Accelerate vaccine development using seamless phase 2/3 trial designs.

BACKGROUND: Traditional vaccine development, often a lengthy and costly process of three separated phases. However, the swift development of COVID-19 vaccines highlighted the critical importance of accelerating the approval of vaccines. This article showcases a seamless phase 2/3 trial design to expedite the development process, particularly for multi-valent vaccines. RESEARCH DESIGN AND METHODS: This study utilizes simulation to compare the performance of seamless phase 2/3 design with that of conventional trial design, specifically by re-envisioning a 9-valent HPV vaccine trial. Across three cases, several key performance metrics are evaluated: overall power, type I error rate, average sample size, trial duration, the percentage of early stop, and the accuracy of dose selection. RESULTS: On average, when the experimental vaccine was assumed to be effective, the seamless design that performed interim analyses based solely on efficacy saved 555.73 subjects, shortened trials by 10.29 months, and increased power by 3.70%. When the experimental vaccine was less effective than control, it saved an average of 887.73 subjects while maintaining the type I error rate below 0.025. CONCLUSION: The seamless design proves to be a compelling strategy for vaccine development, given its versatility in early stopping, re-estimating sample sizes, and shortening trial durations.

DAPT Attenuates Cadmium-Induced Toxicity in Mice by Inhibiting Inflammation and the Notch/HES-1 Signaling Axis.

The small molecule DAPT inhibits the Notch signaling pathway by blocking γ-secretase mediated Notch cleavage. Given the critical role of the Notch signaling axis in inflammation, we asked whether DAPT could block Notch-mediated inflammation and thus exert neuronal protection. We established a mouse model of chronic exposure to cadmium (Cd)-induced toxicity and treated it with DAPT. DAPT was effective in ameliorating Cd-induced multi-organ damage and cognitive impairment in mice, as DAPT restored abnormal performance in the Y-maze, forced swimming and Morris water maze (MWM) tests. DAPT also reversed Cd-induced neuronal loss and glial cell activation to normal as observed by immunofluorescence and immunohistochemistry of brain tissue sections. In addition, Cd-intoxicated mice showed significantly increased levels of the Notch/HES-1 signaling axis and NF-κB, as well as decreased levels of the inflammatory inhibitors C/EBPß and COP1. However, DAPT down regulated the elevated Notch/HES-1 signaling axis to normal, eliminating inflammation and thus protecting the nervous system. Thus, DAPT effectively eliminated the neurotoxicity of Cd, and blocking γ-secretase as well as Notch signaling axis may be a potential target for the development of neuronal protective drugs.

[A mini-review on anti-tumor effect of cannabidiol].

Cannabidiol is the main non-psychoactive component of Cannabis sativa, which has multiple medicinal activities, such as antiepileptic, immunomodulation, analgesic, antioxidant, anticonvulsant, anti-anxiety and other functions. In recent years, it has been found that cannabidiol can inhibit the proliferation of various tumor cells, induce apoptosis and autophagy of tumor cells, arrest cell cycle, interrupt invasion and metastasis of tumor cells, regulate tumor microenvironment, exert synergistic therapy with other chemotherapeutic drugs, and reduce the toxicity of chemotherapeutic drugs. However, its anti-tumor effect remains controversial and its application is limited. The study of microspheres, nano liposomes and other new drug delivery systems can improve the anti-tumor effect of cannabidiol. In this study, the anti-tumor mechanism and application of cannabidiol were summarized and discussed in order to provide inspirations for its further investigation and application.

Gisenoside Rg1 attenuates cadmium-induced neurotoxicity in vitro and in vivo by attenuating oxidative stress and inflammation.

OBJECTIVE: Gisenoside Rg1 is a potent neuroprotectant in ginseng. The aim of this study was to investigate the elimination effect of Rg1 on cadmium (Cd)-induced neurotoxicity. MATERIALS AND METHODS: A cumulative Cd exposure mouse model was established. Also, the toxicity of Cd and the protective effect of Rg1 were examined in vitro using cultured neurons and microglia. RESULTS: We found that Cd-intoxicated mice exhibited significant injury in the liver, kidney, small intestine, and testis, along with cognitive impairment. Antioxidant enzymes such as SOD, GSH-Px and CAT were reduced in the blood and brain, and correspondingly, the lipid peroxidation product MDA was elevated. In the brain, astrocytes and microglia were activated, characterized by an increase in inflammatory factors such as TNF-α, IL-1ß and IL-6, as well as their protein markers GFAP and IBA1. However, Rg1 eliminated Cd-induced toxicity and restored oxidative stress and inflammatory responses, correspondingly restoring the behavioral performance of the animals. Meanwhile, the BDNF-TrkB/Akt and Notch/HES-1 signaling axes were involved in the Rg1-mediated elimination of Cd-induced toxicity. CONCLUSION: Rg1 is a promising agent for the elimination of Cd-induced toxicity.

