Overexpression of Fibrinogen-Like Protein 2 Promotes Tolerance in a Fully Mismatched Murine Model of Heart Transplantation.

Fibrinogen-like protein 2 (FGL2) is an immunomodulatory protein that is expressed by regulatory T cells (Tregs). The objective of this study was to determine if recombinant FGL2 (rFGL2) treatment or constitutive FGL2 overexpression could promote transplant tolerance in mice. Although rFGL2 treatment prevented rejection of fully mismatched cardiac allografts, all grafts were rejected after stopping treatment. Next, we generated FGL2 transgenic mice (fgl2(Tg) ) that ubiquitously overexpressed FGL2. These mice developed normally and had no evidence of the autoimmune glomerulonephritis seen in fgl2(-/-) mice. Immune characterization showed fgl2(Tg) T cells were hypoproliferative to stimulation with alloantigens or anti-CD3 and anti-CD28 stimulation, and fgl2(Tg) Tregs had increased immunosuppressive activity compared with fgl2(+/+) Tregs. To determine if FGL2 overexpression can promote tolerance, we transplanted fully mismatched cardiac allografts into fgl2(Tg) recipients. Fifty percent of cardiac grafts were accepted indefinitely in fgl2(Tg) recipients without any immunosuppression. Tolerant fgl2(Tg) grafts had increased numbers and proportions of Tregs and tolerant fgl2(Tg) mice had reduced proliferation to donor but not third party antigens. These data show that tolerance in fgl2(Tg) recipients involves changes in Treg and T cell activity that contribute to a higher intragraft Treg-to-T cell ratio and acceptance of fully mismatched allografts.

2016 Comprehensive Update of the Banff Working Group on Liver Allograft Pathology: Introduction of Antibody-Mediated Rejection.

The Banff Working Group on Liver Allograft Pathology reviewed and discussed literature evidence regarding antibody-mediated liver allograft rejection at the 11th (Paris, France, June 5-10, 2011), 12th (Comandatuba, Brazil, August 19-23, 2013), and 13th (Vancouver, British Columbia, Canada, October 5-10, 2015) meetings of the Banff Conference on Allograft Pathology. Discussion continued online. The primary goal was to introduce guidelines and consensus criteria for the diagnosis of liver allograft antibody-mediated rejection and provide a comprehensive update of all Banff Schema recommendations. Included are new recommendations for complement component 4d tissue staining and interpretation, staging liver allograft fibrosis, and findings related to immunosuppression minimization. In an effort to create a single reference document, previous unchanged criteria are also included.

Protease inhibitors partially overcome the interferon nonresponse phenotype in patients with chronic hepatitis C.

The outcome of triple therapy with protease inhibitors (PI) depends on the intrinsic response to interferon. Interferon-stimulated gene (ISG) expression differs by cell type in the liver and is a strong predictor of interferon responsiveness. Patients who respond well to interferon have low/absent ISG expression in hepatocytes but significant ISG expression in macrophages. Nonresponders (NRs) show the opposite pattern. We aimed to determine the association between cell-type-specific ISG staining and treatment outcome with PI-based triple therapy. Liver biopsy tissue from consecutive patients treated with boceprevir or telaprevir with peginterferon and ribavirin was stained for myxovirus A (MxA). Staining was scored 0-3 in macrophages (M-MxA) and hepatocytes (H-MxA), and IL28B genotyping was performed. Of 56 patients included 41 achieved SVR (73%) (sustained virological response), 2 (4%) relapsed, 10 (18%) were NRs, and 3 (5%) were lost to follow-up. Median M-MxA staining was stronger and H-MxA staining was weaker in patients who achieved SVR. MxA staining correlated with IL28B genotype and with the HCV RNA decline during lead-in phase. However, unlike with dual therapy, the negative predictive value (NPV) of absent or weak M-MxA staining was poor (42%), while the positive predictive value improved (93%). Although by multivariable logistic regression M-MxA staining was significantly associated with SVR (OR 4.35, 1.32-14.28, P = 0.012), the predictive ability was inadequate to withhold therapy. The interaction between macrophages and hepatocytes plays a critical role in interferon responsiveness; however, the addition of a PI at least partially overcomes the interferon nonresponse phenotype making the predictive ability of ISG staining less clinically useful.

