Which is more suitable for kidney transplantation at the early post-transplantation phase in China - low dosing or standard dosing of enteric-coated mycophenolate sodium?

AIMS

To investigate the pharmacokinetics of enteric-coated mycophenolate sodium (EC-MPS) and the clinical outcome in kidney transplant recipients in the early post-transplantation phase. Then explain which regimen is more suitable for Chinese renal transplant recipients.

METHODOLOGY

In total, 60 de novo kidney transplant recipients treated with tacrolimus and steroids were randomised to receive EC-MPS at standard dose (SD; 1440 mg/day; n = 28) or low dose (LD; 1080 mg/day; n = 32). Efficacy parameters, safety and tolerability were assessed over a 6-month study period. Full mycophenolic acid (MPA) areas under the curve (AUCs) were completed on days 3 and 5, whereas a three-point limited sampling strategy (LSS) was utilised for MPA AUC assessments at 2 weeks and months 1, 3 and 6 (the LSS for three-time-point MPA AUC 0-12 h (mg h/l) = 15.99 + 0.87C1 h  + 0.68C2 h  + 7.85C4 h ; r(2)  = 0.8670.

RESULTS

The mean AUC levels at day 3 and day 5 in the SD group were significantly higher than in the LD group (57.4 mg·h/l vs. 38.2 mg·h/l and 59.3 mg·h/l vs. 44.8 mg·h/l, respectively, p < 0.01). There was a trend for fewer clinically diagnosed acute rejections in the SD group vs. the LD group at 6 months (7.1% vs. 12.5%). This trend was also present when acute rejection was analysed as biopsy-proven cases. There were significantly more acute rejections (all definitions) in patients with MPA AUC levels < 30 mg·h/l compared with those with MPA AUC levels ≥ 30 mg·h/l within 6 months (p < 0.05). Renal function, incidence of infection and haematological disorders were not significantly different in either study group.

CONCLUSIONS

Early adequate MPA exposure in renal transplant recipients can be achieved with a higher starting dose. In addition, a SD regimen was as well-tolerated as a LD regimen. Furthermore, early adequate MPA exposure significantly lowered the rate of acute rejection without compromising safety and tolerability.

Gestational autoimmune disease in newborns with an indeterminate cause of death following a complete autopsy

Gestational alloimmune liver disease (GALD) is the result of neonatal complement-mediated severe liver injury mediated by maternal alloantibodies, which is detected by immunohistochemistry staining for the complement C5b-9 complex. GALD leads to the neonatal hemochromatosis (NH) phenotype, which also shows extrahepatic siderosis, and can result in neonatal death. At autopsy, the histologic damage of the liver in GALD may be subtle and misinterpreted as non-specific post-mortem changes, resulting in the cause of death classified as indeterminate. We reviewed the pathologic diagnoses from autopsy material from 1996 to 2011 of infants 0-90 days of age from our institution. Liver samples were stained with H&E, trichrome and for C5b-9. 13 cases originally diagnosed as indeterminate cause of death were identified and divided in 3 groups: (1) No clinical or autopsy-derived diagnoses (n = 7), (2) Defined clinical diagnoses but no cause of death determined at autopsy (n = 2), and (3) Liver disease, but no clinical or autopsy diagnoses to establish the cause of the liver injury (n = 4). On reexamination, all group 1 and 3 cases were reclassified as GALD, based on a positive C5b-9 stain. Group 2 cases were not GALD, retaining the original, clinically-based cause of death. We conclude that, in cases of indeterminate cause of neonatal death, very careful examination for hepatocyte injury/necrosis, extrahepatic siderosis, liver fibrosis and/or C5b-9 stain should be considered.

Rapid large-scale culturing of microencapsulated hepatocytes: a promising approach for cell-based hepatic support

INTRODUCTION

The efficacy of any bioartificial liver device requires both rapid production and proper bioactivity of the cells for the bioreactor. The goal of this study was to observe the effect of spinner speed and cell density on the proliferation of microencapsulated immortalized human hepatocytes (HepLL) and human hepatoma (HepG2) cells.

MATERIALS AND METHODS

Alginate-chitosan microcapsulated HepG2 and HepLL cells were randomly divided into 2 groups, and each group was further divided into 8 subgroups according to embedded cell density and spinner speed. The growth, metabolism, and functions of the encapsulated cells in each group were evaluated.

