Posterior reversible encephalopathy syndrome and graft-versus-host disease after liver transplantation: a case report and review of the literature.

Case (description): A 52-year-old male patient presented with seizures on the 16th day post liver transplantation suggesting tacrolimus-associated posterior reversible encephalopathy syndrome (PRES). On the 18th day, the patient was diagnosed with graft-versus-host disease (GVHD). Calcineurin inhibitor (CNI) was stopped and the patient received 1 g methylprednisolone and 25 g immunoglobulin. However, on the 21st day, the patient's clinical condition progressively worsened and he died of multi-organ failure. GVHD could have occurred with PRES because the CNI dose was reduced. The best treatment for patients with PRES and GVHD is using immunosuppressants other than CNI. Antibody preparations and steroids could be a standard treatment.

Outcomes in children with biliary atresia following liver transplantation.

BACKGROUND: Congenital biliary atresia is a rare condition characterized by idiopathic dysgenesis of the bile ducts. If untreated, congenital biliary atresia leads to liver cirrhosis, liver failure and premature death. The present study aimed to evaluate the outcomes of orthotopic liver transplantation in children with biliary atresia. METHOD: We retrospectively analyzed 45 patients with biliary atresia who had undergone orthotopic liver transplantation from September 2006 to August 2012. RESULTS: The median age of the patients was 11.0 months (5-102). Of the 45 patients, 41 were younger than 3 years old. Their median weight was 9.0 kg (4.5-29.0), 34 of the 45 patients were less than 10 kg. Thirty-one patients had undergone Kasai portoenterostomy prior to orthotopic liver transplantation. We performed 30 living donor liver transplants and 15 split liver transplants. Six patients died during a follow-up. The median follow-up time of surviving patients was 11.4 months (1.4-73.7). The overall 1-, 2- and 3-year survival rates were 88.9%, 84.4% and 84.4%, respectively. CONCLUSION: With advances in surgical techniques and management, children with biliary atresia after liver transplantation can achieve satisfactory survival in China, although there remains a high risk of complications in the early postoperative period.

Effect of steatosis donor liver transplantation on hepatocellular carcinoma recurrence: experience at a single institution.

BACKGROUND/AIMS: The increasing demand for transplantation has led application of steatotic liver as the graft. The aim of this study was to determine the effect of donor graft steatosis on overall outcome and tumor recurrence after liver transplantation for hepatocellular carcinoma. METHODOLOGY: 131 patients that underwent liver transplantation for hepatocellular carcinoma between 2007 and 2008 were included. Donor steatosis was categorized as non-steatosis group (0%-10%, n=101) and steatosis group (>10%, n=30). The Kaplan-Meier method and Cox proportional hazard regression model was used for data analysis. RESULTS: Postoperative recipient survival rate was 81% and 66.6% at 1 and 3 years, respectively, for non-steatotic graft; 87.5% and 58.3% for mild steatosis; 83.3% and 41.7% for moderate to severe steatosis (p=0.303). Postoperative tumor recurrence rate was 15.8% and 28.7% at 1 and 3 years, respectively, for grafts with no steatosis; 8.3% and 20.8% for those with mild steatosis; 33.3% and 50% for those with moderate to severe steatosis, (p>0.05). CONCLUSIONS: Steatotic donor was not associated with a worse prognosis in early stage postoperative and mild fatty liver did not increase tumor recurrence risks. The moderate to severe status of fatty liver had some effect on tumor recurrence.

[Transport Influence and Potential Sources of Ozone Pollution for Nanjing During Spring and Summer in 2017].

