Successful resection of a huge retroperitoneal venous hemangioma: A case report.

BACKGROUND: Venous hemangioma is a benign and non-invasive type of tumor, which is rarely identified due to the absence of clinical manifestations. A retroperitoneal benign tumor is comparatively rare, and hemangioma is exceptional. Because of the different types and locations of hemangioma, presentations are varied; thus, establishing an accurate diagnosis before surgery is challenging. CASE SUMMARY: A 45-year-old female patient visited our hospital with the complaint of a retroperitoneal mass without symptoms discovered during a medical examination. An abdominal and pelvic computed tomography (CT) revealed a giant hypodense mass that extended from the lower edge of the liver down to the right groin and showed no marked enhancement in the arterial phase of the enhanced CT. On magnetic resonance imaging, the retroperitoneal mass was hyperintense on the T2-weighted image and hypointense on the T1-weighted image. The mass was completely resected and confirmed as a venous hemangioma by pathology. CONCLUSION: Venous hemangioma is rare in adults, and an accurate diagnosis before surgery is challenging. Surgery is the curative treatment for venous hemangioma, and the definitive diagnosis relies on pathology.

[Risk Factors for Acute Renal Failure after Thoracoabdominal Aortic Aneurysm Surgery].

Objective To investigate the risk factors associated with acute renal failure (ARF) after thoracoabdominal aortic aneurysm (TAAA) surgery. Methods A total of 156 patients underwent TAAA repair between January 2009 and December 2017. Renal failure was defined based on the Kidney Disease Improving Global Outcomes criteria. The patients were divided into ARF group and non-ARF group based on the presence/absence of postoperative ARF. The risk factors of ARF were analyzed by univariate analysis and multivariate logistic analysis. Results The subjects included 111 males and 45 females aged (40.4±10.9) years (range:19-65 years). The surgical reasons included aortic dissection (n=130,83.3%),aneurysm (n=22,14.1%),and pseudoaneurysm (n=4,2.6%). The degrees of repair included Crawford extent I in 6 patients (3.8%),extent Ⅱ in 128 patients (82.1%),extent Ⅲ in 20 patients (12.8%),and extent Ⅳ in 2 patients(1.3%). There were 3 patients presented with aortic rupture and 6 patients received emergent operations. Nine patients (5.8%) died within 30 days after surgery,and 8 patients (5.1%) suffered from permanent paraplegia. Thirty-six patients (23.1%) had ARF after surgery,and 18 of them needed dialysis. Multivariate logistic analysis showed that smoking (OR =2.637,95%CI=1.113-6.250,P=0.028),packed red blood cell usage in operation (≥6 U) (OR =5.508,95%CI=2.144-11.930,P=0.000),reoperation for bleeding (OR=3.529,95%CI=1.298-9.590,P=0.013) were independent risk factors for ARF after TAAA repair. Conclusion Smoking,packed red blood cell usage in operation (≥6 U),reoperation for bleeding are the independent risk factors of ARF after TAAA surgery.

Epstein-Barr virus-positive post-transplant lymphoproliferative disordepresenting as hematochezia and enterobrosis in renal transplant recipients in China: A report of two cases.

BACKGROUND: Post-transplant lymphoproliferative disorder (PTLD) is a rare severe complication after renal transplantation, with an incidence of approximately 0.3%-2.0% in patients undergoing renal transplantation. The clinical manifestations of PTLD are often nonspecific, leading to tremendous challenges in the clinical diagnosis and treatment of PTLD. CASE SUMMARY: We report two Epstein-Barr virus (EBV)-positive PTLD cases whose main clinical manifestations were digestive tract symptoms. Both of them admitted to our hospital because of extranodal infiltration symptoms and we did not suspect of PTLD until the pathology confirmation. Luckily, they responded well to the treatment of rituximab. We also discuss the virological monitoring, clinical characteristics, diagnosis, and treatment of PTLD. CONCLUSION: PTLD is a deceptive disease and difficult to diagnose. Once patients are confirmed with PTLD, immune suppressant dosage should be immediately reduced and rituximab should be used as first-line therapy.

D-dimer >2.785 µg/ml and multiple infarcts ≥3 vascular territories are two characteristics of identifying cancer-associated ischemic stroke patients.