RACK1 mediates the advanced glycation end product-induced degradation of HIF-1α in nucleus pulposus cells via competing with HSP90 for HIF-1α binding.

Hyperglycemia can drive advanced glycation end product (AGE) accumulation and associated nucleus pulposus cell (NPC) dysfunction, but the basis for this activity has not been elucidated. Hypoxia-inducible factor-1α (HIF-1α) is subject to cell-type-specific AGE-mediated regulation. In the current study, we assessed the mechanistic relationship between AGE accumulation and HIF-1α degradation in NPCs. Immunohistochemical staining of degenerated nucleus pulposus (NP) samples was used to assess AGE levels. AGE impact on NPC survival and glycolysis-related gene expression was assessed via 3-(4,5)-dimethylthiazol(-z-y1)-3,5-di-phenyltetrazolium bromide assay and quantitative reverse-transcription polymerase chain reaction (qRT-PCR), while HIF-1α expression in NPCs following AGE treatment was monitored via Western blot analysis and qRT-PCR. Additionally, a luciferase reporter assay was used to monitor HIF-1α transcriptional activity. The importance of the receptor for activated C-kinase 1 (RACK1) as a mediator of HIF-1α degradation was evaluated through gain- and loss-of-function experiments. Competitive binding of RACK1 and HSP90 to HIF-1α was evaluated via immunoprecipitation. Increased AGE accumulation was evident in NP samples from diabetic patients, and AGE treatment resulted in reduced HIF-1α protein levels in NPCs that coincided with reduced HIF-1α transcriptional activity. AGE treatment impaired the stability of HIF-1α, leading to its RACK1-mediated proteasomal degradation in a manner independent of the canonical PHD-mediated degradation pathway. Additionally, RACK1 competed with HSP90 for HIF-1α binding following AGE treatment. AGE treatment of NPCs leads to HIF-1α protein degradation. RACK1 competes with HSP90 for HIF-1α binding following AGE treatment, resulting in posttranslational HIF-1α degradation. These results suggest that AGE is an intervertebral disc degeneration risk factor, and highlight potential avenues for the treatment or prevention of this disease.

Scoring selection criteria including total tumour volume and pretransplant percentage of lymphocytes to predict recurrence of hepatocellular carcinoma after liver transplantation.

AIM: The selection criteria for patients with hepatocellular carcinoma (HCC) to undergo liver transplantation should accurately predict posttransplant recurrence while not denying potential beneficiaries. In the present study, we attempted to identify risk factors associated with posttransplant recurrence and to expand the selection criteria. PATIENTS AND METHODS: Adult patients with HCC who underwent liver transplantation between November 2004 and September 2012 at our centre were recruited into the current study (N = 241). Clinical and pathological data were retrospectively reviewed. Patients who died during the perioperative period or died of non-recurrence causes were excluded from this study (N = 25). All potential risk factors were analysed using uni- and multi-variate analyses. RESULTS: Sixty-one recipients of 216 qualified patients suffered from recurrence. Similar recurrence-free and long-term survival rates were observed between living donor liver transplant recipients (N = 60) and deceased donor liver transplant recipients (N = 156). Total tumour volume (TTV) and preoperative percentage of lymphocytes (L%) were two independent risk factors in the multivariate analysis. We propose a prognostic score model based on these two risk factors. Patients within our criteria achieved a similar recurrence-free survival to patients within the Milan criteria. Seventy-one patients who were beyond the Milan criteria but within our criteria also had comparable survival to patients within the Milan criteria. CONCLUSIONS: TTV and L% are two risk factors that contribute to posttransplant recurrence. Selection criteria based on these two factors, which are proposed by our study, expanded the Milan criteria without increasing the risk of posttransplant recurrence.

Impaired translocation and activation of mitochondrial Akt1 mitigated mitochondrial oxidative phosphorylation Complex V activity in diabetic myocardium.