In this study, the 24-hour backward trajectories of air mass at ground level(10 m)in Nanjing were calculated by using the HYSPLIT model with the NCEP global reanalysis data from April 1st to October 31st, 2017. The backward trajectories were then combined with the hourly concentration data of O3 in Nanjing for trajectories clustering analysis and potential pollution sources analysis. The results show that in 2017, the maximum daily 8 h running average O3 level in Nanjing was around 12-261 µg·m-3 with 58 days of O3 pollution in Nanjing, mainly in the spring and summer. The monthly variation of O3 showed a single peak, with the highest O3 concentration, as well as the most days exceeding the standard, occurring in June; the diurnal variation of O3 was unimodal and reached its peak around 14:00. A total number of 5136 trajectories were obtained by simulation, among which the exceeded trajectories accounted for approximately 10%. The exceedance trajectories in May and June were significantly higher, accounting for 60% of the total exceedance trajectories. Six ground-level air mass transporting pathways were identified through clustering analysis, from the NNE, NW, SW, SSE, SE, and NE directions. The SE and SSE directions with higher O3 levels were the dominant transport routes of O3 pollution, contributing to 23.33% and 20.76% of backward trajectories, respectively. As for the potential pollution source analysis, the area with high WCWT value distribution matched the WPSCF result, indicating that the potential sources of O3 pollution were mainly distributed in Changzhou, Wuxi, Suzhou, Huzhou, and other cities around Taihu Lake. Additionally, cities located around Nanjing, such as Taizhou, Ma'anshan, Wuhu, Chuzhou, Nantong, and Lianyungang, were considered the secondary potential sources. The results indicate that O3 pollution in Nanjing is a regional issue and its control requires joint prevention and control strategies in the Yangtze River Delta.

[Causes and therapeutic principles of pulmonary infections in renal transplant recipients].

Pulmonary infection after renal transplantation is a well recognized and prevalent postoperative complication, which can occur at either the early stage or late stage after transplantation. The etiology and this phenomenon and its impacts remains unclear. It may be life-threatening in severe patients. Early diagnosis and treatment are important; meanwhile, the dosage of immunosuppressant should be minimized. Prophylactic management should also be emphasized.

Diagnosis and Management of Immune Related Adverse Events (irAEs) in Cancer Immunotherapy.

Immune checkpoint inhibitors (ICPIs) and chimeric antigen receptor (CAR) T-cell therapy are two main promising methods of immunotherapy, which have become increasingly important in cancer treatment. After the wider application of these medicine in clinic, a range of immune related adverse events (irAEs) covering almost any system arouse the concern for being randomness and unpredictability. Even if most adverse events are mild and controllable after thoughtful management, the occurrence of life-threatening toxicities should not be ignored because of the insidious and atypical symptoms, which makes the early diagnosis even more challenging. In this review, a brief introduction of immunotherapy and mechanisms underlying irAEs is involved. We mainly focus on the early diagnostic method and recommended management of toxicities of different systems separately, and consequently maximized effectiveness of immunotherapy can be achieved.

Liver support therapy with molecular adsorbents recirculating system in liver failure: a summary of 252 cases from 14 centers in China.

BACKGROUND: A liver support therapy, named molecular adsorbents recirculating system (MARS), has been used for more than 700 liver failure patients in China. We made here a summary to evaluate the effects of MARS treatment in different applications with emphasis on hepatitis B virus (HBV) based liver failure. METHODS: This report analyzed data of 252 patients (mean age (44.9+/- 12.7) years) in three groups: acute severe hepatitis (ASH), subacute severe hepatitis (SSH) and chronic severe hepatitis (CSH). The largest group was CSH (156 patients, 61.9%), and 188 patients (74.6%, 188/252) were infected with HBV. RESULTS: MARS treatments were associated with significant reduction of albumin bound toxins and water-soluble toxins. Most of the patients showed a positive response with a significant improvement of multiple organ function substantiated by a significant increase in prothrombin time activity (PTA) and median arterial pressure (MAP). There was a decrease in hepatic encephalopathy (HE) grade and Child-Turcotte-Pugh (CTP) scale. Thirty-nine of 188 HBV patients (20.7%) dropped out of the commendatory consecutive therapy ending with lower survival of 43.6% while the rest of the 149 patients had a survival rate of 62.4%. Survival within the ASH and SSH groups were 81.2% and 75.0%, respectively. In the CSH group, end stage patients were predominant (65/151, 43%), whereas the early and middle stage patients had a better prognosis: early stage survival, including orthotopic liver transplantation (OLT) survival of 91.7%, middle stage survival of 75%, end stage survival of 33.8%. CONCLUSIONS: MARS continues to be the most favorable extracorporeal treatment for liver support therapy in China for a wide range of conditions, including the majority of hepatitis B related liver failure conditions. The appropriate application of MARS for the right indications and stage of hepatic failure, as well as the fulfillment of prescribed treatments, will lead to the optimal therapeutic result.