BACKGROUND: The patterns and mechanisms underlying stroke in cancer patients differ from those of the conventional etiology. In this study, we further investigated the characteristics distinguishing cancer-associated ischemic stroke (CAIS) and the relationship of D-dimer value with CAIS. METHODS: Sixty-one acute ischemic stroke patients with cancer (cancer group) and 76 stroke patients without cancer (control group) were recruited. Cerebrovascular distribution was divided into 3 circulations and 23 vascular territories, and acute multiple brain infarcts (AMBIs) were defined as discrete MRI diffusion-weighted imaging (DWI) lesions in >1 vascular territory. RESULTS: Cancer patients had higher average D-dimer and fibrinogen degradation product values, and fewer stroke risk factors. The numbers of infarct-affected vascular territories, AMBIs, and AMBIs in multiple circulations were significantly higher in the cancer group. Receiver operating characteristic analysis showed that the cutoff value of D-dimer was 2.785 µg/ml; and above features were particularly evident in cancer patients whose D-dimer values were >2.785 µg/ml, while those with D-dimer values ≤2.785 µg/ml were similar to controls. CONCLUSIONS: D-dimer >2.785 µg/ml may be an effective cutoff value and a sensitive index for identifying CAIS patients. AMBIs in ≥3 vascular territories and AMBIs in both the anterior and posterior circulations are two imaging characteristics of CAIS.

Induction of apoptosis in human leukemia cells through an intrinsic pathway by cathachunine, a unique alkaloid isolated from Catharanthus roseus.

BACKGROUND: Catharanthus roseus (L.) G. Don consists of a range of dimeric indole alkaloids with significant antitumor activities. These alkaloids have been found to possess apoptosis-inducing activity against tumor cells in vitro and in vivo mediated by nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) and c-Jun N-terminal kinase (JNK) pathways, in which DNA damage and mitochondrial dysfunction play important roles. In this study, a unique bisindole alkaloid named cathachunine, along with five known dimeric indole alkaloids, was obtained from C. roseus and investigated in vitro. PURPOSE: The aim of this study was to investigate the antitumor activity of isolated alkaloids and the mechanism through which cathachunine exerts its antitumor effect. STUDY DESIGN AND METHODS: Cell growth inhibition was assessed by WST-1 and lactate dehydrogenase (LDH) assays in HL60, K562 leukemia cells and EA.hy926 umbilical vein cells. Induction of apoptosis in HL60 cells was confirmed by observation of nuclear morphology, a caspase-3 activity assay and annexin V-fluorescein isothiocyanate/propidium iodide (FITC/PI) double staining. The intrinsic apoptotic pathway induced by cathachunine was evidenced by B-cell lymphoma 2/Bcl-2-associated X protein (Bcl-2/Bax) dysregulation, loss of mitochondrial membrane potential, translocation of cytochrome c, and cleavage of caspase-3 and poly-ADP ribose polymerase (PARP). Reactive oxygen species (ROS) production after cathachunine treatment was determined by 2',7'-dichlorodihydrofluorescein diacetate (DCFH-DA) staining. Cell cycle arrest of the S phase was also observed in HL60 cells after cathachunine treatment. RESULTS: The WST-1 and LDH assays showed that Catharanthus alkaloids were cytotoxic toward human leukemia cells to a greater extent than toward normal human endothelial cells, and the anti-proliferation and pro-apoptosis abilities of cathachunine were much more potent than other previously reported alkaloids. The induction of apoptosis by cathachunine occurred through an ROS-dependent mitochondria-mediated intrinsic pathway rather than an extrinsic pathway, and was regulated by the Bcl-2 protein family. CONCLUSION: An unprecedented bisindole alkaloid cathachunine which lost C-18' and C-19' was isolated from C. roseus. It exerted a potent antitumor effect toward human leukemia cells through the induction of apoptosis via an intrinsic pathway. Thus, this study provides evidence for a new lead compound from a natural source for anti-cancer investigations.

In Vitro Inhibition of Glyoxalase І by Flavonoids: New Insights from Crystallographic Analysis.