Metabolic syndrome-related hepatocellular carcinoma treated by volumetric modulated arc therapy.

Hepatocellular carcinoma (hcc) is a leading cause of cancer mortality, and its incidence is increasing in developed countries. Risk factors include cirrhosis from viral hepatitis or alcohol abuse. Metabolic syndrome is a newly recognized, but important, risk factor that is likely contributing to the increased incidence of hcc. Surgery is the therapy of choice for hcc, but local therapies are often contraindicated, usually because of advanced disease or comorbid conditions such as cardiac disease (which is associated with metabolic syndrome). Current radiation therapy techniques such as stereotactic body radiotherapy allow for treatment plans that highly conform to the target and provide excellent sparing of normal structures. Radiation therapy is emerging as a viable option in patients not eligible for surgery or other locoregional therapies. Here, we report a case of a large hcc presenting in a patient with metabolic syndrome without significant alcohol history or biochemical liver dysfunction. The patient was not a candidate for locoregional therapies because of cardiac and renal comorbidities typical of patients experiencing the long-term sequelae of metabolic syndrome. Treatment using an arc-based volumetric-modulated arc therapy technique allowed for the highest dose of radiation to be delivered to the tumour while the peripheral radiation dose was minimized. A complete local response was confirmed by computed tomography imaging 21 months after treatment completion.

Normothermic acellular ex vivo liver perfusion reduces liver and bile duct injury of pig livers retrieved after cardiac death.

We compared cold static with acellular normothermic ex vivo liver perfusion (NEVLP) as a novel preservation technique in a pig model of DCD liver injury. DCD livers (60 min warm ischemia) were cold stored for 4 h, or treated with 4 h cold storage plus 8 h NEVLP. First, the livers were reperfused with diluted blood as a model of transplantation. Liver injury was determined by ALT, oxygen extraction, histology, bile content analysis and hepatic artery (HA) angiography. Second, AST levels and bile production were assessed after DCD liver transplantation. Cold stored versus NEVLP grafts had higher ALT levels (350 ± 125 vs. 55 ± 35 U/L; p < 0.0001), decreased oxygen extraction (250 ± 65 mmHg vs. 410 ± 58 mmHg, p < 0.01) and increased hepatocyte necrosis (45% vs. 10%, p = 0.01). Levels of bilirubin, phospholipids and bile salts were fivefold decreased, while LDH was sixfold higher in cold stored versus NEVLP grafts. HA perfusion was decreased (twofold), and bile duct necrosis was increased (100% vs. 5%, p < 0.0001) in cold stored versus NEVLP livers. Following transplantation, mean serum AST level was higher in the cold stored versus NEVLP group (1809 ± 205 U/L vs. 524 ± 187 U/L, p < 0.05), with similar bile production (2.5 ± 1.2 cc/h vs. 2.8 ± 1.4 cc/h; p = 0.2). NEVLP improved HA perfusion and decreased markers of liver duct injury in DCD grafts.

Heterogeneously catalyzed biodiesel production from Azadiricha Indica oil: Predictive modelling with uncertainty quantification, experimental optimization and techno-economic analysis.

This study presents predictive modelling with uncertainty analysis, optimization and techno-economic feasibility of Bio-catalyzed Biodiesel Production from Azidirica Indica Oil (BCBPAIO). Central Composite Design (CCD) predictive model and optimum conditions for BCBPAIO were developed in Design Expert software. The model uncertainty analysis was performed using Monte Carlo simulation. The BCBPAIO simulation and economic analysis were conducted in ASPEN Batch Process Developer V10. The correlation coefficient (R2) and adjusted R2 value of the CCD model were 0.9922 and 0.9780 respectively. CCD model certainty gave 73.51% with 100,000 trials; the oil transesterification optimum conditions gave 87.04% conversion with 3.62 wt% of catalysts; and methanol to oil molar ratio of 8:1 at 59 °C for 4 h. The annual production cost, total capital investment, payback time and internal rate of returns are $ 3537105, $ 5243784, 2.67 and 43% respectively. This study shows that the production is profitably feasible.