Insulin can translocate Akt to mitochondria in cardiac muscle. The goals of this study were to define sub-mitochondrial localization of the translocated Akt, to dissect the effects of insulin on Akt isoform translocation, and to determine the direct effect of mitochondrial Akt activation on Complex V activity in normal and diabetic myocardium. The translocated Akt sequentially localized to the mitochondrial intermembrane space, inner membrane, and matrix. To confirm Akt translocation, in vitro import assay showed rapid entry of Akt into mitochondria. Akt isoforms were differentially regulated by insulin stimulation, only Akt1 translocated into mitochondria. In the insulin-resistant Type 2 diabetes model, Akt1 translocation was blunted. Mitochondrial activation of Akt1 increased Complex V activity by 24% in normal myocardium in vivo and restored Complex V activity in diabetic myocardium. Basal mitochondrial Complex V activity was lower by 22% in the Akt1(-/-) myocardium. Insulin-stimulated Complex V activity was not impaired in the Akt1(-/-) myocardium, due to compensatory translocation of Akt2 to mitochondria. Akt1 is the primary isoform that relayed insulin signaling to mitochondria and modulated mitochondrial Complex V activity. Activation of mitochondrial Akt1 enhanced ATP production and increased phosphocreatine in cardiac muscle cells. Dysregulation of this signal pathway might impair mitochondrial bioenergetics in diabetic myocardium.

A learning curve for living donor liver transplantation.

BACKGROUND: The number of living donor liver transplantations performed has increased rapidly in many Eastern transplant centres. However, the impact of the transplant centres' experience and learning on the transplant outcomes are not well established. Aim of the study was to evaluate the learning curve for living donor liver transplantation in our centre. METHODS: Data from 156 recipients and 156 donors who underwent surgery were reviewed. Intraoperative data and postoperative outcomes of both donors and recipients were retrospectively analysed. Recipients and donors were divided into three groups that consisted of 52 consecutive cases each. RESULTS: Surgical duration and intraoperative blood loss during donor surgery were decreased significantly between the earlier and the more recent cases (423±39 vs. 400±44 min and 959±523 vs. 731±278 mL, respectively; P<0.01). Rates of postoperative complications and functional changes were not statistically different amongst the three donor groups. Immediate complication rate of the first 52 recipients was higher than those of the second and third cohorts. Long-term survival rates of the three recipient groups were similar. CONCLUSIONS: The learning curve greatly influenced immediate outcomes of recipients during the early transplant period. However, it had little influence on donor outcome; long-term outcome improvement of recipients did not depend on the accumulation of experience alone.

Risk factors and outcomes of massive red blood cell transfusion following living donor liver transplantation.

OBJECTIVES: To identify the factors influencing blood loss and secondary blood transfusion and to investigate the outcomes of patients who underwent a massive blood transfusion (MBT) following living donor liver transplantation (LDLT). METHODS: Patients who underwent primary adult-to-adult right hepatic lobe LDLT were included in the study, and were divided into the MBT group [≥6 red blood cell (RBC) units in 24 h] and the non-massive blood transfusion (NMBT) group (<6 RBC units in 24 h). All potential risk factors, length of intensive care unit (ICU) stay and long-term survival rate of the patients in the two groups were analyzed. RESULTS: The data of 181 eligible patients were retrospectively analyzed. A decreased long-term survival rate, a higher incidence of postoperative infection and prolonged ICU stay were observed in the MBT group. No significant difference was observed in survival rate between patients having platelet transfusion>2 units and ≤2 units. Hemoglobin<100 g/L, platelet counts<70×10(9)/L, fibrinogen level<1.5 g/L and history of upper abdominal surgery were found to be independent risk factors. CONCLUSIONS: Blood transfusion during LDLT can be predicted using preoperative variables. Massive RBC transfusion may lead to poor long-term survival, higher postoperative infection rate and prolonged ICU stay. Platelet transfusion may not be a risk factor for long-term survival.

Graft size alone should not affect donors selection and be used to predict the prognosis of recipients after living donor liver transplantation.