The antitumor pharmacological property of flavonoids is correlated with inhibition towards glyoxalase I (GLOI), a critical zinc-enzyme in the methylglyoxal detoxification pathway. In this study, 16 flavonoids were examined, and only baicalein (Ki of 0.183 µM) is identified as a potent in vitro GLOI inhibitor. X-ray crystallographic analysis reveals that baicalein chelates with the catalytic Zn(2+) via its characteristic C6/C7 hydroxyl groups. The coordination ability of flavonoids, and therefore their ability to inhibit GLOI, is determined by the Zn(2+) coordination geometry, the rigid skeleton of flavonoids and the geometry of the hydrophobic cavity of the GLOI active site. This structural basis could be useful in predicting GLOI inhibition of other natural polyphenols.

Structural basis for 18-ß-glycyrrhetinic acid as a novel non-GSH analog glyoxalase I inhibitor.

AIM: Glyoxalase I (GLOI), a glutathione (GSH)-dependent enzyme, is overexpressed in tumor cells and related to multi-drug resistance in chemotherapy, making GLOI inhibitors as potential anti-tumor agents. But the most studied GSH analogs exhibit poor pharmacokinetic properties. The aim of this study was to discover novel non-GSH analog GLOI inhibitors and analyze their binding mechanisms. METHODS: Mouse GLOI (mGLOI) was expressed in BL21 (DE3) pLysS after induction with isopropyl-ß-D-1-thiogalactopyranoside and purified using AKTA FPLC system. An in vitro mGLOI enzyme assay was used to screen a small pool of compounds containing carboxyl groups. Crystal structure of the mGLOI-inhibitor complex was determined at 2.3 Å resolution. Molecular docking study was performed using Discovery Studio 2.5 software package. RESULTS: A natural compound 18-ß-glycyrrhetinic acid (GA) and its derivative carbenoxolone were identified as potent competitive non-GSH analog mGLOI inhibitors with Ki values of 0.29 µmol/L and 0.93 µmol/L, respectively. Four pentacyclic triterpenes (ursolic acid, oleanolic acid, betulic acid and tripterine) showed weak activities (mGLOI inhibition ratio <25% at 10 µmol/L) and other three (maslinic acid, corosolic acid and madecassic acid) were inactive. The crystal structure of the mGLOI-GA complex showed that the carboxyl group of GA mimicked the γ-glutamyl residue of GSH by hydrogen bonding to the glutamyl sites (residues Arg38B, Asn104B and Arg123A) in the GSH binding site of mGLOI. The extensive van der Waals interactions between GA and the surrounding residues also contributed greatly to the binding of GA and mGLOI. CONCLUSION: This work demonstrates a carboxyl group to be an important functional feature of non-GSH analog GLOI inhibitors.

Repositioning suture of the erector spinae muscle for lumbar spine surgery via the posterior approach: a prospective randomized study.

We prospectively studied the effectiveness of the repositioning suture of the erector spinae muscle for lumbar spine surgery using the posterior approach. 393 patients undergoing lumbar spine surgery were randomized to receive the repositioning or conventional suture of the erector spinae muscle. Time to stitch removal and drainage volume was recorded at 24 and 48 h after operation. Hemoglobin loss rate was determined at 48 h post operation and the rate of malunion (redness, swelling and effusion at stitch removal and would disruption after stitch removal) was recorded. Low back pain was evaluated using the visual analog scale (VAS) preoperatively and 6 and 12 months after operation. Time to stitch removal was comparable in lumbar spine surgery patients receiving the repositioning or conventional suture of the erector spinae muscle (P > 0.05). Compared with the conventional suture, the repositioning suture was associated with significantly reduced drainage volume both at 24 (P < 0.01) and 48 h after operation (P < 0.05). Hemoglobin loss rate at 48 h post operation was also markedly lower in lumbar spine surgery patients receiving the repositioning suture than in those receiving the conventional suture (P < 0.01 or 0.05). Furthermore, the malunion rate in lumbar spine surgery patients using the repositioning suture was markedly lower than that in the conventional group (P < 0.05 or 0.001). There was no difference in preoperative VAS scores in both the groups (P > 0.05). Compared with the conventional suture, the repositioning suture was associated with significantly reduced VAS scores both at 24 and 48 h after operation (P < 0.01 in both). The repositioning suture of the erector spinae muscle is superior to the conventional suture in posterior lumbar spine surgery with marked lessened pain and reduced drainage volume.

High expression of zinc-binding protein-89 predicts decreased survival in esophageal squamous cell cancer.

