups showed no statistical significance (1.1 +/- 0.43 and 1.0 +/- 0.34 cm2, respectively, p > 0.2). When the study subjects were divided into two groups (< 50 and > or = 50 years) according to age, the comparison of mitral valve volume between these two groups (9.37 +/- 2.18 and 8.56 +/- 2.14 ml, p > 0.2) showed no statistical significance.

CONCLUSIONS

Quantitative 3-D echocardiography can be applied for the measurement of mitral valve volume in vivo. Patients with rheumatic mitral valve stenosis with atrial fibrillation have a propensity to have a larger mitral valve volume and are older than the patients with sinus rhythm; however, the age per se does not seem to be a cause for larger mitral valve volume.

PCR-SSCP and &lt;i&gt;Hin6&lt;/i&gt;I PCR-RFLP detecting novel anonymous SNPs within ovine &lt;i&gt;PROP1&lt;/i&gt; gene (Brief report)

Abstract. PROP1 plays a direct or indirect key role in the ontogenesis of pituitary gonadotropes, as well as somatotropes, lactotropes and caudomedial thyrotropes (WU et al., 1998). Mutations of PROP1 are responsible for deficiencies of POU1F1, GH, prolactin (PRL) and thyroid stimulating hormone (TSH) in Snell and Jackson dwarf mice and in man, as well as deficiencies of LH and FSH, suggesting that the PROP1 gene is a potential candidate gene associating with production traits in animal breeding and genetics. To date, no polymorphism of PROP1 gene has been reported in ruminant animals except bovine (PAN et al., 2007). So, the objective of this study is to investigate the polymorphism of all coding regions within ovine PROP1 gene by PCR-SSCP, DNA sequencing and PCR-RFLP methods, which will possibly contribute to conducting association analysis and evaluating them as genetic markers in animal breeding and genetics.

Comparison of vildagliptin and acarbose monotherapy in patients with Type 2 diabetes: a 24-week, double-blind, randomized trial

AIMS

To compare the efficacy and tolerability of the dipeptidyl peptidase-4 inhibitor, vildagliptin, with the alpha glucosidase inhibitor, acarbose, in drug-naive patients with Type 2 diabetes.

METHODS

This multi-centre, randomized, double-blind, parallel-arm study compared the efficacy and tolerability of vildagliptin (100 mg daily, given as 50 mg twice daily, n = 441) and acarbose (up to 300 mg daily, given as three equally divided doses, n = 220) during 24-week treatment in drug-naive patients with Type 2 diabetes.

RESULTS

Monotherapy with vildagliptin or acarbose decreased glycated haemoglobin (HbA(1c)) (baseline approximately 8.6%) to a similar extent during 24-week treatment. The adjusted mean change from baseline to end-point (AMDelta) in HbA(1c) was -1.4 +/- 0.1% and -1.3 +/- 0.1% in patients receiving vildagliptin and acarbose, respectively, meeting the statistical criterion for non-inferiority (upper limit of 95% confidence interval for between-treatment difference < or = 0.4%). The decrease in fasting plasma glucose was similar with acarbose (-1.5 +/- 0.2 mmol/l) and vildagliptin (-1.2 +/- 0.1 mmol/l). Body weight did not change in vildagliptin-treated patients (-0.4 +/- 0.1 kg) but decreased in acarbose-treated patients (-1.7 +/- 0.2 kg, P < 0.001 vs. vildagliptin). The proportion of patients experiencing any adverse event (AE) was 35% vs. 51% in patients receiving vildagliptin or acarbose, respectively; gastrointestinal AEs were significantly more frequent with acarbose (25.5%) than vildagliptin (12.3%, P < 0.001). No hypoglycaemia was reported for either group.

CONCLUSIONS

Vildagliptin is effective and well tolerated in patients with Type 2 diabetes, demonstrating similar glycaemic reductions to acarbose, but with better tolerability.

Diagnosis and treatment for tuberculosis infection in liver transplant recipients: case reports

AIM

Tuberculosis (TB) infection after liver transplantation was described, diagnosed and treated herein.

METHODS

We reviewed the clinical presentation, methods of diagnosis, and treatment of 2 cases of TB infection posttransplantation.

RESULTS

Mycobacterium TB infection occurred in 2 of 110 (1.8%) patients undergoing liver transplantation between 2001 and 2006. Pyrexia, poor appetite, and weight loss were common presentations. The diagnosis was confirmed using lymph node biopsy and treated with standard antituberculous agents. One patient was suspected of having TB infection by clinical presentation, and tentative anti-TB drugs were used. The duration of treatment was 9 months.

CONCLUSIONS

Early diagnosis and treatment are important in these patients. Careful monitoring of liver function and immunosuppressant levels are essential for patients who receive standard anti-TB drugs.

Spectroscopic imaging of the pilocarpine model of human epilepsy suggests that early NAA reduction predicts epilepsy

Reduced hippocampal N-acetyl aspartate (NAA) is commonly observed in patients with advanced, chronic temporal lobe epilepsy (TLE). It is unclear, however, whether an NAA deficit is also present during the clinically quiescent latent period that characterizes early TLE. This question has important implications for the use of MR spectroscopic imaging (MRSI) in the early identification of patients at risk for TLE. To determine whether NAA is diminished during the latent period, we obtained high-resolution (1)H spectroscopic imaging during the latent period of the rat pilocarpine model of human TLE. We used actively detuneable surface reception and volume transmission coils to enhance sensitivity and a semiautomated voxel shifting method to accurately position voxels within the hippocampi. During the latent period, 2 and 7 d following pilocarpine treatment, hippocampal NAA was significantly reduced by 27.5 +/- 6.9% (P < 0.001) and 17.3 +/- 6.9% (P < 0.001) at 2 and 7 d, respectively. Quantitative estimates of neuronal loss at 7 d (2.3 +/- 7.7% reduction; P = 0.58, not significant) demonstrate that the NAA deficit is not due to neuron loss and therefore likely represents metabolic impairment of hippocampal neurons during the latent phase. Therefore, spectroscopic imaging provides an early marker for metabolic dysfunction in this model of TLE.

Five novel single nucleotide polymorphisms (SNPs) of the prophet of PIT1 (<i>PROP1</i>) gene in bovine (Brief report)

Abstract. The prophet of Pit1 (PROP1) gene encodes a paired class homeodomain transcription factor of 226 amino acids and is organized of 3 exons. PROP1 is necessary for the specification, differentiation and proliferation of cells. Its function is essential for anterior pituitary organogenesis, and heritable mutations in this gene are associated with combined pituitary hormone deficiency (CPHD) in human patients and animals (SAVAGE et al., 2003; CARVALHO et al., 2006). To date, no polymorphisms of the bovine PROP1 gene were described. In the present experiment, the 5' flanking region, the coding region and partial introns of bovine PROP1 were scanned for single nucleotide polymorphism (SNPs) in five cattle breeds of China.