BACKGROUND/AIMS: Graft size is recognized as one of the most important factors that affect prognosis of the liver recipients. This study determines whether the graft to recipient weight ratio (GRWR) alone can be used to select the liver donor and as an outcome predictor before living donor liver transplantation (LDLT). METHODOLOGY: LDLT patients (202) were divided into three groups according to the GRWR: Group S (n=46, GRWR <0.8); Group M (n=83, GRWR 0.8-1.0); Group L (n=73, GRWR >1.0). Recovery of graft function, incidence of small-for-size syndrome and rate of complications were compared among the three groups. RESULTS: There were no significant differences in the baseline characteristics in both the donors and recipients, nor in the intensive care unit stay hours, re-operation rate, hospital stay after operation, Clavien System score and recovery of graft function after transplantation, among the three groups. The small-for-size syndrome rates were 13%, 7.23% and 11% in Groups S, M and B, and no significant difference was noted among the three groups. CONCLUSIONS: GRWR may not be the only factor affecting recipient prognosis after LDLT. Local graft dysfunction such as impaired venous outflow, severity of disease and portal hyperperfusion in the recipient, and fatty liver in donor may influence the graft and thus the prognosis of transplantation.

Quality of life and psychological outcome of donors after living donor liver transplantation.

AIM: To investigate the health related quality of life (HRQoL) and psychological outcome of donors after living donor liver transplantation. METHODS: Participants were 92 consecutive liver transplant donors who underwent hepatectomy without middle hepatic vein at West China Hospital of Sichuan University between January 2007 and September 2010. HRQoL was measured using the Chinese version of the Medical Outcomes Study Short Form-36 (SF-36), and psychological symptoms were measured using the Symptom Checklist-90-Revised (SCL-90-R). Data collected from donors were compared to previously published data from the general population. Clinical and demographic data were collected from medical records and questionnaires. RESULTS: The general health score of the SF-36 was significantly lower in females (59.78 ± 12.25) than in males (75.83 ± 22.09). Donors more than 40 years old scored higher in social functioning (85.71 ± 14.59) and mental health (82.61 ± 20.00) than those younger than 40 (75.00 ± 12.13, 68.89 ± 12.98; social functioning and mental health, respectively). Donors who had surgery more than two years prior to the study scored highest in physical functioning (P = 0.001) and bodily pain (P = 0.042) while those less than one year from surgery scored lowest. The health of the liver recipient significantly influenced the general health (P = 0.042), social functioning (P = 0.010), and role-emotional (P = 0.028) of donors. Donors with full-time employment scored highest in role-physical (P = 0.005), vitality (P = 0.001), social functioning (P = 0.016), mental health (P < 0.001), the physical component summary scale (P < 0.001), and the mental component summary scale (MCS) (P < 0.001). Psychological measures indicated that donors were healthier than the general population in obsessive-compulsive behavior, interpersonal sensitivity, phobic anxiety, and paranoid ideation. The MCS of the SF-36 was significantly correlated with most symptom scores of the SCL-90-R. CONCLUSION: HRQoL and psychological outcome were favorable in living liver transplant donors after donation. Specifically, gender, age, time since operation, recipient health condition, and employment after donation, influenced postoperative quality of life.

Mitochondrial Akt-regulated mitochondrial apoptosis signaling in cardiac muscle cells.

We recently reported translocation and activation of Akt in cardiac mitochondria. This study was to determine whether activation of Akt in mitochondria could inhibit apoptosis of cardiac muscle cells. Insulin stimulation induced translocation of phosphorylated Akt to the mitochondria in primary cardiomyocytes. A mitochondria-targeted constitutively active Akt was overexpressed via adenoviral vector and inhibited efflux of cytochrome c and apoptosis-inducing factor from mitochondria to cytosol and partially prevented loss of mitochondria cross-membrane electrochemical gradient. Activation of caspase 3 was suppressed in the cardiomyocytes transduced with mitochondria-targeted active Akt, whereas a mitochondria-targeted dominant negative Akt enhanced activation of caspase 3. Terminal deoxynucleotidyl transferase dUTP-mediated nick-end labeling assay showed that mitochondrial activation of Akt significantly reduced the number of apoptotic cells. When the endogenous Akt was abolished by LY294002, the antiapoptotic actions of mitochondrial Akt remained effective. These experiments suggested that mitochondrial Akt suppressed apoptosis signaling independent of cytosolic Akt in cardiac muscle cells.

Role of contrast-enhanced ultrasound in decision support for diagnosis and treatment of hepatic artery thrombosis after liver transplantation.