BACKGROUND: Zinc-binding protein-89 (ZBP-89), a Krüppel-type four-zinc finger transcription factor, is associated with many cellular functions, including cell growth, differentiation, and apoptosis. It has been reported to be involved in several human cancers. However, ZBP-89 expression pattern and its clinical significance have not yet been investigated in esophageal squamous cell cancer. METHODS: In this study, immunostaining was performed to detect ZBP-89 expression in esophageal squamous cell cancer, and then the correlations between ZBP-89 expression and both clinicopathologic variables and overall survival were analyzed. RESULTS: Compared with adjacent normal tissues, ZBP-89 expression was significantly upregulated in esophageal squamous cell cancer tissues. Increased ZBP-89 expression was associated with N category (p = 0.009) and TNM stage (p = 0.023). Patients with high expression of ZBP-89 demonstrated shortened overall survival compared with those with low expression of ZBP-89 (mean overall survival, 56.961 months versus 76.029 months; p < 0.001). Multivariate Cox regression analysis indicated that ZBP-89 expression had a significant, independent predictive value for survival of esophageal squamous cell cancer (relative risk, 1.581; p = 0.024). CONCLUSIONS: Our data show that increased expression of ZBP-89 is associated with poor prognosis for esophageal squamous cell cancer patients and may act as a novel, useful, and independent prognostic indicator for esophageal squamous cell cancer. Further studies are warranted.

Immunomodulatory effects of crude phenylethanoid glycosides from Ligustrum purpurascens.

ETHNOPHARMACOLOGICAL RELEVANCE: Ligustrum purpurascens, named as "Ku ding cha", has been used as a kind of functional tea in southern China for about two thousand years, which has the effects on diuresis, anti-hypertension, weight-loss and anti-inflammation. THE AIM OF THE STUDY: This study was aimed to investigate the immune enhancement effects of the crude phenylethanoid glycosides (CPGs) from Ligustrum. Purpurascens on mice and analyze the chemical profiles of phenylethanoid glycosides in the CPGs. MATERIALS AND METHODS: The immune functions enhancing potential of CPGs was determined using serum hemolysin antibody, phagocytosis, splenocyte antibody production, and NK cells activity assays. The contents of five major constituents in the crude glycosides of Ligustrum purpurascens were determined by using liquid chromatography, other five glycosides were deduced according to their UV and MS spectra compared with the literature as well. RESULTS: In the immunizing experiment, mice treated with different doses of CPGs showed an increase (p<0.01) in the haemagglutination titre compared with the control group. The increases (p<0.05) were found to be significant at doses of 440 mg/kg and 1.32 g/kg in the experiments of antibody production of spleen cells, MΦ phagocytosis of chicken RBCs and NK cell activity. Further chemical characterization yielded 10 constituents from CPGs, five glycosides were quantified by HPLC and the structures of other five compounds were speculated according to their UV and MS spectra. CONCLUSION: The results suggested that phenylethanoid glycosides from Ligustrum purpurascens have immunomodulatory effects on mice.

Evaluation and treatment of marginal grafts with surgical diseases in kidney transplantation.

BACKGROUND: Marginal renal grafts may alleviate the shortage of suitable organs to meet an increasing demand of kidney transplantation, especially when live donors are currently limited to relatives of patients in China. The aim of this study was to investigate how to increase the available donors pool, evaluation, and treatment of marginal donors. METHODS: We had performed 121 kidney transplantation cases with living relative donors. Five out of these cases applied marginal grafts with surgical diseases, including one renal stone, one duplex kidney, one renal leiomyoma and two cases of simple renal cysts. In each case, particular surgical interventions were exerted on the graft prior to standard engrafting procedures. RESULTS: All recipients recovered with functioning transplants given that their serum creatinine levels declined to a normal range within one week after operation. These recipients were subsequently followed up for 10 months on average and their kidney functions remained stable. CONCLUSIONS: Marginal renal grafts with surgical diseases, which can be treated surgically before engrafting, may provide satisfying transplantation outcomes. Positive and cautious consideration of these grafts may increase renal donor pool.

Rituximab induction therapy in highly sensitized kidney transplant recipients.

