Emotion regulation and tic disorders in children

Tic disorders (TD) are developmental neuropsychiatric conditions often accompanied by comorbid conditions, and psychosocial hardships for child and family. The etiology of tics is unknown, and is complex and multifactorial. Stress is known to aggravate tic expression as well as associated comorbidities. Consequently, this study focused on possible connections between stress, emotion regulation, tic expression, and related psychopathology. Sixty consecutive admissions were assessed for perceived stress, emotional dysregulation, severity of obsessions and compulsions, anxiety, depression, attention deficit disorder, and tic expression at a TD clinic, in a university affiliated pediatric hospital. The results indicated that stress and emotion dysregulation were significantly related to both tic expression and severity of comorbidities. We discuss the role of emotion regulation dimensions regarding TD and related psychopathology as well as the mediating role of emotion regulation, and how they may contribute to the development of improved therapies for children with TD.

Role of Mechanotransduction in Periodontal Homeostasis and Disease

Novel findings broaden the concept of mechanotransduction (MT) in biophysically stimulated tissues such as the periodontium by considering nuclear MT, convergence of intracellular MT pathways, and mechanoresponsive cotranscription factors such as Yes-associated protein 1 (YAP1). Regarding periodontal disease, recent studies have elucidated the role of bacterial gingipain proteases in disturbing the barrier function of cadherins, thereby promoting periodontal inflammation. This leads to dysregulation of extracellular matrix homeostasis via proteases and changes the cell's biophysical environment, which leads to alterations in MT-induced cell behavior and loss of periodontal integrity. Newest experimental evidence from periodontal ligament cells suggests that the Hippo signaling protein YAP1, in addition to integrin-FAK (focal adhesion kinase) mechanosignaling, also regulates cell stemness. By addressing mechanosignaling-dependent transcription factors, YAP1 is involved in osteogenic and myofibroblast differentiation and influences core steps of autophagy. Recent in vivo evidence elucidates the decisive role of YAP1 in epithelial homeostasis and underlines its impact on oral pathologies, such as periodontitis-linked oral squamous cell carcinogenesis. Here, new insights reveal that YAP1 contributes to carcinogenesis via overexpression rather than mutation; promotes processes such as apoptosis resistance, epithelial-mesenchymal transition, or metastasis; and correlates with poor prognosis in oral squamous cell carcinoma. Furthermore, YAP1 has been shown to contribute to periodontitis-induced bone loss. Mechanistically, molecules identified to regulate YAP1-related periodontal homeostasis and disease include cellular key players such as MAPK (mitogen-activated protein kinase), JNK (c-Jun N-terminal kinase), Rho (Ras homologue) and ROCK (Rho kinase), Bcl-2 (B-cell lymphoma 2), AP-1 (activator protein 1), and c-myc (cellular myelocytomatosis). These findings qualify YAP1 as a master regulator of mechanobiology and cell behavior in human periodontal tissues. This review summarizes the most recent developments in MT-related periodontal research, thereby offering insights into outstanding research questions and potential applications of molecular or biophysical strategies aiming at periodontal disease mitigation or prevention.

Effect of ultraviolet photofunctionalisation on the cell attractiveness of zirconia implant materials

Ultraviolet (UV) light treatment of implant surfaces has been demonstrated to enhance their bioactivity significantly. This study examined the effect of UV treatment of different zirconia surfaces on the response of primary human alveolar bone-derived osteoblasts (PhABO). Disks of two zirconia-based materials with two different surface topographies (smooth, roughened) were exposed to UV light. Qualitative and quantitative assessment of PhABO on zirconia surfaces, by means of immunofluorescence, scanning electron microscopy and DNA quantification at 4 and 24 h revealed a higher number of initially attached osteoblasts on UV-treated surfaces. Cell area and perimeter were significantly larger on all UV-treated surfaces (p<0.05). The proliferation activity was significantly higher on both roughened UV-treated surfaces than on untreated samples at day 3 of culture (p<0.05). The expression levels of collagen I, osteopontin and osteocalcin at day 14 and alkaline phosphatase activity at day 7 and 14 of culture period were similar among UV-treated and untreated surfaces. Alizarin-Red-Staining at day 21 demonstrated significantly more mineralised nodules on UV-treated samples than on untreated samples. Contact angle measurements and X-ray photoelectron spectroscopy showed that UV light transformed zirconia surfaces from hydrophobic to (super-) hydrophilic (p<0.05) and significantly reduced the atomic percentage of surface carbon. The results showed that UV light pre-treatment of zirconia surfaces changes their physicochemical properties and improves their attractiveness against PhABO, primarily demonstrated by an augmented cell attachment and spreading. This may result in faster healing and better bone-to-implant contact of zirconia implants in vivo following such a pre-treatment.

Disturbances of basic self and prodromal symptoms among non-psychotic help-seeking adolescents

BACKGROUND

The goal of this study was to explore the notion that anomalies of self-experience (ASE) are a core, 'not-yet-psychotic' clinical phenotype of emerging schizophrenia and its spectrum. Method To accomplish this goal, we examined the relationship between ASE and commonly accepted risk markers in a sample of 87 help-seeking, non-psychotic adolescents (aged 14-18 years). ASE were assessed with the Examination of Anomalous Self-Experience (EASE), subclinical psychotic symptoms were assessed with the Prodromal Questionnaire and the Structured Interview for Prodromal Syndromes, deterioration in psychosocial functioning was assessed with the Social and Role Functioning Scales, and level of distress with the Mood and Anxiety Symptoms Questionnaire.

RESULTS

About 82 participants completed the entire EASE interview. The number of participants who reported ASE at a clinically meaningful level (n = 18, 22%) was smaller than that who met diagnostic criteria for a prodromal syndrome (n = 28, 34%). The degree of overlap between the two conditions was moderate but statistically significant (χ2 (1) = 7.01, p = 0.008). An exploratory factor analysis revealed that ASE load on a different factor than prodromal symptoms and deterioration in functioning, but that there is a moderate correlation between the three factors.

CONCLUSIONS

These results suggest that ASE are prevalent among non-psychotic help-seeking adolescents, yet at a considerably lower rate than prodromal symptoms. In addition, they suggest that ASE and prodromal symptoms constitute distinct but moderately related dimensions of potential risk. Taken together, they provide preliminary support for the clinical usefulness of supplementing and refining the methods of early detection of risk with assessment of ASE.