RESULTS

In each group, the cell number, ammonium removal, albumin synthesis, and diazepam clearance increased significantly with the spinner speed, whereas embedded cell density had no impact. Albumin synthesis, removal of ammonium, and diazepam clearance were significantly higher in the microencapsulated HepLL groups than in HepG2 cells at any time point, without any significant difference in cell numbers.

CONCLUSIONS

Spinner culture significantly promoted microencapsulated HepLL and HepG2 cell bioactivity. Wrapped cells had optimal function on day 10 in rolling culture groups. These data show that HepLL cells would be a promising candidate for cell-based liver support therapy.

Management of a patient with small-area burns, severe sepsis and superficial vein thrombosis

Sepsis is frequently seen in severely burned patients, however it is not common in those with small-area burns. We present a case of a 22-year-old man suffering from a hot crush injury to his left hand dorsum covering 1% of his total body surface area. The patient developed severe sepsis and superficial vein thrombosis, probably due to wound infection. Culture of the wound secretion indicated Corynebacterium striatum. Following intensive topical and systemic treatment the severe sepsis was controlled. The local wound was repaired by the abdominal skin pedicle flap which had taken well by day 27 post admission. A topical superficial vein thrombosis, unintentionally found 42 days after admission, was partially excised. This case demonstrates that when treating severe sepsis in patients with small-area burns, the timely recognition and diagnosis along with active systemic support, play a vital role in successful management.

DECLARATION OF INTEREST

None of the authors have any financial interest to declare.

TBX6 null variants and a common hypomorphic allele in congenital scoliosis

BACKGROUND

Congenital scoliosis is a common type of vertebral malformation. Genetic susceptibility has been implicated in congenital scoliosis.

METHODS

We evaluated 161 Han Chinese persons with sporadic congenital scoliosis, 166 Han Chinese controls, and 2 pedigrees, family members of which had a 16p11.2 deletion, using comparative genomic hybridization, quantitative polymerase-chain-reaction analysis, and DNA sequencing. We carried out tests of replication using an additional series of 76 Han Chinese persons with congenital scoliosis and a multicenter series of 42 persons with 16p11.2 deletions.

RESULTS

We identified a total of 17 heterozygous TBX6 null mutations in the 161 persons with sporadic congenital scoliosis (11%); we did not observe any null mutations in TBX6 in 166 controls (P<3.8×10(-6)). These null alleles include copy-number variants (12 instances of a 16p11.2 deletion affecting TBX6) and single-nucleotide variants (1 nonsense and 4 frame-shift mutations). However, the discordant intrafamilial phenotypes of 16p11.2 deletion carriers suggest that heterozygous TBX6 null mutation is insufficient to cause congenital scoliosis. We went on to identify a common TBX6 haplotype as the second risk allele in all 17 carriers of TBX6 null mutations (P<1.1×10(-6)). Replication studies involving additional persons with congenital scoliosis who carried a deletion affecting TBX6 confirmed this compound inheritance model. In vitro functional assays suggested that the risk haplotype is a hypomorphic allele. Hemivertebrae are characteristic of TBX6-associated congenital scoliosis.

CONCLUSIONS

Compound inheritance of a rare null mutation and a hypomorphic allele of TBX6 accounted for up to 11% of congenital scoliosis cases in the series that we analyzed. (Funded by the National Basic Research Program of China and others.).

Interplay of spin-orbit interactions, dimensionality, and octahedral rotations in semimetallic SrIrO(3)

We employ reactive molecular-beam epitaxy to synthesize the metastable perovskite SrIrO(3) and utilize in situ angle-resolved photoemission to reveal its electronic structure as an exotic narrow-band semimetal. We discover remarkably narrow bands which originate from a confluence of strong spin-orbit interactions, dimensionality, and both in- and out-of-plane IrO(6) octahedral rotations. The partial occupation of numerous bands with strongly mixed orbital characters signals the breakdown of the single-band Mott picture that characterizes its insulating two-dimensional counterpart, Sr(2)IrO(4), illustrating the power of structure-property relations for manipulating the subtle balance between spin-orbit interactions and electron-electron interactions.