BACKGROUND: The number of highly sensitized patients is rising, and sensitization can lead to renal transplant failure. The present study aimed to investigate the safety and efficacy of renal transplantation following induction therapy with rituximab in highly sensitized kidney transplant recipients. METHODS: Seven highly sensitized kidney transplant recipients who underwent rituximab therapy from December 2008 to December 2009 were retrospectively analyzed. There were 3 men and 4 women, with a mean age of 38.5 years (range, 21-47 years). The duration of hemodialysis was 3-12 months, with a mean duration of 11 months. For 4 patients, this was the second transplant; the previous graft survival time was 2-11 years, with a mean survival time of 5.8 years. All the female recipients had history of multiple pregnancies, and all patients had previously received blood transfusions. All donors were men, with a mean age of 32.5 years (range, 25-37 years). In 2 of the 7 patients, both class I and class II of panel reactive antibody were high; the remaining 5 patients showed either high in class I or in class II of panel reactive antibody. The mean panel reactive antibody value was 31% for class I and 51% for class II respectively. The donors and the recipients had the same blood type, with low lymphocyte cytotoxicity ranging from 2% to 5%. The human leukocyte antigen (HLA) mismatch numbers were from 2 to 4. All patients received tacrolimus (0.1 mg × kg(-1) × d(-1)) and mycophenolate mofetil (750 mg twice per day) orally 3 days prior to surgery. All patients received a single dose of 600 mg rituximab (375 mg/m(2)) infusion on the day before surgery and polyclonal antibody (antithymocyte globulin) on the day of surgery. Postoperative creatinine, creatinine clearance rate, and occurrence of rejection by pathological biopsy confirmation were monitored. RESULTS: No patient had delayed graft function after surgery. Two patients had acute rejection, one on day 7 and the other on day 13 post-surgery. Diagnosis of acute rejections was based on the clinical assessments and pathological biopsy results. According to the Banff 07 classification of renal allograft pathology, one of the patients was Ia and the other was IIa; the C4d staining was negative in both patients. One patient received methylprednisolone plus cyclophosphamide and the other received antithymocyte globulin (ATG) therapy, both leading to successful reversion of the acute rejection. All patients were discharged postoperatively and all had normal renal function during the 7th to 12th month follow-up. Pulmonary infection occurred in 1 patient 4 months after surgery and was successfully cured. CONCLUSION: Rituximab induction therapy can reduce the occurrence of postoperative humoral rejection in highly sensitized renal transplant recipients, suggesting that kidney transplantation may be safe and effective for these patients.

Monitoring immune function after rapid corticosteroid reduction in kidney transplant recipients.

BACKGROUND: Long-term use of steroid with large dosage might cause many adverse effects in kidney transplant patients; reducing steroid dosage to a low level for maintenance is helpful in avoiding the side-effects, but meanwhile, acute rejection may rise to be a main concern. The present research monitored the immune function changes and the incidence of acute rejection and infection after rapid steroid reduction to investigate the safety of this strategy. METHODS: A prospective trial was conducted, using tacrolimus and mycophenolate mofetil as the basic immunosuppressive regimen, in addition to antibody induction with basiliximab. Corticosteroid dosage was rapidly reduced to 10 mg/d seven days post-transplantation in the experimental group, and the standard corticosteroid therapy was employed in the control group. Patient immunity was monitored by the Immune Cell Function Assay pre- and two weeks post-transplantation. The incidence of acute rejection and infection were compared between the experimental and control group. RESULTS: Comparison of intracellular adenosine triphosphate (iATP) values detected two weeks post-transplantation for the control group ((324 ± 45) ng/ml) and the experimental group ((345 ± 91) ng/ml) did not reveal a significant difference (P > 0.05). The incidence of acute rejection was analogous between groups (P > 0.05), while an increased incidence of infection was observed in the control group (53% (n = 16)) versus the experimental group (22% (n = 6), P < 0.05). Overall, recipients in the control group had longer and more recurrent infections than those in the experimental group (P < 0.05). Patients in the control group had a lower immune response ((235 ± 35) ng/ml) than those in the experimental group ((286 ± 16) ng/ml) when infection occurred (P < 0.05). CONCLUSION: Rapid reduction of steroid early after kidney transplantation does not lead to a significant rise in patient immunity. It is a safe and effective therapy for kidney transplant patients.

Multidetector row-CT in evaluation of living renal donors.