Environmental Biomechanics Substantiated by Defined Pillar Micropatterns Govern Behavior of Human Mesenchymal Stem Cells

While evidence on the impact of the biomechanical environment elasticity on human mesenchymal stem cell (hMSC) behavior is growing, the aspect of micropatterning is still poorly understood. Thus, the present study aimed at investigating the influence of defined environmental micropatterning on hMSC behavior. Following characterization, hMSCs were grown on defined pillar micropatterns of 5, 7, 9, and 11 μm. With respect to cell behavior, primary hMSC adhesion was detected by indirect immunofluorescence (iIF) for paxillin, vinculin, integrin αV, and actin, while proliferation was visualized by histone H3. Morphogenesis was monitored by scanning electron microscopy and the expression of stem cell-specific biomarkers by real-time PCR. Favoritism of primary adhesion of hMSCs on pillar tops occurred at smaller pillar micropatterns, concomitant with cell flattening. While vinculin, integrin αV, and paxillin appeared initially more cytoplasmic, high pillar micropatterns favored a progressive redistribution with polarization to cell tension sites and at cell borders. Accomplishment of morphogenesis at day 3 revealed establishment of fully rotund cell somata at 5 μm, while hMSCs appeared progressively elongated at rising micropatterns. The hMSC proliferation capacity was influenced by pillar micropatterns and gene expression analysis of stem cell- and differentiation-associated biomarkers disclosed clear modulation by distinct pillar micropatterns. In response to environmental biomechanics, our results show that hMSC behavior is governed by pillar micropatterning. In turn, these findings may form the basis to prospectively direct lineage specificity of hMSCs in a customized fashion.

Liver transplantation for primary biliary cirrhosis: results of aggressive corticosteroid withdrawal

INTRODUCTION

A subset of patients with primary biliary cirrhosis (PBC) may require long-term corticosteroid (CS) therapy following liver transplantation (OLT) due to concern over the possibility of recurrence. Our center has attempted to minimize CS use in all of our OLT recipients. In this study, we review our experience in this cohort to determine (1) patient outcome including PBC recurrence following transplantation and (2) the long-term requirement for CS use in PBC patients.

METHODS

From 1988 to 2006, 1102 OLTs were performed in 1032 adults at the University of Colorado, of which 70 patients (6.8%) with PBC received 74 allografts. Bivariate and multivariate analyses were used to evaluate predictors of CS withdrawal. Thirteen potential predictors of CS discontinuation were considered: age, gender, body mass index (BMI), race, type of graft (cadaveric or living donor [LD]), recurrence of PBC, warm ischemia time, and immunosuppressant.

RESULTS

Overall survival at 5 years was 85%. The 1-, 5-, and 10-year recurrence-free survivals were 90%, 72%, and 54%, respectively. PBC recurred in 18 patients (25.7%). Of these, none received a second transplant due to disease recurrence. At the time of last follow-up, 73% of recipients were steroid free. Independent predictors of CS discontinuation are age (>54; P = .0059) and LD graft type (P = .0008). Conversely, cyclosporine (P = .0007), female gender (P = .0216), and BMI > 31 (P = .0306) were negatively associated with CS withdraw. Importantly, steroid discontinuation did not influence PBC recurrence.

CONCLUSIONS

While long-term outcomes in PBC patients are favorable, disease recurrence can generally be managed medically without the need for a second transplant. Using an aggressive CS minimization approach, nearly three-quarters of the patients were CS free at the time of last follow-up. Increasing age and LD grafts were associated with successful CS withdraw. Conversely, cyclosporine use, female gender, and increasing BMI were associated with unsuccessful steroid discontinuation.

Prevalence of emotional distress in newly diagnosed lung cancer patients

GOALS OF WORK

Distress is defined by the National Comprehensive Cancer Network as a multifactorial unpleasant emotional experience of a psychological, social, and/or spiritual nature that may interfere with the ability to cope effectively with cancer. We investigated the prevalence and associated symptoms of distress in newly diagnosed lung cancer patients.

PATIENTS AND METHODS

Between November 2005 and July 2007, 98 newly diagnosed lung cancer patients completed an assessment. The Distress Thermometer (DT) and Edmonton Symptom Assessment Scale (ESAS) were used as screening tools.

MAIN RESULTS

Fifty (51%) patients reported clinically significant distress (>or=4) on the DT. Of those, 26 (52%) patients reported high levels of depression, nervousness, or both on ESAS. The remaining 24 (48%) patients had elevated levels of distress but no significant depression or nervousness. A correlation between the DT and the total ESAS score was observed (Pearson correlation = 0.46). The ten items of the ESAS together explained 46% of the variability in DT scores. The depression and nervousness ESAS items were significant predictors of DT score (p < 0.01 for both items). However, once the two psychosocial items, depression and nervousness, were removed from the total ESAS score, leaving only physical symptoms and the sleeplessness item, the predictive power of the model decreased to R(2) = 0.12.

CONCLUSIONS

The prevalence of distress in lung cancer patients is high. The DT appears to discriminate between physical and emotional distress. This easily measured score may determine which patients require further intervention for emotional distress.

Disseminated angiostrongylosis with fatal cerebral haemorrhages in two dogs in Germany: a clinical case study

Canine angiostrongylosis is a nematode infection in domestic dogs and wild carnivores. Few single case reports describing the occurrence of this disease in Germany exist and until recently angiostrongylosis has not been considered endemic in this country. The present report focuses on clinical, pathological and parasitological findings in two cases of fatal disseminated canine angiostrongylosis associated with multifocal haemorrhages in the central nervous system. Both animals, which lived in Germany, presented with rapidly progressive neurological signs including depression, ataxia, unilateral central blindness and epileptic seizures. Blood work revealed grossly elevated D-dimers and mild thrombocytopenia. Both animals were subsequently euthanised due to progressive clinical aggravation. Necropsy showed cerebral and lung haemorrhages in both animals. Multiple sections of nematode larvae consistent with Angiostrongylus vasorum were identified on histopathological sections of the brain, heart, kidney and lung in both animals and a predominantly granulomatous inflammation with the occurrence of multinucleated giant cells was observed. Adult nematodes were found in the larger lung arteries of one dog and Angiostrongylus infection was subsequently confirmed by PCR-analysis and sequencing in both dogs. A. vasorum larvae were not detected by faecal Baermann examination performed in one of the dogs. It was concluded that canine angiostrongylosis should be considered as differential diagnosis in dogs in Germany, even if faecal examination is negative. There is currently still a lack of studies investigating the occurrence of angiostrongylosis in dogs and intermediate hosts in Germany which would be necessary to survey the endemic realities of this disease.