[Analysis of the causes of death in patients awaiting liver transplantation].

OBJECTIVE: To analyze the causes of death of patients awaiting liver transplantation, in order to improve the management of these patients. METHODS: Data of 63 patients died in our hospital from January 2003 to June 2007 while waiting for liver transplantation were analyzed retrospectively, including waiting time, general condition, treatment and causes of death. RESULTS: The average length of stay awaiting liver transplantation and stay in intensive care unit was (32.53+/-17.21) days and (12.75+/-9.77)days, respectively. While on the waiting list, the incidence of upper gastrointestinal bleeding, encephalopathy and infection was 47.62%, 39.68% and 74.60%, respectively. The predominant causes of death were septic shock or multiple organ failure (MOF) and varicose vein bleeding, accounting for a mortality of 39.68% and 26.98%, respectively. Blood purification, when used timely, offered therapeutic effects for hepatic encephalopathy and hepatic renal syndrome. CONCLUSION: For the candidates in the waiting list of liver transplantation, the major causes of death were infection and lethal upper digestive tract bleeding.

Proteomic investigation of resistance to chemotherapy drugs in osteosarcoma.

BACKGROUND: Osteosarcoma, which is also termed osteogenic sarcoma or osteoma sarcomatosum, is the most common form of bone cancer. Typical osteosarcoma can occur at any age, including in infants, children, and the elderly, but more than half of cases occur in individuals who are 10-20 years old. OBJECTIVE: Here, the objective was to search for protein markers to indicate resistance to cisplatin in osteosarcoma and provide a theoretical basis for the early and accurate use of cisplatin to treat osteosarcoma. METHODS: Thirty patients with osteosarcoma were selected for the study. Experimental studies on the chemosensitivity of osteosarcoma using an in vitro kit method were performed, and cisplatin-resistant and cisplatin-sensitive osteosarcoma tissues were obtained. A representative sample was chosen to analyze and identify differentially expressed proteins in cisplatin-resistant tissues. RESULTS: The osteosarcoma-sensitive tissue was analyzed using 2-D electrophoresis and time-of-flight mass spectrometry. Differently expressed proteins were analyzed by western blotting to identify markers. Cisplatin-resistant and cisplatin-sensitive osteosarcoma tissues were obtained. Five significantly differentially expressed proteins were identified, including ALDOA and PGK1. CONCLUSIONS: The results indicate that ALDOA and PGK1 might be appropriate markers that can be used when treating osteosarcoma with cisplatin.

Measuring upper limb movement to analyze intra-body communication channel attenuation characteristics.

BACKGROUND: This experiment was designed to study the respective effects of the closed-state human palm and dynamic arm bending on intra-body communication channel attenuation. METHODS: We selected the right upper arm of a healthy adult male as the experimental object to measure channel attenuation variation in a closed or open palm, and when the arm was bent, so as to analyze channel characteristics. CONCLUSIONS: The experiment showed that, in a quasi-static stable system, the effects of a closed palm on channel attenuation were negligibly minimal. In contrast, the physiological signal of the living body significantly interfered with the channel in the low-frequency mode. In the dynamic arm-bending experiment, we found that the attenuation variation range corresponds to the intersection angle (90∘⩽θ⩽ 180∘) of the upper arm and forearm; these results provide the basis for the establishment of a theoretical model.