BACKGROUND: Multidetector-row CT (MDCT) has been evolving to the standard evaluating method of potential living donor in most centers, and can provide excellent details for selecting candidates and determining surgical technique. This study aimed to assess the value of MDCT in evaluation of the anatomy of living kidney donors and to reveal the prevalence of renal vascular variations in a Chinese population. METHODS: One hundred and four potential donors underwent MDCT and the data sets were post-processed for reformatted images with various techniques, such as maximum intensity projection (MIP), a volume-rendering technique (VR), and multiplanar reformation (MPR). Donor nephrectomies were performed on 97 candidates after MDCT evaluation with the findings during surgery constituting the standard of reference. Resulting MDCT images were compared with actual anatomy found during surgery. RESULTS: The MDCT images accurately displayed the anatomic structure of the main renal arteries and veins as well as the upper ureters, except in one case with horseshoe kidney. The prevalence of accessory arteries revealed in images was 27.2% (28/103) and early branching was found in 12.6% (13/103). Compared with findings during surgery, the detection of accessory arteries in MDCT images was 85.7% (6/7), and the detection of larger accessory arteries (> 1.5 mm in diameter) was 100%. Detection of early branching was 100%. CONCLUSION: MDCT helps accurately evaluate the renal anatomy of potential donors thus facilitating the planning of surgery.

Treatment of complex coarctation and coarctation with cardiac lesions using extra-anatomic aortic bypass.

BACKGROUND: Coarctation of the aorta with cardiac lesions or complex coarctation is a formidable challenge for cardiac surgeons. Extra-anatomic bypass allows simultaneous intracardiac repair or an alternative approach for patients with complex coarctation. METHODS: Between July 1997 and March 2008, 43 patients with coarctation of the aorta underwent extra-anatomic bypass grafting, including 10 ascending-to-descending aorta bypasses and 33 ascending aorta-to-infrarenal abdominal aorta bypasses. Forty patients had additional cardiovascular disorders and concomitant procedures performed including aortic valve replacement, mitral valve replacement, coronary artery bypass grafting, closure of ventricular septal defect and patent ductus arteriosus, ascending aorta repair, and the Bentall procedure. The other three patients had complex coarctation of the aorta, including a long-segment coarctation in two cases, and descending aortic aneurysm in one. RESULTS: Two patients died perioperatively: one due to air embolism during the cardiopulmonary bypass; one due to septic shock. There were no late deaths. Complications included laparotomy for mechanical ileus in one and re-exploration for bleeding in one case. There were no strokes or paraplegia and no grafted-related complication during follow-up period. Systolic blood pressure dropped from 160 +/- 27 mm Hg before surgery to 114 +/- 16 mm Hg postoperatively. Only two patients with mild hypertension postoperatively needed oral medicine. CONCLUSIONS: Extra-anatomic aortic bypass via median sternotomy or median sternotomy-laparotomy can be performed with low morbidity and mortality. It is a preferable single-stage approach for patients with concomitant complex coarctation and cardiovascular disorders.

Reduction and fixation of the avulsion fracture of the tibial eminence using mini-open technique.

The purpose of this prospective study is to present and evaluate a new technique using suture anchors for the treatment of the avulsion fractures of the tibial eminence. Twenty-three consecutive patients with the displaced avulsion fracture of the tibial attachment of anterior cruciate ligament were treated using mini-open technique with suture anchors between 2005 and 2008. According to the classification of Meyers and McKeever, there were 5 type II, 13 type III, and 5 type IV fractures. The median follow-up period was 18 months (range, 12-32 months). The patient assessment included Lysholm score, Tegner score, IKDC score, and radiographic evaluation. The median Lysholm score improved from 32 (range, 28-48) preoperatively to 98 (range, 85-100) postoperatively. The median preoperative Tegner score was 3 (range, 2-5), and the median postoperative Tegner score was 7 (range, 5-9). The global IKDC objective score was normal (A) in 21 knees and nearly normal (B) in 2 knees. At final follow-up, the Lachman test and anterior drawer test were negative. The results showed that mini-open reduction and fixation of avulsion fracture of the tibial eminence with suture anchors have achieved satisfactory results. We suggest the use of this technique for treating avulsion fractures of the tibial eminence.

Protein A immunoadsorption combined with rituximab in highly sensitized kidney transplant recipients.