Liver transplantation for autoimmune hepatitis and the success of aggressive corticosteroid withdrawal

Our center has attempted to minimize corticosteroid (CS) use in all of our orthotopic liver transplantation (OLT) recipients. Because patients with autoimmune hepatitis (AIH) typically require CSs after transplantation, we reviewed our experience in this cohort of patients to determine (1) patient outcomes including recurrent disease and (2) long-term requirements for CS use in AIH patients. From 1988 to 2006, 1102 OLTs were performed in 1032 adult patients at the University of Colorado, of whom 66 (6%) with AIH received 68 allografts. Recurrence was defined by a clinically worsening examination and histological evidence from biopsy. Bivariate and multivariate analyses were used to evaluate predictors of CS withdrawal. Twelve potential predictors of CS discontinuation were considered: age, gender, presence of inflammatory bowel disease (IBD), type of graft (cadaver or living donor), recurrence of AIH, warm ischemia time, follow-up time (time since transplant), and immunosuppressants (cyclosporine, tacrolimus, sirolimus, azathioprine, and mycophenolate mofetil). Overall survival at 5 years was 91%. The 1- and 5-year recurrence-free survival was 88% and 59%, respectively. Risk (incidence) of recurrent AIH at 1, 3, and 5 years was 12%, 26%, and 36%, respectively. Disease recurred in 23 of 66 patients or 34.8%. Of the 23 patients who developed recurrent disease, none received a second transplant because of recurrent disease. CSs were withdrawn in 50% of patients at the time of review. Only 2 factors on multivariate analysis were strongly associated negatively with CS withdrawal: (1) an increasing dose of the immunosuppressant and (2) the presence of IBD. Controlling for these other factors, we found that recurrent disease did not strongly influence CS withdrawal. In conclusion, outcomes in AIH patients were quite favorable, and none of the patients required retransplantation for recurrent AIH. With a CS minimization approach, one-half of the patients were able to remain CS-free.

Absence of Pneumocystis jiroveci pneumonia in liver transplantation recipients receiving short-term (3-month) prophylaxis

Pneumocystis jiroveci (formerly known as Pneumocystis carinii) is a fungal pathogen that causes pneumonia (PCP) in liver transplant recipients. Consequently, prophylaxis with trimethoprim-sulfamethoxazole (TMP/SMZ) is typically administered for at least 1 year at most liver transplant programs. At our center we have utilized a short-term (3-month) prophylactic regimen with TMP/SMZ for the past decade and report our experience and speculate on the potential widespread application of this approach.

METHODS

For patients transplanted at our center between January 1997 and January 2007, we recorded all documented PCP infections by review of our liver transplant database and hospital-based electronic medical records system, both of which record all infections and culture results.

RESULTS

We recorded no cases of PCP in any of the liver transplant recipients at our center during the study period.

CONCLUSIONS

We report the absence of PCP in a large cohort of liver transplant recipients receiving a short-term (3-month) prophylaxis with TMP/SMZ. These findings provide a rational basis to consider short-term (3-month) PCP prophylaxis or avoidance of prophylaxis altogether in selected low-risk patients.

Clinically recurrent primary sclerosing cholangitis following liver transplantation: a time course

Orthotopic liver transplantation (OLT) is the treatment of choice for patients with end-stage primary sclerosing cholangitis (PSC). This study sought to chronicle the natural history of PSC recurrence following OLT and identify clinical variables that may contribute to disease reemergence. From 1988 to 2006, 1102 OLTs were performed in 1032 adults at the University of Colorado Health Sciences Center. Of these, 130 patients (12.6%) with PSC received 146 allografts. Recurrence was defined by a clinically worsening examination and radiographic evidence. A total of 9 potential predictors were considered, using both bivariate log rank and multivariate Cox analysis, including: age > 55, gender, surgical technique (piggyback technique), presence of inflammatory bowel disease, intact colon before transplant, or cholangiocarcinoma (CCA), cold ischemia time, sirolimus-based immunosuppression, and graft type. The 1, 5, and 10-year recurrence-free survival was 91%, 76%, and 61%, respectively. The crude incidence of disease recurrence was 22 of 130 patients or 16.9%. Patients' risk of recurrent PSC at 1, 5, and 10 years was 2%, 12%, and 20%, respectively (mortality censored). Of the 22 patients that developed recurrent disease, 7 received a second transplant. Of the 9 factors considered, the presence of CCA prior to OLT is significantly predictive of disease recurrence [risk ratio (RR) = 3.77; P = 0.0038]. Once a patient was diagnosed with recurrent disease, the median survival without receiving a second transplant was 39.1 months (95% confidence interval: 27.6-50.6 months). In conclusion, recurrent PSC following OLT is a formidable but protracted problem following OLT. Patients may require a second transplant following reemergent disease with reasonable survival benefit.

Predictors of long-term outcome following liver transplantation for hepatocellular carcinoma: a single-center experience

Orthotopic liver transplantation (OLT) is increasingly being applied for cure in patients with cirrhosis and concomitant hepatocellular carcinoma (HCC). In recipients with limited tumor burden, OLT achieves reasonable long-term outcome. This study sought to identify clinical and pathologic variables predictive of long-term disease-free survival and the presence of vascular invasion. From 1992 to 2006, 130 patients underwent OLT for cirrhosis and HCC. Malignancy was diagnosed in 107 patients prior to OLT and in 23 patients on pathologic examination of the explant. Nine clinical and pathologic variables were considered including: TNM stage, nodularity, vascular invasion, Milan criteria, incidental lesion, differentiation, tumor size, preOLT transarterial chemoembolization (TACE), and administration of sirolimus-based immunosuppression. The overall incidence of HCC recurrence was 17% with the majority (82%) being stage III. Cumulatively, tumor recurrence-free survival (RFS) is 84, 74, and 67% at 1, 3, and 5 years respectively. Independent predictors of RFS included stage III and poorly differentiated lesions (P<0.05). Furthermore, stage III tumors and those >3.5 cm in size were predictive of vascular invasion. Importantly, preOLT, TACE and postOLT sirolimus had no influence on survival. Pathologic variables including tumor stage and grade have a significant impact on outcome. Importantly, it seems that TACE and sirolimus had no beneficial effect.