Black-box modelling, bi-objective optimization and ASPEN batch simulation of phenolic compound extraction from Nauclea latifolia root.

Nauclea latifolia root (NLR) extract is one of phytochemicals used to treat various ailments in most of developing countries. This investigation focuses on modelling, optimization and computer-aided simulation of phenolic solid-liquid extraction from NLR. The extraction experiments were conducted at extraction temperature (ET: 33.79-76.21 °C), process time (PT: 2.79-4.21 h) and solid-liquid ratio (SLC: 0.007929-0.018355 g/ml). Regression models (RM) were developed, using Response Surface Methodology (RSM) in Design Expert software, for predicting and optimizing total phenolic content (TPC) and total flavonoid content (TFC) and also compared with adaptive neuro-fuzzy inference system (ANFIS) modelling in Matlab environment. Aspen Batch Process Developer (ABPD) V10 was used to simulate phenolic extract production and perform material balance of the process. Both Coefficients of determination (R2) of RSM (TFC: 0.9996, TPC: 0.9932) and ANFIS models (TFC: 0.99998, TPC: 0.9982) were compared and predicted satisfactorily. Optimization results show: ET (2.79 h), PT (38.8 °C), SLC (0.0198 g/ml), TFC (25.92 25.92 µg RE/g) and TPC (8.47 mg GAE/g). The phenolic extraction base case simulation results gave batch throughput, annual throughput, number of batches per year 0.0089 g/batch, 0.139 g/year and 1019 batches, respectively. The ABPD predicted TPC and experimental TPC results were compared and gave mean relative deviation error of 3.75%. Thus, ABPD simulation model is reasonably reliable for the scale-up design engineering of the phenolic extract production from NLR.

Rotavirus infection in adult small intestine allografts: a clinicopathological study of a cohort of 23 patients.

Rotavirus enteritis (RVE) is increasingly recognized as a cause of small bowel allograft dysfunction but its significance in adult patients is unknown. We have studied 23 adult small bowel transplant patients aged 19.8-59 years (mean = 38.2 years), who were presented with diarrhea and tested positive for rotavirus by enzyme-linked immunosorbent assay methods. Serial follow-up biopsies, as well as clinical data, are documented and analyzed. These patients were followed up for an average of 168 days (range 33-534 days). Mean time of rotavirus diagnosis from transplant day was 794 days (range 38-2907 days). Self-limited diarrhea lasting 6-13 days (mean = 9 days) was the main presentation. Sixteen (69.6%) patients developed acute cellular rejection either concurrently with (i.e. six patients) or after (10 patients) RVE, often characterized by prominent mucosal plasmacytosis at an average of 22 days (range 0-94 days) from the day RVE was diagnosed. One-third of patients with acute rejection (i.e. five out of 16) required muromonab-CD3 rescue therapy. Two patients experienced graft loss (one from chronic rejection, another from sepsis). Rotavirus infection is a cause of diarrhea in adult small bowel transplant patients. The infection appeared to trigger cellular rejection that was associated with mucosal plasmacytosis, and sometimes required aggressive rescue therapy.

Fibrillary glomerulonephritis: a report of 2 cases with extensive glomerular and tubular deposits.

Deposition of nonamyloid fibrillary material in glomeruli is well known. It is, however, unusual to find these fibrils in the tubular basement membranes and unprecedented to have fibrils of different sizes in the same patient. We present 2 cases with nephrotic range proteinuria with evidence of renal insufficiency. In both cases, strong, polyclonal immunoglobulin (Ig)G with C3 deposits were shown in the glomeruli and along tubular basement membranes. Ultrastructurally, the first case had 28-nm fibrils deposited extensively in the glomeruli and along tubular basement membranes. The second case had 30-nm fibrils in the glomeruli and 15-nm fibrils in the tubules. In both cases, the fibrils did not react with the regular amyloid stains. These findings are used to support the view that fibrillary glomerulopathy is not a disease, but rather the morphologic expression of an etiologically diverse group of diseases as yet incompletely defined.