[Prospective study of effect of recombinant human growth hormone on nutritional status and immune function in early postoperative stage of liver transplantation].

OBJECTIVE: To evaluate influence of recombinant human growth hormone (rhGH) on nutritional status and immune function in early postoperative stage of liver transplantation including hepatic function, acute rejection and infection rate, in order to assess its safety in clinical use. METHODS: Sixty patients with non-malignant diseases of the liver in terminal stages were randomly divided into two groups: treatment group (rhGH treatment n=30) and control group (n=30). All the patients received the same nutritional support and immunodepressant treatment regimes. The patients in treatment group received rhGH 10 U hypodermically daily for 10 days 24 hours after liver transplantation. The following parameters including siderophilin, prealbumin, albumin, urea nitrogen, CD4/CD8, immunoglobulin G (IgG), IgM, IgA, growth hormone (GH), insulin-like growth factor-1 (IGF-1), aspartate aminotransferase (AST), alanine aminotransferase (ALT), dosage of insulin to control blood sugar (8-10 mmol/L) were determined on 1st, 4th, 8th, 14th days after the operation, and acute rejection rate after 28 days of operation (confirmed by liver acupuncture biopsy), and infection rate were also assessed. RESULTS: Compared with control group, levels of siderophilin, prealbumin, CD4/CD8, GH, IGF-1 within 14 days in treatment group were increased significantly 14 days after the operation (all P<0.05), and level of urea nitrogen was decreased significantly (P<0.05). The level of albumin in treatment group was lower than that in control group 14 days after operation (P<0.05), while dosages of exogenous insulin were higher on 4th and 8th days after operation than that in control group (both P<0.05). There were no significant differences in levels of AST, ALT within 14 days, or acute rejection rate and infection rate within 28 days between two groups (all P>0.05). CONCLUSION: rhGH can accelerate recovery of nutritional status in the early liver transplantation period. It does not show superiority in improving immune function and influence on recovery of hepatic function, acute rejection or infection rate. The safety has been challenged by inducing high blood sugar as a side effect.

[Alteration in serum cytokines of patients with multiple organ dysfunction syndrome after liver transplantation].

OBJECTIVE: To explore the serum cytokine fluctuation in those adult patients with multiple organ dysfunction syndrome (MODS) during the post-operation stage of orthotopic liver transplantation (OLT) to guide the clinical treatment. METHODS: Serum levels of tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), IL-8 and IL-10 were determined in 53 MODS patients who had received OLT. They were divided into two groups as control group and experimental group, according to whether continuous blood purification (CBP) had been performed or not. The levels of serum cytokines and intensive care unit (ICU) stay time, intubation time, mortality and ICU expenses were compared between the two groups. RESULTS: The levels of serum TNF-alpha, IL-6 and IL-8 rose, while that of IL-10 increased dramatically compared with normal values (all P<0.05). After CBP, the serum levels of TNF-alpha, IL-6 and IL-8 all dropped to certain extent and became lower than those before the treatment (all P<0.05). IL-10's serum level was not changed compared with that before treatment. Those who received CBP stayed in the ICU for a longer period compared with control group, and the ICU expenses increased evidently with significant differences (P<0.05 or P<0.01). However, there was no difference in mortality between the two groups. CONCLUSION: Under the effect of immunosuppressant in the post-OLT period, the excessive release of the anti-inflammatory mediators may become dominant leading to imbalance between proinflammatory and anti-inflammatory mediators leading to MODS. CBP may remove serum proinflammatory cytokines to act as an effective supportive treatment.

A numerical model for blast injury of human thorax based on digitized visible human.