Do most newly diagnosed advanced NSCLC patients need nutritional intervention?

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Background: Depletion of nutritional reserves and significant weight loss are commonly noted in patients (pts) with non-small cell lung cancer (NSCLC). The Patient Generated Subjective Global Assessment (PG-SGA) is a nutritional screening tool for cancer pts, recommended by the Oncology Network of Dietitians of Canada and the American Dietetic Association. The PG-SGA categorizes total scores into 4 ranges for nutritional triage: 0–1 requires no intervention, 2–3 requires education, 4 - 8 requires intervention by a dietitian, and =9 requires urgent symptom control and nutrition intervention. (Ottery, 2000). Methods: We determined the prevalence of malnutrition in 92 newly diagnosed advanced NSCLC pts (stages 3 / 4) in an outpatient clinic who had completed a baseline PG-SGA. We also investigated the association between CRP (an inflammatory marker which correlates with poor prognosis) and the PG-SGA. PG-SGA score was based on the sum of 4 subscales: symptoms, weight history, food intake and functional status. Results: 92 pts (M 48, F 44) aged 65 ±11 years were studied. 21 (23%) pts had a PG-SGA score of 0–3, 23 (25%) 4–8, and 48 (52%) of 9 or greater. The most common symptoms accounting for a high PG-SGA score were: no appetite 37 (40%), pain 27 (29%), constipation 26 (28%), feeling full 24 (26%), dry mouth 22 (24%) and taste changes 19 (21%). 51 (55%) pts lost 0–4.9% of their body weight in the past month, 17 (19%) had a weight loss of 5–9.9% and 24 (26%) had a weight loss =10 %. In pts with a PG-SGA score of 0–3 the median CRP was 7.0 mg/L (range: 0.7–66.0), in those with a score of 4–8 the median CRP was 41.8 mg/L (0.8–266.1) and in those with a score of =9 the median CRP was 18.5 mg/L (0.3–219.0) (p=0.02). Conclusion: At time of diagnosis, 77% of advanced NSCLC pts were in need of nutritional intervention; 52% required urgent intervention. The PG-SGA is a simple screening tool which should be incorporated into patient care in outpatient oncology clinics.

No significant financial relationships to disclose.

Cognition, psychosocial adjustment and coping in familial cases of velocardiofacial syndrome

Velocardiofacial syndrome (VCFS) is characterized by both physical manifestations and neuropsychiatric disabilities. About 6-28% of cases are familial. The aim of the present study was to compare the clinical characteristics of subjects with familial and nonfamilial VCFS, with a special focus on cognitive and psychiatric disabilities. In addition, the complexities of coping with the disease in families in which both a parent and children are affected were highlighted in case vignettes. Sixteen patients from six families with VCFS were compared to 63 subjects with nonfamilial VCFS for physical parameters, IQ, and rate of major psychiatric disorders. After controlling for the effect of age, IQ was significantly lower in the familial compared to the nonfamilial group of VCFS patients. Rate of psychiatric disorders was similarly high in both groups. The familial group had fewer cardiac and palate anomalies. A significant negative correlation was found between IQ and age. Most of the adults with familial VCFS were neuropsychiatrically disabled. Thus, although familial VCFS seems to be associated with a milder physical phenotype than nonfamilial VCFS, the neuropsychiatric deficits are significant in both types, at all ages.

IMAGING DIAGNOSIS - INTRACRANIAL EPIDERMOID CYST IN A DOBERMAN PINSCHER

A 4-year-old Doberman Pinscher was evaluated for chronic progressive central vestibular disease and aggressiveness. A cyst-like lesion was identified in the region of the left cerebellopontine angle. The lesion was hypointense on T1-weighted and hyperintense on T2-weighted images. Differentials included an epidermoid or dermoid cyst, cystic neoplasm, and brain abscess. Hyperintensity on subsequent fluid-attenuated inversion recovery images excluded an arachnoid cyst. The histopathologic diagnosis was epidermoid cyst within the fourth ventricle.

Analysis of interleukin-1β-modulated mRNA gene transcription in human gingival keratinocytes by epithelia-specific cDNA microarrays

BACKGROUND/OBJECTIVES

Proinflammatory cytokines such as interleukin-1beta are known to be synthesized in oral gingivitis and periodontitis and lead to the activation of the transcription factor nuclear factor-kappaB (NF-kappaB). Although numerous effects of interleukin-1beta on mesenchymal cells are known, e.g. up-regulation of intercellular adhesion molecule-1 in endothelial cells, little is known of the effects of interleukin-1beta on oral keratinocytes. The purpose of the present study was to seek interleukin-1beta-mediated alterations in mRNA gene transcription and a putative activation of NF-kappaB in oral gingival keratinocytes.

METHODS

As an in vitro model for gingivitis and periodontitis, immortalized human gingival keratinocytes (IHGK) were stimulated with the proinflammatory cytokine interleukin-1beta. An epithelia-specific cDNA microarray was used to analyze mRNA expression profiles from IHGK cells treated with 200 units interleukin-1beta/ml for 3, 6, 9, 12, and 24 h. Indirect immunofluorescence was carried out to detect NF-kappaB in IHGK following interleukin-1beta treatment.

RESULTS

Detailed analysis revealed distinct patterns of time-dependent changes, including genes induced or repressed early (3-6 h) or late (12-24 h) after interleukin-1beta treatment. Differentially expressed genes were involved in (i) cell stress, (ii) DNA repair, (iii) cell cycle and proliferation, (iv) anti-pathogen response, (v) extracellular matrix turnover, and (vi) angiogenesis. A large number of genes were responsive to NF-kappaB and induction was concomitant with nuclear translocation of the p65 RelA subunit of NF-kappaB. Interestingly, many of these genes contain multiple NF-kappaB binding sites in their promoters.