ATF3-mediated NRF2/HO-1 signaling regulates TLR4 innate immune responses in mouse liver ischemia/reperfusion injury

Activating transcription factor 3 (ATF3) is a stress-induced transcription factor that has been shown to repress inflammatory gene expression in multiple cell types and diseases. However, little is known about the roles and mechanisms of ATF3 in liver ischemia/reperfusion injury (IRI). In warm and cold liver IRI models, we showed that ATF3 deficiency significantly increased ischemia/reperfusion (IR)-stressed liver injury, as evidenced by increased serum alanine aminotransferase levels, histological liver damage, and hepatocellular apoptosis. These may correlate with inhibition of the intrahepatic nuclear factor erythroid-derived 2-related factor 2/heme oxygenase-1 (NRF2/HO-1) signaling pathway leading to enhancing Toll-like receptor 4/nuclear factor kappa beta (TLR4/NF-κB) activation, pro-inflammatory programs and macrophage/neutrophil trafficking, while simultaneously repressing anti-apoptotic molecules in ischemic liver. Interestingly, activation of NRF2/HO-1 signaling using an NRF2 activator, oltipraz (M2), during hepatic IRI-rescued ATF3 anti-inflammatory functions in ATF3-deficient mice. For in vitro studies, ATF3 ablation in lipopolysaccharide (LPS)-stimulated bone marrow-derived macrophages (BMMs) depressed levels of NRF2/HO-1 and PI3K/AKT, resulting in enhanced TLR4/NF-κB activation. Pretreatment of LPS-stimulated BMMs with M2 increased NRF2/HO-1 expression, promoted PI3K/AKT, which in turn suppressed TLR4/NF-κB-mediated proinflammatory mediators. Thus, our results first demonstrate ATF3-mediated NRF2/HO-1 signaling in the regulation of TLR4-driven inflammatory responses in IR-stressed livers. Our findings provide a rationale for a novel therapeutic strategy for managing IR-induced liver injury.

Preoperative serum CA125 is an independent predictor for prognosis in operable patients with non-small cell lung cancer

The role of serum CA125 and CEA in the prognosis of non-small cell lung cancer (NSCLC) remains controversial, especially in early stage patients, which need further clarification. Thus, in this study we carried out a large scale retrospective analysis of the prognostic value of CA125 and CEA in 645 patients with NSCLC, to explore their predictive value in the NSCLC. Patients who underwent curative surgical resection for NSCLC were from Zhejiang Cancer Hospital of China from 2006 to 2011. Microparticle enzyme immunoassay was used to measure preoperative serum CA125 and CEA. Univariate analyses and a multivariable proportional hazard Cox regression model were applied to assess the prognostic significance of the different covariates. Kaplan-Meier method was used to analyze survival curve. Both CA125 and CEA were correlated with stage, but also CA125 was different by grade, and CEA was related to histology. The Kaplan-Meier survival analysis showed that patients with elevated CA125 or CEA had unfavorable disease progression-free and overall survival time compared to those with normal CA125 or CEA. Furthermore, multivariate Cox analysis revealed that elevated CA125 had significantly higher risk for relapse (HR, 1.76; p=0.001) and death (HR, 1.80; p<0.001), but not for elevated CEA as relapse (HR, 1.06; p=0.736) and death (HR, 1.25; p= 0.119) both were statistically non significant. This study showed that both CA125 and CEA play important roles in disease progression while only CA125 as an independent predictive marker for prognosis in patients with NSCLC.

Detection of fetal sex chromosome aneuploidy by massively parallel sequencing of maternal plasma DNA: initial experience in a Chinese hospital

OBJECTIVES

To evaluate the performance of a massively parallel sequencing (MPS)-based test in detecting fetal sex chromosome aneuploidy (SCA) and to present a comprehensive clinical counseling protocol for SCA-positive patients.

METHODS

This was a retrospective study in a large patient cohort of 5950 singleton pregnancies which underwent MPS-based testing as a prenatal screening test for trisomies 21, 18 and 13, with X and Y chromosomes as secondary findings, in Southwest Hospital in China. MPS-based SCA-positive women were offered the choice of knowing whether their SCA results were positive and those who did commenced a two-stage post-test clinical counseling protocol. In Stage 1, general information about SCA was given, and women were given the option of invasive testing for confirmation of findings; in Stage 2, those who had chosen to undergo invasive testing were informed about the specific SCA affecting their fetus and their management options.

RESULTS

Thirty-three cases were classified as SCA-positive by MPS-based testing. After Stage 1 of the two-stage post-test clinical counseling session, 33 (100%) of these pregnant women chose to know the screening test results, and 25 (75.76%) underwent an invasive diagnostic procedure and karyotype analysis, in one of whom karyotyping failed. In thirteen cases, karyotyping confirmed the MPS-based test results (two X0 cases, seven XXX cases, three XXY cases and one XYY case), giving a positive predictive value of 54.17% (13/24 cases confirmed by karyotyping). After post-test clinical counseling session Stage 2, seven women chose to terminate the pregnancy: one X0 case, two XXX cases, the three XXY cases and the single XYY case. Six women decided to continue with pregnancy: one X0 case and five XXX cases.