OBJECTIVE: To assess role of contrast-enhanced ultrasound (CEUS) in decision support for diagnosis and treatment of hepatic artery thrombosis (HAT) after liver transplantation. MATERIALS AND METHODS: Between January 2005 and January 2011, 605 patients underwent liver transplantation in our medical center. All the liver transplant recipients received Doppler ultrasound scanning and CEUS examination was performed in 45 patients with suspected HAT on Doppler ultrasound. Sensitivity, specificity, accuracy, positive predict value and negative predictive value of CEUS in diagnosing HAT were determined based on the results from angiography, surgery and clinical follow-up. RESULTS: Fourteen HATs, including one late HAT, were diagnosed by CEUS. Twelve HAT cases were confirmed by angiographic and/or surgical findings, while the late HAT and other 31 patients with negative CEUS finding were confirmed by the clinical follow-up. There was a false positive HAT diagnosed by CEUS in which angiography revealed a patent hepatic artery. The sensitivity, specificity, accuracy, positive predict value and negative predictive value of CEUS in diagnosing HAT were 100%, 96.9%, 97.8%, 92.9% and 100%, respectively. In our series of 605 liver transplants, the incidence and mortality of HAT was 2.2% (13/605) and 53.8% (7/13), respectively. CONCLUSIONS: Our study demonstrates the important role of CEUS in decision support for diagnosis and treatment of HAT after liver transplantation. When HAT is suspected by Doppler ultrasound, CEUS shall immediately be performed to elucidate its nature. A negative CEUS finding shall avoid invasive angiography. Such as, CEUS may alter the clinical workflow on HAT detection after liver transplantation.

Cholangiocarcinoma accompanied by desmoid-type fibromatosis.

BACKGROUND: Cholangiocarcinoma complicated by intra-abdominal desmoid-type fibromatosis (DTF) is uncommon. There are no reports on patients with this type of fibromatosis, in which the pre-operative treatment (including diagnosis), surgical approach, post-operative pathologic reports, and prognosis are discussed. METHOD: The clinicopathological features of a 49-year-old man were retrospectively analyzed. RESULTS: Cholangiocarcinoma located in the inferior segment of the bile duct was considered pre-operatively on the basis of clinical findings. At the time of pancreaticoduodenectomy, the mesojejunum was stiff without nodules or a mass at a distance of approximately 80 cm from the ligament of Treitz. Complete excision of the entire lesion of the intestinal mesenteric contracture and its subsidiary was performed. Post-operative pathologic findings confirmed an adenocarcinoma located at the extremity of the common bile duct and infiltrating the full thickness of the common bile duct as well as the deep muscular layer of the duodenum. The contracted jejunal mesentery was shown to have DTF. The patient was alive with no evidence of recurrence after a follow-up of 6 months. CONCLUSIONS: The patient had a rare hereditary disease with intra-abdominal DTF, which manifests the characteristics of an aggressive growth pattern and a high rate of local recurrence; conservative therapy is recommended. Complete excision of the fibromatous lesion during pancreaticoduodenectomy may maximally decrease the risk of local recurrence.

Outcome of hepatocellular carcinoma treated by liver transplantation: comparison of living donor and deceased donor transplantation.

BACKGROUND: Liver transplantation (LT) has been widely accepted as the treatment of choice for end-stage liver diseases. Due to the scarcity of cadaveric donors, adult-to-adult living donor liver transplantation (LDLT) is advocated as a practical alternative to deceased donor liver transplantation (DDLT). However, some reports suggest that the long-term and recurrence-free survival rates of LDLT are poorer than those of DDLT for hepatocellular carcinoma (HCC). This study aimed to compare the long-term and recurrence-free survival rates of HCC between LDLT and DDLT. METHODS: We retrospectively analyzed the clinical data of 150 patients with HCC from January 2005 to March 2009. Eleven patients who died of complications during the perioperative period were excluded. The remaining 139 eligible patients (101 DDLT and 38 LDLT) were regularly followed up to October 2009. The Chi-square test or Fisher's exact test were used to compare the characteristics of LDLT and DDLT. The long-term and recurrence-free survival curves of both groups were determined using the Kaplan-Meier method with comparisons performed using the log-rank test. One-way analysis of variance was performed to compare the waiting time of the two groups. RESULTS: Survival rates at 1, 2, 3, and 4 years for LDLT were 81%, 62%, 53%, and 45% and for DDLT were 86%, 60%, 50%, and 38%, respectively. The overall 1-, 2-, 3-, and 4-year recurrence-free rates for LDLT were 71%, 49%, 42%, and 38%, and for DDLT were 76%, 52%, 41%, and 37%, respectively. No significant differences were found by the log-rank test on both long-term and recurrence-free survival rates. CONCLUSIONS: The role of LDLT is reinforced by our study. It may expand the donor pool and achieve the same long-term and recurrence-free survival rates of DDLT.