CONCLUSION

Analysis of altered gene expression allows identification of gene networks associated with inflammatory responses. In addition to a number of well-known genes involved in gingivitis and periodontitis, we identified novel candidates that might be associated with the onset and maintenance of an inflammatory disease.

Low incidence of cytomegalovirus disease in liver transplant recipients receiving sirolimus primary immunosuppression with 3-day corticosteroid taper

BACKGROUND

Cytomegalovirus (CMV) disease is the most common infection following liver transplantation, occurring in approximately 20% of recipients. In liver transplant recipients, CMV is associated with a higher cost following transplantation, subsequent infections, and recurrent hepatitis C. Since we have initiated a prednisone-free immunosuppressive regimen in January 2000, we have noted an extremely low incidence of CMV disease in our cohort of liver transplant recipients. We report our findings here.

METHODS

All 150 patients transplanted between January 2000 and December 2002 with tacrolimus (or cyclosporin A) and sirolimus, and 3-day corticosteroid taper were retrospectively analyzed. Recipients who were CMV IgG negative with a CMV IgG-positive donor ("CMV mismatch") received conventional prophylactic therapy with intravenous and oral ganciclovir. The incidence of CMV disease (defined as positive tissue culture or positive immunohistochemical stain of affected tissue or CMV-DNA >3000 associated with clinical symptoms) was recorded for each patient.

RESULTS

The proportion of "CMV mismatches" (donor CMV IgG positive, recipient CMV IgG negative) was 15%. The mean total number of days of ganciclovir prophylaxis (intravenous and/or oral) administered to "CMV mismatch" patients was 45.6 days. The incidence of CMV disease in patients receiving sirolimus primary immunosuppression was 2%. The mean time to diagnosis of CMV disease was 139 days.

CONCLUSIONS

(1) The incidence of CMV disease is very low using a prednisone-free, sirolimus immunosuppressive regimen. (2) Two possible explanations for this finding include appropriate prophylaxis with ganciclovir and low levels of immunosuppression including the absence of prednisone.

Impact of pretransplant diagnosis of hepatocellular carcinoma on cadveric liver allocation in the era of MELD

The allocation system based on the Model for End-stage Liver Disease (MELD) has led to more patients diagnosed with hepatocellular carcinoma (HCC) being transplanted. We hypothesized that more patients misdiagnosed with HCC are also being transplanted, leading to inappropriate organ allocation. Therefore, we retrospectively analyzed all liver transplants at our center from July 14, 2000, to October 22, 2002 (N = 172; 129 pre-MELD, 43 post-MELD), comparing pretransplant HCC diagnosis to explant histology. Thirty patients met the United Network for Organ Sharing (UNOS) diagnostic criteria for pretransplant HCC diagnosis. There were 25 men (median age, 52.5 yr), and 80% had hepatitis C. The proportion of patients transplanted who had an HCC diagnosis increased from 12% (15/129) pre-MELD to 35% (15/43) post-MELD implementation (P < 0.01). Three of 15 (20%) transplanted pre-MELD and 5 of 15 (33%) transplanted post-MELD lacked HCC in the explant (P = 0.10). Of the three false-positives pre-MELD, one was Status 2B already, and two received living-donor livers. Of the 5 false-positives post-MELD, three had score upgrades that led to early transplantation (13 to 29, 20 to 29, and 9 to 24) while two had MELD scores of 35 and 36 already. The percentage of organs that could have gone to patients with more advanced liver disease without HCC increased from 0% (0/129) pre-MELD to 7% (3/43) post-MELD (P < 0.01). Since the implementation of MELD, the proportion of patients transplanted who had an HCC diagnosis nearly tripled, and a small but significant proportion of organs are now going to patients misdiagnosed with HCC. More stringent HCC diagnostic criteria will be required to decrease the effect that misdiagnosis has on organ allocation.

Comparison of beam characteristics of a gold x-ray target and a tungsten replacement target

A new W-Cu target was designed to replace the existing Au target on a linear accelerator model in common use in radiotherapy. This work shows that targets of different material composition can be designed to produce beams with the same dosimetric character over a wide range of beam energies without adjusting the beam energy. The target design objective was to improve mechanical robustness, replacing water in the beam path with a Cu heat sink, without altering the beam properties for the nominal clinical energy range of 4-25 MV. The W-Cu could then be installed in place of the Au target without recommissioning. The effect of the target swap was measured in the test cells for 11 different beams ranging in nominal energy from 4 to 25 MV, with focus on open field dose distributions, including diagonal profiles taken for the largest (40x40 cm) field, measured at 4 different gantry angles. Depth dose curves agreed to 0.4% or better, profiles to 1.2% or better. Monte Carlo simulations of the treatment head were done for representative energies of 6 and 18 MV. Calculated and measured dose distributions generally matched within 1%, although dose measured in the build-up region of large fields was significantly more than in the simulations. Calculated spectral distributions on the central axis and angular distributions of energy fluence matched for the two targets, whereas angular distributions of fluence were significantly different. Matching energy fluence gave a more favorable match of dose profiles than matching fluence. The target was further tested on several machines operating in a radiotherapy clinic. Measurements were made for a wide range of open field sizes and with selected wedges and blocks. Dose distributions for the two targets agreed to 1.4% or better, including the dose in wedged fields. Wedge factors changed by no more than 0.5%, transmission through a 4.4 HVL block no more than 1.5%. The response of the monitor chamber was found to change, generally by 1%-2%. Therefore, when the W-Cu target was used to replace the Au target, the output of the machine was measured and adjusted appropriately, but there was no requirement for recommissioning.