CONCLUSION

Our study showed the feasibility of clinical application of the MPS-based test in the non-invasive detection of fetal SCA. Together with a two-stage post-test clinical counseling protocol, it leads to a well-informed decision-making procedure.

Epidemiological comparison of clinical manifestations according to HLA-B*27 carrier status of Chinese ankylosing spondylitis patients

The aim of the study was to investigate and compare the clinical manifestations between HLA-B27(+) and HLA-B27(-) ankylosing spondylitis (AS) patients in order to obtain knowledge of the impact of HLA-B27 status on AS, and to inform clinical treatment. A nationwide epidemiological investigation was performed from November 2008 to October 2010. The demographic data and clinical characteristics, and the status of HLA-B27 were collected using questionnaires and laboratory assay, respectively. A total of 2144 patients (78.5% males and 78.4% HLA-B27(+) AS patients) participated in this study. The percentages of males, patients with family history, and involvement of lumbar spine, thoracic spine and hip joints, were observed to be significantly higher in the HLA-B27(+) AS patients than in their HLA-B27(-) AS peers.

Atypical interference effect of action observation in autism spectrum conditions

BACKGROUND

Observing incongruent actions interferes with ongoing action execution. This 'interference effect' is larger for observed biological actions than for non-biological actions. The current study used virtual reality to investigate the biological specificity of interference effects of action observation in autism spectrum conditions (ASC).

METHOD

High-functioning adults with ASC and age- and IQ-matched healthy controls performed horizontal sinusoidal arm movements whilst observing arm movements conducted by a virtual reality agent with either human or robot form, which moved with either biological motion or at a constant velocity. In another condition, participants made the same arm movements while observing a real human. Observed arm movements were either congruent or incongruent with executed arm movements. An interference effect was calculated as the average variance in the incongruent action dimension during observation of incongruent compared with congruent movements.

RESULTS

Control participants exhibited an interference effect when observing real human and virtual human agent incongruent movements but not when observing virtual robot agent movements. Individuals with ASC differed from controls in that they showed no interference effects for real human, virtual human or virtual robot movements.

CONCLUSIONS

The current study demonstrates atypical interference effects in ASC.

Increased progesterone receptor A expression in labouring human myometrium is associated with decreased promoter occupancy by the histone demethylase JARID1A

Progesterone regulates female reproductive function predominantly through two nuclear progesterone receptors (PRs), PR-A and PR-B. During human parturition myometrial PR expression is altered to favour PR-A, which activates pro-labour genes. We have previously identified histone H3 lysine 4 trimethylation (H3K4me3) as an activator of myometrial PR-A expression at labour. To further elucidate the mechanisms regulating PR isoform expression in the human uterus at labour, we have (i) determined the methylation profile of the cytosine-guanine dinucleotides (CpG) island in the promoter region of the PR gene and (ii) identified the histone-modifying enzymes that target the H3K4me3 mark at the PR promoters in term and preterm human myometrial tissues obtained before and after labour onset. Bisulphite sequencing showed that despite overall low levels of PR CpG island methylation, there was a significant decrease in methylated CpGs with labour in both preterm (P < 0.05) and term (P < 0.01) groups downstream of the PR-B transcription start site. This methylation change was not associated with altered PR-B expression, but may contribute to the increase in PR-A expression with labour. Chromatin immunoprecipitation revealed that the histone methyltransferase, SET and MYND domain-containing protein 3 (SMYD3), bound to the PR gene at significantly higher levels at the PR-A promoter compared with the PR-B promoter (P < 0.010), with no labour-associated changes observed. The H3K4 demethylase, Jumonji AT-rich interactive domain 1A (JARID1A), also bound to the PR-A, but not to the PR-B promoter prior to term labour, and decreased significantly at the onset of labour (P = 0.014), providing a mechanism for the previously reported increase in H3K4me3 level and PR-A expression with labour. Our studies suggest that epigenetic changes mediated by JARID1A, SMYD3 and DNA methylation may be responsible, at least in part, for the functional progesterone withdrawal that precipitates human labour.