Knowledge of the pressure distribution around human thorax in blast help to understand the injury mechanisms and their assessment. To investigate the transmission mechanism of the pressure on human thorax in blast, a three dimension surface model of human thorax was constructed in this work. To increase the precious of this model, tetrahedron element division method was applied to transfer the rough 3D surface model to hexahedral elements model. Using this model, the high pressure duration was computationally solved using numerical simulation of the hexahedral elements. Simulation results showed that the apex of lungs was subjected to the largest stress in a blast. In order to verify this result, an animal experiment was performed on a dog. The animal experimental results was shown to have a same variation tendency with the calculation results based on our numerical model of human thorax, which made this model reliable for the blast injury research.

Modeling of sectionally continuous communication channel with inhomogeneously distributed tissues.

BACKGROUND: This study aimed to investigate effects on the transmission channel caused by heterogeneous distribution in tissues and joint characteristics. METHOD: Human arm section scans were taken using CT technology, and zoned, following which, a circumference measurement experiment was performed to analyze the effect of inhomogeneous distribution of tissues. In order to analyze the arm joint's effect on channel transmission, we proposed a piecewise modeling method in combination with connection conditions. CONCLUSIONS: It can be seen from the experiment that, in the quasi-static mode, the communication channel error caused by the inhomogeneous distribution of tissues is small enough to be negligible. The error between calculated and experimental results is reduced by 3.93 dB in this experiment relative to models that did not include joint characteristics, and the average error is lowered by 0.73 dB. The variation curve fit to experimental data is also improved in this method. As such, it can be quantitatively determined that a channel model with joint characteristics is superior to models excluding joint characteristics.

Modeling and analysis of visual digital impact model for a Chinese human thorax.

OBJECTIVE: To establish a three-dimensional finite element model of the human chest for engineering research on individual protection. METHOD: Computed tomography (CT) scanning data were used for three-dimensional reconstruction with the medical image reconstruction software Mimics. The finite element method (FEM) preprocessing software ANSYS ICEM CFD was used for cell mesh generation, and the relevant material behavior parameters of all of the model's parts were specified. The finite element model was constructed with the FEM software, and the model availability was verified based on previous cadaver experimental data. RESULTS: A finite element model approximating the anatomical structure of the human chest was established, and the model's simulation results conformed to the results of the cadaver experiment overall. CONCLUSION: Segment data of the human body and specialized software can be utilized for FEM model reconstruction to satisfy the need for numerical analysis of shocks to the human chest in engineering research on body mechanics.

Path Loss Measurement and Channel Modeling with Muscular Tissue Characteristics.

BACKGROUND: The galvanic coupling intra-body communication has low radiation and strong anti-interference ability, so it has many advantages in the wireless communication. METHOD: In order to analyze the effect of muscle tissue's characteristics upon the communication channel, we selected the muscle of pig buttock as the experimental sample, and used it to study the attenuation property with the galvanic coupling intra-body communication channel along the parallel direction and the transverse direction relative to the muscular fibre line as well as on the surface of destroyed muscular fibre; the study frequency ranges from 1kHz to 10MHz.In the isotropic experiment, in order to destroy muscle's fibre characteristics, we grinded the muscle four times, at least five minutes for each time. 0dbm sine-wave signal was input to measure the channel attenuation parameter S21 when the transmitter and the receiver were placed at different positions and different distances d1 and d2 (20mm, 40mm, 60mm), so as to analyze channel loss. CONCLUSION: Within the same frequency range and at the same communication distance, the maximum error of channel attenuation was 10dB; within the same frequency, as the communication distance was increased, the channel attenuation rose gradually, with 4dB increased every 20mm. The conclusion provides the basis for building the theoretical model in the future.

[Risk factors for renal failure during the early period after standard orthotopic liver transplantation without veno venous bypass].