Different immunosuppressive regimens and recurrence of primary sclerosing cholangitis after liver transplantation

Primary sclerosing cholangitis (PSC) is the fourth leading diagnosis in liver transplant recipients in the United States. The disease is known to recur in 15% to 30% of liver transplant recipients. We set out to investigate how different immunosuppression regimens affected natural history of PSC after liver transplantation at our center. We reviewed records of all patients who underwent a liver transplantation at our institution in between 1988 and 2000 and had a diagnosis of PSC at the time of liver transplantation. Primary sclerosing cholangitis recurred in 15 of 71 patients (21.1%) who had complete records and survived more than 30 days after liver transplantation. Although recurrence of primary sclerosing cholangitis was most often seen (but not statistically significantly so) in patients who received maintenance corticosteroids, the time to recurrence was not significantly different between those who were treated with maintenance, those who were not successfully weaned, and those who successfully weaned off corticosteroids within 3 months after liver transplantation. Orthoclone (OKT3) therapy (Ortho-Biotech, Inc., Raritan, NJ) was associated with a higher risk of primary sclerosing cholangitis recurrence (29% versus 10%, P <.05). Recurrence was not influenced by immunosuppression with either cyclosporine or tacrolimus. Coexistent inflammatory bowel disease was a cause of failure to wean off corticosteroids, was associated with a shorter time to recurrence of sclerosing cholangitis, and was responsible for significant comorbidity (colon cancer in 7.3%). Primary sclerosing cholangitis recurrence is commonly seen after liver transplantation. More immunosuppression seems to be detrimental to the outcome of our patients with sclerosing cholangitis: use of OKT3 was associated with a greater incidence of recurrence. Length of corticosteroid use did not affect timing or risk of recurrence, and because it has been proven that early corticosteroid withdrawal after liver transplantation is beneficial, we continue to recommend this practice.

Model for End-Stage Liver Disease score does not predict patient or graft survival in living donor liver transplant recipients

Although living donor liver transplantation (LDLT) is a successful procedure for most recipients, outcomes in patients who undergo transplantation as United Network for Organ Sharing status 2A are marginal. There are no published data on living donor liver transplant recipient outcomes relative to Model for End-Stage Liver Disease (MELD) scores. Such information could be useful in living donor liver transplant recipient selection. We retrospectively analyzed all non-fulminant hepatic failure, right hepatic lobe, adult-to-adult living donor liver transplant recipients at our center between August 1997 and March 2002. We calculated MELD scores at the time of LDLT and correlated scores with 1-year patient and graft survival and hospital days during the 90-day post-LDLT period. There were 62 recipients with greater than 6 months of follow-up: 38 men, 24 women; mean age, 47.9 years; 42 white, 1 black, 17 Hispanic, and 2 Asian patients. Twenty-nine patients had hepatitis C virus infection; 4 patients, hepatitis C virus infection and alcoholic liver disease; 4 patients, alcoholic liver disease; 4 patients, cryptogenic cirrhosis; 13 patients, primary sclerosing cholangitis; 5 patients, autoimmune hepatitis; and 3 patients, primary biliary cirrhosis. Mean and median MELD scores were 15.2 and 13, respectively (range, 6 to 40). One-year patient and graft survival were 59 of 62 patients (95%) and 52 of 62 patients (84%), respectively. There was no statistically significant difference between median MELD scores of dead versus living patients (15 v 13; P =.15) or patients who underwent retransplantation versus those who did not (16.5 v 13; P =.30). Mean and median hospital days in the 90-day post-LDLT period were 23.7 and 16.0 days, respectively. Living donor liver transplant recipients with a MELD score of 18 or greater had significantly more hospital days compared with recipients with a MELD score less than 18 (35.2 v 19.8 days; P =.01). In conclusion, MELD scores did not predict post-LDLT patient or graft survival at 1 year. However, higher MELD scores (> or =18) were associated with more hospital days during the 3-month post-LDLT period.

Sirolimus as primary immunosuppression in liver transplantation is not associated with hepatic artery or wound complications

Sirolimus is a new immunosuppressive agent increasingly being used in liver transplant recipients. There is concern that sirolimus may be associated with wound complications and hepatic artery thrombosis (HAT). We have used sirolimus as primary immunosuppression in 170 liver transplant recipients and therefore reviewed our experience with wound complications and HAT in our cohort of patients. Records of all 170 patients administered sirolimus as primary immunosuppression and 180 historic controls were reviewed. Numbers of wound and hepatic artery complications were recorded, as well as the prevalence of obesity, reoperation, diabetes, and OKT3 use, all of which are risk factors for wound complications. The prevalence of wound complications was 12.4% in sirolimus-treated patients compared with 13.9% in historic controls (P = not significant [NS]). The prevalence of hepatic artery complications was 5.3% in sirolimus-treated patients compared with 8.3% in historic controls (P = NS). The prevalence of obesity and OKT3 administration was significantly lower in sirolimus-treated patients. Multivariate analysis failed to show an association between sirolimus therapy and hepatic artery or wound complications. The prevalence of wound and hepatic artery complications is not different in liver transplant recipients administered sirolimus as part of a primary immunosuppressive regimen compared with historic controls.

Comprehensive cost comparison of adult-adult right hepatic lobe living-donor liver transplantation with cadaveric transplantation

BACKGROUND

An important long-term consideration for living-donor liver transplantation (LDLT) is the expense compared with cadaveric-liver transplantation. LDLT is a more complex procedure than cadaveric transplantation and the cost of donor evaluation, donor surgery, and postoperative donor care must be included in a cost analysis for LDLT. In this study, we compare the comprehensive cost of LDLT with that of cadaveric-liver transplantation.

METHODS

All costs for medical services provided at our institution were recorded for 24 LDLT and 43 cadaveric recipients with greater than 1 year follow-up transplanted between August 1997 and April 2000. The donor costs include donors evaluated and rejected, donors evaluated and accepted, donor right hepatectomy costs, and donor follow-up costs (365 days postdonation). LDLT and cadaveric recipient costs include medical care 90 days pre-LDLT, recipient transplant costs, and recipient follow-up costs (365 days posttransplant) including retransplantation. Cost is expressed as an arbitrary cost unit (CU) that is a value between $500 to $1,500.

RESULTS

Total LDLT costs (evaluations of rejected donors+evaluations of accepted donors+donor hepatectomy+donor follow-up care for 1 year+pretransplant recipient care [90 days pretransplant]+recipient transplantation+recipient 1-year posttransplant care)= 162.7 CU. Total mean cadaveric transplant costs (pretransplant recipient care [90 days pretransplant]+recipient transplantation [including organ acquisition cost]+recipient 1-year posttransplant care)= 134.5 CU, (P =ns).