Essential obstetric care: assessment and determinants of quality.

This paper reports on a study to develop and to apply methods for measuring the quality of essential obstetric care (EOC) in health centers. Based on a Nigerian guideline and an international guideline, and in consultation with local experts in primary care obstetrics, norms were established for equipment, personnel, supplies and the process of EOC, focusing on critical tasks. A combination of assessment methods was used, including observation of tasks performed during intrapartum care; use of data from records of care kept by midwives during the period of observation; use of data from records kept by midwives in the calendar year preceding the period of observation; exit interviews with clients; and inventories of equipment and supplies. Twelve health centers in three Local Government Areas (LGAs) and 360 clients in labor were included in the study. Quality of care was measured quantitatively as a score, calculated for each task and for each delivery in the health center. The results show that the methods developed are useful for: identifying quality score differences among health centers, and the effects of methods of assessment on quality scores; identifying aspects of EOC requiring improvements within each health center; and identifying factors influencing the quality of care, as a basis for effective quality improvement efforts. Regression models show that the most consistent and important predictor of quality scores is the use of printed forms (i.e. routine records of labor) during intrapartum care. Printed forms served as job aids, providing prompts that reminded midwives to perform specific tasks.

Developing a primary health care management information system that supports the pursuit of equity, effectiveness and affordability.

A key set of goals of primary health care (PHC) includes equity, effectiveness and affordability. By equity, we mean universal coverage and care according to need; by effectiveness, that the system has a favorable impact on mortality and serious morbidity; by affordability, that the system is within the budgetary reach of government and communities. There are other requirements of PHC as well: that the system be socially and culturally acceptable, and that communities are active participants in the development and implementation of the system. Further, the PHC system should be compatible with larger system of a region or country, and possibly serve as a prototype for the development of larger health systems. With these requirements in mind, the Aga Khan University has developed a series of community-based, urban PHC systems, each serving a population of about 10,000, in the katchi abadis (squatter settlements) of Karachi. These communities are severely deprived, with high infant, child and maternal mortality rates. The PHC systems are designed to achieve equity, effectiveness and affordability, and within 3-5 years have advanced substantially toward those goals. A key factor in those developments has been the management information system (MIS), which has served as a basis for planning, managing and evaluating the PHC systems. Central questions about such an MIS are: What kind of MIS design is necessary to support the pursuit of those goals? What problems arise in the MIS as such a system is implemented? What kinds of changes and adaptations need to be considered in the MIS as the PHC system itself matures? What does the PHC system cost, and what part of the total cost of the PHC system is attributable to the MIS? How practical is this kind of MIS, developed in small prototype PHC systems, for replicability in larger health systems? What are the possibilities and requirements for simplification in order to be used in health systems that are less intensively managed? The experience of AKU in Pakistan in the development of PHC systems, with associated management information systems, helps to answer these questions.

A case of fibrillary glomerulonephritis with linear immunoglobulin G staining of the glomerular capillary walls.

We report a case of crescentic glomerulonephritis that presented with extensive crescent formation and fibrinoid necrosis in the glomeruli. Immunofluorescence staining was strongly positive for linear and pseudolinear staining of the capillary walls for immunoglobulin G (IgG) in the absence of significant mesangial staining. Histologic examination and immunofluorescence staining suggested a diagnosis of anti-glomerular basement membrane disease. However, electron microscopy showed the presence of numerous fibrillary deposits in the subepithelial areas of the glomerular capillary walls, supporting the diagnosis of fibrillary glomerulonephritis. Test results for circulating anti-glomerular basement membrane antibodies were negative. We report this interesting case to illustrate the point that fibrillary glomerulonephritis should be considered in the differential diagnosis of crescentic glomerulonephritis with linear and pseudolinear IgG deposits within the capillary walls. In such cases, electron microscopy is critical in differentiating the cause of crescentic glomerulonephritis.