Recurrence of hepatocellular carcinoma after liver transplantation: recurrence characteristics and risk factors.

BACKGROUND/AIMS: The aim of this study was to investigate tumor recurrence characteristics of hepatocellular carcinoma (HCC) after liver transplantation (LT), including recurrence sites, time and risk factors, and to provide a basis for predicting and preventing tumor recurrence. METHODOLOGY: Data from 224 consecutive patients with HCC who underwent LT between Feb 1999 and December 2008 at our center had been retrospectively analyzed. Tumor-unrelated, perioperative and in hospital deaths were excluded (n = 39). All the cases were followed-up regularly. According to recurrence or not, the cases were divided into recurrence group (n = 103) and non-recurrence group (n = 99). The data were analyzed statistically. RESULTS: Extrahepatic and single site recurrences were more common in early postoperative days, especially in the lung. No significant relation was observed between recurrence sites and time. Exceeding Milan criteria (MC), macrovascular invasion, liver capsule invasion, satellite lesions and Tumor-Node-Metastasis (TNM) classification of UICC were observed significant different in univariate analysis. TNM classification and macrovascular invasion were considered 2 independent risk factors in multivariate analysis. Macrovascular invasion was a independent risk factor for very early recurrences (6 months). CONCLUSIONS: Recurrence of HCC after LT was not frequent at intrahepatic but extrahepatic sites. The recurrence time was mainly in early operative days. TNM classification and macrovascular invasion are risk factors. Macrovascular invasion is associated with early recurrence.

Increased caveolin-1 expression associated with prolonged overall survival rate in hepatocellular carcinoma.

AIMS: Recent study indicates that the binding of caveolin-1 (CAV1), the essential constituent of caveolae, to endothelial nitric oxide synthase (eNOS) prevents nitric oxide (NO) production in cirrhotic human liver. However, their interplay in hepatocellular carcinoma (HCC) remains undetermined. METHODS: Paraffin-embedded sections from 73 HCC patients were included in this study. The expression patterns of CAV1 and eNOS determined by immunohistochemistry were correlated with the clinicopathological characteristics and overall survival. RESULTS: Although CAV1 expression did not correlate with any clinicopathological characteristic, increased CAV1 expression was associated with prolonged overall survival (p = 0.021), even when using the multivariate Cox's regression model (OR = 0.25, 95%CI = 0.08-0.72, p = 0.011). eNOS expression was correlated with an increased histological grade (p = 0.002) and intriguingly, the patients had a decreased overall survival when their lesions presented with high eNOS but low CAV1 expression concomitantly (p = 0.003). Meanwhile, the increased CAV1/eNOS merged level determined by immunofluorescence was significantly associated with a decreased histological grade and better overall survival (p = 0.023 and 0.001, respectively). CONCLUSIONS: Our results suggest CAV1 may play a tumour-suppressive role and can serve as a predictive biomarker in HCC. The impacts of CAV1 on hepatocarcinogenesis may occur partly through its modulation of eNOS.

Management of venous stenosis in living donor liver transplant recipients.

AIM: To retrospectively evaluate the management and outcome of venous obstruction after living donor liver transplantation (LDLT). METHODS: From February 1999 to May 2009, 1 intraoperative hepatic vein (HV) tension induced HV obstruction and 5 postoperative HV anastomotic stenosis occurred in 6 adult male LDLT recipients. Postoperative portal vein (PV) anastomotic stenosis occurred in 1 pediatric left lobe LDLT. Patients ranged in age from 9 to 56 years (median, 44 years). An air balloon was used to correct the intraoperative HV tension. Emergent surgical reoperation, transjugular HV balloon dilatation with stent placement and transfemoral venous HV balloon dilatation was performed for HV stenosis on days 3, 15, 50, 55, and 270 after LDLT, respectively. Balloon dilatation followed with stent placement via superior mesenteric vein was performed for the pediatric PV stenosis 168 d after LDLT. RESULTS: The intraoperative HV tension was corrected with an air balloon. The recipient who underwent emergent reoperation for hepatic stenosis died of hemorrhagic shock and renal failure 2 d later. HV balloon dilatation via the transjugular and transfemoral venous approach was technically successful in all patients. The patient with early-onset HV stenosis receiving transjugular balloon dilatation and stent placement on the 15th postoperative day left hospital 1 wk later and disappeared, while the patient receiving the same interventional procedures on the 50th postoperative day died of graft failure and renal failure 2 wk later. Two patients with late-onset HV stenosis receiving balloon dilatation have survived for 8 and 4 mo without recurrent stenosis and ascites, respectively. Balloon dilatation and stent placement via the superior mesenteric venous approach was technically successful in the pediatric left lobe LDLT, and this patient has survived for 9 mo without recurrent PV stenosis and ascites. CONCLUSION: Intraoperative balloon placement, emergent reoperation, proper interventional balloon dilatation and stent placement can be effective as a way to manage hepatic and PV stenosis during and after LDLT.