CONCLUSIONS

The total comprehensive cost of LDLT is 21% higher than cadaveric transplantation, although this difference is not significant.

Congenital insensitivity to pain

We reviewed 13 patients with congenital insensitivity to pain. A quantitative sweat test was carried out in five and an intradermal histamine test in ten. DNA examination showed specific mutations in four patients. There were three clinical presentations: type A, in which multiple infections occurred (five patients); type B, with fractures, growth disturbances and avascular necrosis (three patients); and type C, with Charcot arthropathies and joint dislocations, as well as fractures and infections (five patients, four with mental retardation).

Patient education, shoeware and periods of non-weight-bearing are important in the prevention and early treatment of decubitus ulcers. The differentiation between fractures and infections should be based on aspiration and cultures to prevent unnecessary surgery. Established infections should be treated by wide surgical debridement. Deformities can be managed by corrective osteotomies, and shortening by shoe raises or epiphysiodesis. Joint dislocations are best treated conservatively.

Congenital insensitivity to pain. Orthopaedic manifestations

We reviewed 13 patients with congenital insensitivity to pain. A quantitative sweat test was carried out in five and an intradermal histamine test in ten. DNA examination showed specific mutations in four patients. There were three clinical presentations: type A, in which multiple infections occurred (five patients); type B, with fractures, growth disturbances and avascular necrosis (three patients); and type C, with Charcot arthropathies and joint dislocations, as well as fractures and infections (five patients, four with mental retardation). Patient education, shoeware and periods of non-weight-bearing are important in the prevention and early treatment of decubitus ulcers. The differentiation between fractures and infections should be based on aspiration and cultures to prevent unnecessary surgery. Established infections should be treated by wide surgical debridement. Deformities can be managed by corrective osteotomies, and shortening by shoe raises or epiphysiodesis. Joint dislocations are best treated conservatively.

Role of multileaf collimator in replacing shielding blocks in radiation therapy

To facilitate the use of multileaf collimator (MLC) in field shaping, we tested the hypothesis that the changes in the penumbra due to MLC replacing a Cerrobend block can be related to a change in the margin of the block. We also investigated if it is possible to estimate the effect of MLC replacing a block in terms of a change in the block margin. Calculations were performed for a single field as well as a multiple field setup. For the single field setup, blocks with equal areas were drawn at the four corners of a 16 x 20 cm(2) field at angles of 20 degrees, 40 degrees, 60 degrees, and 80 degrees with the horizontal axis. The blocks were then replaced with MLC leaves. For 6 MV x-rays, dose profiles in the penumbra regions of the blocks at 5- and 10-cm depths were compared with those obtained with the corresponding MLC setup. For multiple fields, the same sets of blocks were set up on the anterio-posterior (AP-PA) pair of a four-field setup. The margins of the blocks were increased (i.e., block shaved) in 1 mm steps to a maximum of 6 mm. The similarity between MLC and the change in the block margin was examined by comparing the dose-volume histogram (DVH) of the normal tissues in the penumbral regions for the different setups. To correlate the effect of MLC with a change in the block margin, difference dose-volume histograms (DDVH) of the normal tissues relative to the original block were compared for the MLC setup with those for the changes in the block margin. The correlation obtained was used to predict the effect on the penumbra region of the MLC setup for the lateral fields of a patient irradiated with a four-field setup. The calculations were carried out with 15 MV x-rays. For the single field setup, dose undulation is largest for the 50% isodose line (IDL) as reflected in the largest increase in the 50% to 20% isodose region compared with the 90% to 10% and the 80% to 20% regions. The increase in the penumbral width is largest for the 20 degrees block when replaced by the MLC and is smaller as the angle increases. The increase in the penumbral width also increases with depth. The effect of replacing a Cerrobend block with an MLC is similar to an increase in the block margin. For 15 MV x-rays, the increase varies inversely with the angle of the blocks, from > 6 mm increase in block margin for the 20 degrees block to about 1 mm for the 80 degrees block. In the clinical example, replacing the blocks in the lateral fields of a four-field irradiation with MLC is similar to changing the margin of the blocks. For the posterior block, MLC is similar to a 1- to 2-mm increase in the margin of the block, whereas for the anterior block the effect is similar to 1 mm for the straight portion of the block to about 6 mm in the superior portion of the block. Characterization of an MLC setup replacing a Cerrobend block is necessary for adequate coverage of target volume. The effect of MLC replacing a Cerrobend block is similar to a change in the block margin. It is possible to estimate with reasonable accuracy the effect of MLC replacing a Cerrobend block.

Adult-to-adult living donor liver transplantation using right-lobe grafts: results and lessons learned from a single-center experience

Living donor liver transplantation (LDLT) for adults is now a practical alternative to cadaveric liver transplantation. Use of right-lobe grafts has become the preferred donor procedure. Because of the complexity of this operation, a learning curve is to be expected. We report the outcome of our first 41 LDLTs at the University of Colorado Health Sciences Center (Denver, CO). We also discuss the lessons learned and the resultant modifications in the procedure that evolved during our series. Patient records were retrospectively reviewed between August 1997 and February 2001 for the following end points: recipient survival, graft survival, and donor and recipient complications. Thirty-eight of 41 living donor liver transplant recipients (93%) are alive and well postoperatively with a mean follow-up of 9.6 months. Four patients required retransplantation secondary to technical problems (9.8%); all 4 patients were in our initial 11 cases. Modification of the donor liver plane of transection resulted in venous outflow improvement. Also, biliary management was modified during the series. Donor complications are listed; all 41 donors have returned to normal pretransplantation activity. Our results indicate that LDLT can be performed safely with excellent donor and recipient outcomes. Dissemination of our experience can help shorten the learning curve for other institutions.