Fine needle aspiration cytology in the management of thyroid enlargement: Ibadan experience.

This report reviews our experience with fine needle aspiration (FNA) cytology in the assessment of thyroid enlargement in Ibadan between January 1995 and December 1997. The diagnostic accuracy of the procedure for malignancy was 80.6% with a sensitivity and specificity 83% and 80% respectively in this series. FNAC of thyroid enlargement is now a first line investigative procedure for thyroid enlargements in the University College Hospital, Ibadan.

Primary extranodal non-Hodgkin's lymphoma of the upper aerodigestive tract--a descriptive analysis of the pattern seen in the University College Hospital, Ibadan.

This retrospective review highlights primary extranodal non-Hodgkin's lymphoma (NHL), of the upper aerodigestive tract as seen in Ibadan over a ten-year period. There was a male preponderance (m:f ratio of 2:1), with a mean age of 42.5 years and a bimodal age presentation at the fourth and fifth decades. The Waldeyer's ring was the commonest affected site while the tonsil is the highest involved subsite. Sixty-eight percent of the patients had regional lymphadenopathy and thirty eight percent also 'B' symptom at presentation. The peculiar presentations of this NHL are the short duration (10 months) of symptoms, mainly intermediate/high grade diffuse large cell lymphoma especially in the Waldeyer's ring and sinonasal region with absence of low-grade small cell lymphoma. The majority of patients (64.3%) presented with Stage IV disease, which shows that the disease has an aggressive course with high mortality and generally poor outcome with 53.6% of the patients dead within one-year onset of symptoms. The overall mean survival period was 14 months. Comparison of the median survival of the patients that died when matched with the site, Ann Arbor staging, histological grade/subtype and treatment modality yielded no significant differences. These further confirm the aggressive nature of the disease in our environment.

Case report on hereditary non-polyposis colon cancer (HNPCC) in Nigeria.

The role of genetic factors in the etiology of colorectal cancers (CRCs) has recently been elucidated with the discovery of the mismatch repair. These genes are responsible for less than 5% of all cases of CRCs in Caucasian series. In this pilot study, tumors from 5 randomly ascertained CRC patients were subjected to microsatellite analysis, and two were microsatellite unstable. Both of these two patients had germline mutations in MSH2. If this finding can be confirmed in a larger series of patients, it suggests that MMR genes play an important role in the etiology of CRCs in Africa.

Angiotensin blockade does not affect fibrosis progression in recurrent hepatitis C after liver transplantation.

BACKGROUND: Liver transplantation (LT) for hepatitis C virus (HCV)-related end-stage liver disease is impaired by universal disease recurrence and suboptimal response to antiviral therapy. Inhibition of angiotensin-II signalling by angiotensin-converting enzyme inhibitors (ACE-I) or angiotensin-II receptor blockers (ARB) decreases hepatic stellate cell activation in vitro and hepatic fibrogenesis in animal models. A single-center retrospective analysis suggested that angiotensin blockade (AB) inhibits fibrosis progression in recurrent HCV post-LT. This study assessed the effect of AB on fibrosis progression in an independent patient cohort. METHODS: Chart review of all patients who underwent transplantation in our institution for HCV-related ESLD between January 2000 and February 2008 revealed 109 patients with ≥2 protocol liver biopsies and free of antiviral therapy post-LT up to the last biopsy analyzed; 27 of 109 patients were treated with ACE-I/ARB for ≥12 months, 82 were not. Fibrosis was staged using METAVIR. RESULTS: Live-donor LT was more frequent in controls than in the AB group (25% vs 11%; P < .05). However, parameters known to affect outcome of recurrent HCV, including donor age, prevalence of diabetes, acute cellular rejection, and immunosuppression, were similar in both groups. Time between first and last biopsy (median, 23 months), stage of fibrosis, fibrosis progression rates (median 0.47 vs 0.45 unit/y; P = .46), and time to develop fibrosis stage ≥2 did not differ between groups. Results held true if deceased-donor LT were analyzed separately. CONCLUSION: Our study does not support the contention of a previous report that use of AB reduces fibrosis progression in recurrent HCV post-LT.