Insulin stimulates Akt translocation to mitochondria: implications on dysregulation of mitochondrial oxidative phosphorylation in diabetic myocardium.

Mitochondrial oxidative phosphorylation is the major source of energy in cardiac muscle. In the streptozotocin-induced diabetic (STZ-DM) mice, myocardial oxidative phosphorylation was perturbated and oxidative phosphorylation complex V (ATP synthase) activity was significantly reduced. To determine the independent effects of hyperglycemia and insulin deficiency on the changes of myocardial complex V, we used phlorizin (Ph) to normalize blood glucose in the diabetic mice. Ph treatment did not improve myocardial complex V activity in the STZ-DM mice, whereas insulin treatment normalized myocardial complex V activity in the diabetic mice. Therefore, the reduction of complex V activity was caused by insulin deficiency and not by hyperglycemia in STZ-DM myocardium. Acute insulin stimulation induced phosphorylation of Akt and translocation of Akt to mitochondria in myocardium. Translocation of phospho-Akt to mitochondria was enhanced in the STZ-DM mice and was blunted in the diet-induced diabetic mice. In parallel, insulin activation of complex V was enhanced in the STZ-DM myocardium and suppressed in the diet-induced diabetic myocardium. In vivo inhibition of Akt blocked insulin stimulation of phospho-Akt translocation and blunted activation of complex V. Insulin-activated Akt translocation to mitochondria in cardiac muscle is a novel paradigm that may have important implications on myocardial bioenergetics.

Clinicopathological characteristics of 15 patients with combined hepatocellular carcinoma and cholangiocarcinoma.

BACKGROUND: Combined hepatocellular carcinoma and cholangiocarcinoma (cHCC-CC) is a rare subtype of primary liver cancer, and clinicopathological features of cHCC-CC have seldom been reported in detail. This study was undertaken to explore the diagnosis and clinicopathological characteristics of cHCC-CC in comparison with hepatocellular carcinoma (HCC) and cholangiocarcinoma (CC), respectively. METHODS: The clinical data from 15 patients with cHCC-CC, 132 patients with HCC and 44 patients with CC who had undergone hepatic resection were analyzed retrospectively. Clinicopathological characteristics of cHCC-CC, HCC and CC such as hepatitis B viral infection, serum hepatitis C virus (HCV) antibody, serum alpha-fetoprotein (AFP) level, cirrhosis, vascular invasion, lymph node metastasis, surgical procedure and adjuvant treatment were also analyzed. Follow up was carried out in the patients, and their 1-, 3-, and 5-year survival rates were calculated. RESULTS: Two patients with cHCC-CC were correctly diagnosed by enhanced CT before operation, the other 13 patients were diagnosed by histology and immunohistochemistry after operation. Radical (8/15) and conservative hepatectomy (7/15) for cHCC-CC was similar to that for HCC and CC (P>0.05). Pathologically cHCC-CC showed more significantly vascular invasion and lymph node metastasis than HCC (P<0.05), and a similarity to CC (P>0.05). Hepatitis B viral infection, serum HCV antibody, cirrhosis, and serum AFP level of cHCC-CC patients were similar to those of HCC patients (P>0.05) but different from CC patients (P<0.05). The cumulative 1-, 3-, and 5-year survival rates in patients with cHCC-CC were poorer than in patients with HCC or CC (P<0.05). CONCLUSIONS: Patients with cHCC-CC are seldom diagnosed before operation. The progression of cHCC-CC is more rapid than that of HCC or CC. Survival rate of patients with cHCC-CC after hepatic resection is poorer than that of patients with HCC or CC.