Evaluation of 100 patients for living donor liver transplantation

The initial success of living donor liver transplantation (LDLT) in the United States has resulted in a growing interest in this procedure. The impact of LDLT on liver transplantation will depend in part on the proportion of patients considered medically suitable for LDLT and the identification of suitable donors. We report the outcome of our evaluation of the first 100 potential transplant recipients for LDLT at the University of Colorado Health Sciences Center (Denver, CO). All patients considered for LDLT had first been approved for conventional liver transplantation by the Liver Transplant Selection Committee and met the listing criteria of United Network for Organ Sharing status 1, 2A, or 2B. Once listed, those patients deemed suitable for LDLT were given the option to consider LDLT and approach potential donors. Donors were evaluated with a preliminary screening questionnaire, followed by formal evaluation. Of the 100 potential transplant recipients evaluated, 51 were initially rejected based on recipient characteristics that included imminent cadaveric transplantation (8 patients), refusal of evaluation (4 patients), lack of financial approval (6 patients), and medical, psychosocial, or surgical problems (33 patients). Of the remaining 49 patients, considered ideal candidates for LDLT, 24 patients were unable to identify a suitable donor for evaluation. Twenty-six donors were evaluated for the remaining 25 potential transplant recipients. Eleven donors were rejected: 9 donors for medical reasons and 2 donors who refused donation after being medically approved. The remaining 15 donor-recipient pairs underwent LDLT. Using our criteria for the selection of recipients and donors for LDLT gave the following results: (1) 51 of 100 potential transplant recipients (51%) were rejected for recipient issues, (2) only 15 of the remaining 49 potential transplant recipients (30%) were able to identify an acceptable donor, and (3) 15 of 100 potential living donor transplant recipients (15%) were able to identify a suitable donor and undergo LDLT. Recipient characteristics and donor availability may limit the widespread use of LDLT. However, careful application of LDLT to patients at greatest risk for dying on the waiting list may significantly reduce waiting list mortality.

Early steroid withdrawal in liver transplantation is safe and beneficial

This report reviews the literature and discusses steroid withdrawal after hepatic transplantation. Our experience with steroid withdrawal is highlighted. The hypothesis is that steroid withdrawal from liver transplant recipients is safe and beneficial. A review of the English literature yielded 16 reports with a total of 901 patients (749 adults and 152 children). Most reports were nonrandomized and uncontrolled. Only two reports were randomized, controlled trials; three reports featured early steroid withdrawal (</= 3 months); and one report featured very early steroid withdrawal (14 days). Steroid withdrawal was achieved in approximately 85% of the patients. Acute rejection was not significantly increased by steroid withdrawal; rates were 5% to 14% in uncontrolled trials and 7% versus 7% (late steroid withdrawal v control; P = not significant [NS]) and 4% versus 8% (early steroid withdrawal v control; P = NS) in controlled trials. Acute rejection rates after very early steroid withdrawal (14 days posttransplantation) were 42% to 46%, similar to or less than the 40% to 70% reported for steroid-containing regimens. Chronic rejection was not increased by steroid withdrawal; the rate was 3.9% in one uncontrolled trial and 0% versus 3% (early steroid withdrawal v control; P = NS) in one controlled trial. Patient and graft survival were not adversely affected. Steroid withdrawal was associated with reduced rates and better control of hypertension, reduced total cholesterol levels, reduced rate of posttransplantation diabetes mellitus, improved control of diabetes, and reduced rate of obesity. The aggregate experience with steroid withdrawal suggests it is safe, associated with improvement in several posttransplantation complications, and deserves broader clinical application.

Prednisone withdrawal 14 days after liver transplantation with mycophenolate: a prospective trial of cyclosporine and tacrolimus

BACKGROUND

The long-term complications of immunosuppressive therapy such as diabetes, hypercholesterolemia, and hypertension are a major source of morbidity in liver transplant recipients. In this prospective, randomized, open-label study we completely withdrew prednisone (PRED) 14 days after liver transplantation in an effort to decrease these metabolic complications. Patients were maintained on mycophenolate mofetil (MMF) in combination with either cyclosporine (CsA; Neoral formulation) or tacrolimus (TAC). Thus, we also were able to compare CsA to TAC in patients not receiving PRED with respect to efficacy, toxicity, and effect on posttransplant metabolic complications.

METHODS

A total of 71 patients were randomized to receive either TAC-MMF (n=35) or CsA-MMF (n=36) after liver transplantation and were analyzed for patient and graft survival. Fifty-eight patients continued the immunosuppressive protocol for at least 6 months after transplantation and were analyzed for the incidence of acute rejection and the prevalence of diabetes, hypertension, and hypercholesterolemia.

RESULTS

The 6-month patient survival rates were 94.4% for CsA-MMF and 88.6% for TAC-MMF. Corresponding 6-month graft survival rates were 88.7% and 85.71% with no immunologic graft losses in either group. The incidence of biopsy-proven acute rejection was 46% for CsA-MMF and 42.3% for TAC-MMF. Six patients were converted from CsA to TAC (four for recurrent rejection) and seven patients were converted from TAC to CsA (four for neurotoxicity). Only one patient (in the TAC-MMF group) developed new-onset posttransplant diabetes. In contrast, four of eight patients in the CsA-MMF group who were diabetic before transplant became nondiabetic in the first 3 months after transplant. The mean serum cholesterol level was significantly lower in the TAC-MMF group than in the CsA-MMF group (145.2+/-41.8 mg/dl and 190.3+/-62.2, respectively; P<0.001) and the incidence of hypertension was lower in the TAC-MMF group (12% vs. 30.3% in the CsA-MMF group, P<0.01). Both groups had a lower incidence of metabolic complications compared with a historical group (n=100) maintained on CsA and PRED (10 mg/day at 6 months).

CONCLUSIONS

MMF in combination with either TAC or CsA allows withdrawal of PRED 14 days after liver transplantation with a moderate rejection rate and no immunologic graft losses. Early PRED withdrawal decreases posttransplant diabetes, hypercholesterolemia, and hypertension, but patients maintained on TAC have lower serum cholesterol levels and a lower incidence of hypertension than CsA-treated patients.

Penicillin-resistant pneumococcal meningitis in Israel

Penicillin-resistant Streptococcus pneumoniae (PRP) is of worldwide concern. Treatment failures and fatalities of meningitis caused by PRP have been reported in other locations but not yet in Israel. We describe an 11-month-old infant with meningitis caused by PRP who failed to respond to initial treatment with cefotaxime. Vancomycin treatment caused a prompt cure. The minimal inhibitory concentrations of the isolate to penicillin, cefuroxime and cefotaxime were 1.0, 4.0 and 1.0 micrograms/ml, respectively. New guidelines for the treatment of meningitis in Israel are suggested.