Liver allograft pathology: approach to interpretation of needle biopsies with clinicopathological correlation.

The spectrum of diseases encountered in post-transplant liver pathology biopsies is broad. In this review, these have been divided as belonging to one of three categories: (1) new-onset/de novo post-transplant abnormalities (early and late), (2) rejection, and (3) recurrence of original disease. The clinical and pathological features of the entities making up each category, with the relevant differential diagnosis and overlaps between and within these groups, are discussed and illustrated. Recurrent or de novo neoplasms make up a fourth category not included in this review. Early new-onset conditions are mostly related to surgical complications, donor factors and ischaemia to the graft. These include reperfusion/preservation injury, lipopeliosis, small-for-size-syndrome, biliary sludge syndrome and hepatic artery thrombosis. The various forms of rejection (cellular, chronic, antibody-mediated, and late atypical rejection) are detailed. Most chronic liver diseases can and do recur in the graft. They may display features that overlap with de novo conditions (eg, primary sclerosing cholangitis versus chronic rejection). As with most cases of allograft biopsy interpretation, accurate diagnosis rests with careful correlation of histological features with clinical, imaging and laboratory findings, and often comparison with previous sequential and follow-up biopsies. Late-onset new diseases include biliary strictures, idiopathic chronic hepatitis and de novo autoimmune hepatitis, among others. This review provides a practical approach to the interpretation of these challenging biopsies. Selected difficult scenarios or conundrums are identified and discussed in the relevant sections.

Priorities for medium-term development in the health sector of Bosnia and Herzegovina.

In the medium term, the World Bank will work with the Government of Bosnia and Herzegovina, non-government organizations, and international development agencies to complete the reconstruction work already begun. There will be an increased emphasis on developing sustainable health finance regime and establishing a basic health system.

Costs and financing of improvements in the quality of maternal health services through the Bamako Initiative in Nigeria.

This paper reports on a study to assess the quality of maternal health care in public health facilities in Nigeria and to identify the resource implications of making the necessary quality improvements. Drawing upon unifying themes from quality assurance, basic microeconomics and the Bamako Initiative, locally defined norms were used to estimate resource requirements for improving the quality of maternal health care. Wide gaps existed between what is required (the norm) and what was available in terms of fixed and variable resources required for the delivery of maternal health services in public facilities implementing the Bamako Initiative in the Local Government Areas studied. Given such constraints, it was highly unlikely that technically acceptable standards of care could be met without additional resource inputs to meet the norm. This is part of the cost of doing business and merits serious policy dialogue. Revenue generation from health services was poor and appeared to be more related to inadequate supply of essential drugs and consumables than to the use of uneconomic fee scales. It is likely that user fees will be necessary to supplement scarce government budgets, especially to fund the most critical variable inputs associated with quality improvements. However, any user fee system, especially one that raises fees to patients, will have to be accompanied by immediate and visible quality improvements. Without such quality improvements, cost recovery will result in even lower utilization and attempts to generate new revenues are unlikely to succeed.

PIP: The authors report on a study conducted to assess the quality of maternal health care in public health facilities in Nigeria and to identify the resource implications of making the necessary quality improvements. The authors draw upon unifying themes from quality assurance, basic microeconomics, and the Bamako Initiative. Locally defined norms were used to estimate resource requirements for improving the quality of maternal health care. The study identified the existence of wide gaps between what fixed and variable resources are required and what was available to deliver maternal health services in public facilities implementing the Bamako Initiative in the local government areas studied. It was highly unlikely that acceptable standards of care could be met without additional resources. Revenue generation from health services was poor and appeared to be more related to the inadequate supply of essential drugs and consumables than to the use of uneconomic fee scales. Any user fee system implemented will have to be accompanied by immediate and visible quality improvements.