OBJECTIVE: To study the risk factors for renal failure during the early period after standard orthotopic liver transplantation (SOLT) without veno venous bypass (VVBP). METHODS: Clinical data of 100 cases in whom SOLT without VVBP was performed were reviewed. They were divided into two groups according to serum creatine level just after operation. In both groups, Child-Turcotte-Pugh (CTP) score, model for end stage liver disease (MELD) score, acute physiology and chronic health evaluation III (APACHE III) scores, 8 laboratory variables before operation and 10 variables during the operation were analyzed, in order to screen presumable risk factors. RESULTS: With univariate analysis, it was found that there was significant difference between the two groups in the following variables: CTP score, MELD score, APACHE III score, duration of operation and anhepatic phase, amount of blood loss, lowest mean artery pressure, and duration of low blood pressure. With logistic regression analysis, it was revealed that CTP score, volume of blood loss, and duration of anhepatic phase and low blood pressure were risk factors for development of acute renal failure. CONCLUSION: CTP score, volume of blood loss, duration of anhepatic phase and low blood pressure are risk factors for development of acute renal failure after SOLT without VVBP.

[Study on risk factors for early postoperative infection after orthotopic liver transplantation in adults].

OBJECTIVE: To analyze risk factors related to infection during early postoperative period after orthotopic liver transplantation in adults. METHODS: Retrospective study of 400 cases of orthotopic liver transplantation in adults performed between 2003 and 2004. Pre-, intra- and postoperative variables of recipients were analyzed in two groups according to whether or not infection developed. RESULTS: Infection developed in 121 patients (30.3%). Bacterial infections were most common, accounting for 62.0% (75/121 cases), followed by fungal infection with the percentage of 20.6% (25/121 cases), and virus infection accounting for 12.4% (15/121 cases). The common infection sites were lung (63 cases, 52.1%), gallbladder (23 cases, 19.0%), peritoneal cavity (22 cases, 18.2%), and venous catheter (13 cases, 10.7%). Significant risk factors for infection as shown by the multivariate analysis were acute renal failure, graft dysfunction, acute lung injury, postoperative bleeding, pulmonary edema, history of diabetes mellitus or new onset diabetes mellitus, Child-Pugh stage>10, age>60. CONCLUSION: Early postoperative infection after orthotopic liver transplantation in adults is a common and serious complication that continues to be difficult to control. Certain risk factors can be improved with careful management such as acute kidney failure and graft dysfunction. Appropriate anti-infection remedy is very important to prevent drug resistance. However, immunosuppression agents acts as a real predisposing factor of infection with regard to both its development and its clinical manifestation.

[Management of nutritional support and stress hyperglycemia after orthotopic liver transplantation].

OBJECTIVE: To study the influence of different nutritional regimes on the stress hyperglycemia and the outcome after orthotopic liver transplantation, for the purpose of optimizing nutritional regime for early post-operative period. METHODS: One hundred and seventy-two patients who received liver transplantation for chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) induced hepatic function failure or end-stage cirrhosis were enrolled, and the post-operative complications and length of stay in intensive care unit (ICU) were retrospectively analyzed, in regard to high caloric (HC) or low caloric (LC) nutritional regime with their blood glucose controlled to a optimal level. RESULTS: After the liver transplantation, those patients who were supplied with LC (83.7-104.6 kJ.kg(-1).d(-1)), energized stepwise with higher fat ratio (sugar:fat=50%:35%) with blood glucose being maintained <8 mmol/L, had less exogenous insulin requirement (P<0.01), lower infection-related mortality rate (P<0.05), and shortened weaning from mechanical ventilation time and length of stay in ICU (both P<0.05), compared with those who were supplied with HC nutrition (125.5-146.4 kJ.kg(-1).d(-1)) with routine sugar and fat ratio (55%:35%), and blood glucose maintained at the same level. However, there was no significant differences in serum bilirubin contents, incidences of poor healing of incision and anastomosis as well as hypoglycemia, and extrinsic albumin requirement between two groups. CONCLUSION: LC nutrition regime and controlling the blood glucose <8 mmol/L during the early post-operative period may reduce the incidence of post-operative complications without influencing the prognosis.