BACKGROUND: The number of highly sensitized patients is rising, and sensitization can lead to renal transplant failure. The present study aimed to investigate the safety and efficacy of protein A immunoadsorption combined with rituximab (RTX) in highly sensitized recipients of kidney transplants. METHODS: Seven highly sensitized recipients of living-related renal transplants (4 men and 3 women, mean aged 42.5 years old (range 33 - 51)) were pretreated with this combination. Human leukocyte antigen (HLA) mismatch number was 2 - 5. Panel reactive antibody (PRA) of class I was high in 2 cases and that of class II was high in 1 case. All patients were pretreated with immunoadsorption 2 - 10 times. Immunoglobulin and PRA changes were monitored before and after absorption. The operation was conducted when PRA or immunoglobulin levels were at or below normal levels. Immunosuppressive drugs were provided 3 - 5 days before the operation, and one dose of RTX (375 mg/m(2)) was infused with polyclonal antibody on the day of operation. Postoperative creatinine (Cr), creatinine clearance rate (Ccr), PRA ratio, and immunoglobulin changes were monitored. RESULTS: All 7 patients had good recovery without delayed graft function. Acute rejection occurred in 3 cases at postoperative days 8, 10, and 14, respectively. The Banff 07 biopsy grades were Ia in 1 case and IIa C4d0 in 2 cases. Successful reversion was achieved after giving methylprednisolone or antithymocyte immunoglobulin + cyclophosphamide. All patients were discharged with normal renal function, mean class I PRA was 14% and mean class II PRA was 35%. PRA was completely negative in 3 cases. CONCLUSION: Protein A immunoadsorption combined with RTX can safely reduce the occurrence of humoral rejection in highly sensitized renal transplant recipients.

[Testis necrosis following repeated misdiagnosis of testicular torsion: a case report and literature review].

OBJECTIVE: To improve clinicians' ability of diagnosing testicular torsion. METHODS: We reviewed the data of a case of testicular torsion that resulted in necrosis because of delayed presentation and repeated misdiagnosis, and analyzed its anatomic features, clinical manifestations, ultrasound results, the causes of misdiagnosis and relevant literature. RESULTS: The patient presented 5 hours after the onset of symptoms, complaining of severe paroxysmal pain in the lower left abdomen, accompanied with nausea and vomiting, and was twice misdiagnosed as having enterospasm or ureteral calculus at two different hospitals. Fifteen hours later, surgical exploration revealed an about 900-degree testicular torsion in the spermatic cord, which necessitated orchiectomy for non viability of the testis. Postoperative pathological examination confirmed testicular necrosis and diffused hemorrhage in the testis and epididymis. CONCLUSION: Timely presentation, correct diagnosis and proper treatment are keys to saving the affected testis. Color Doppler ultrasound is an ideal option for the definite diagnosis of acute scrotal diseases, and it offers a valuable guidance for related surgery as well.

Primary pulmonary artery sarcoma: surgical management and differential diagnosis with pulmonary embolism and pulmonary valve stenosis.

BACKGROUND AND AIM OF THE STUDY: Primary pulmonary artery sarcomas are rare and lethal tumors that are usually diagnosed during surgery or autopsy. We present six cases of primary pulmonary artery sarcomas and discuss clinical features, differential diagnosis, surgical treatment, and outcome of the tumors. METHODS: Between January 1994 and July 2008, six patients were identified with the disease during operation. Three patients were initially diagnosed with pulmonary valve stenosis, and two patients had a presumptive diagnosis of chronic pulmonary embolism. Two patients had simple or partial tumor resection. Four patients had radical tumor resection and homograft reconstruction of the pulmonary arteries. RESULTS: Histological examinations showed five malignant mesenchymomas and one fibrosarcoma. One patient died of refractory pulmonary hypertension during operation. Two patients died 4 months postoperatively because of brain metastases. Two patients were alive for 3 and 9 months, respectively after the operation with recurrent tumor. One patient is alive even 2 years after resection with no signs of recurrence or metastasis. CONCLUSIONS: Because of similar clinical features, pulmonary artery sarcomas are often confused with other pulmonary vascular obstructive diseases. Computed tomography scanning and gadolinium-enhanced magnetic resonance imaging could be useful methods for differential diagnosis. The prognosis is very poor. The survival time after resection varies from several months to several years depending on the presence of recurrence or metastasis. Early diagnosis and radical surgical resection presents the only opportunity for a potential cure.