Transplantation After Successful Downstaging by Multimodal Treatments of American Joint Committee on Cancer Stage IIIB Hepatocellular Carcinoma With Portal Vein Thrombi: A Case Report.

The effective treatment for hepatocellular carcinoma (HCC) with American Joint Committee on Cancer stage IIIB remains controversial and challenging because of the high recurrence rate after resection and low survival rate. The median survival of those with macroscopic portal vein tumor thrombus (PVTT) is short. We reported such a case which received liver transplantation (LT) after successful consecutive downstaging therapies. A 40-year-old man with alcohol related liver cirrhosis and repeated esophageal varices bleeding had HCC with tumor thrombi in right main portal vein and the second portal branch of segment VI (stage IIIB). The received percutaneous alcohol injection, radiofrequency ablation, 8 sessions of transcatheter hepatic arterial chemoembolization, radiotherapy, and target therapy with sorafenib. Computed tomography (CT) scan and magnetic resonance imaging after treatments showed no viable fragments in the tumor and revealed both the right main portal vein and V1 branch were patent. One month later, the patient received a deceased LT. The perioperative course was rather smooth. After discharge, the interval follow-up CT studies of the chest and liver and whole body bone scan showed no tumor recurrence or metastasis up to 20 months postoperation.

Use of azathioprine for graft-vs-host disease is the major risk for development of secondary malignancies after haematopoietic stem cell transplantation: a nationwide population-based study.

BACKGROUND: As more patients are treated by haematopoietic stem cell transplantation (HSCT), development of secondary malignancy (SM) becomes an increasingly common issue in long-term survivors. METHODS: We conducted a nationwide population-based study of the Taiwanese population to analyse patients who received HSCT between January 1997 and December 2010. Standardised incidence ratios (SIRs) were used to compare the risk of SM in HSCT patients and the general population. Multivariate analysis was performed to identify independent predictors of SM. RESULTS: Patients receiving HSCT had a significantly greater risk of developing SM (SIR 2.00; 95% confidence interval (CI) 1.45-2.69; P<0.001). Specifically, the incidence increased for cancers of the oral cavity (SIR 14.18) and oesophagus (SIR 14.75) after allogeneic HSCT. Multivariate analysis revealed an increased SIR for cancer in patients who received the immunosuppressant azathioprine. The risk of SM also increased with greater cumulative doses of azathioprine. CONCLUSIONS: This study demonstrates an increased incidence of SM in Taiwanese patients who received allogeneic HSCT, especially for cancers of the oral cavity and oesophagus. This finding is different from results in populations of Western countries. Physicians should be cautious about azathioprine use for graft-vs-host disease after HSCT.

Increased cancer risk in patients with haemophilia A: a nationwide population-based 14-year study in Taiwan.

Haemostasis is associated with the development and dissemination of cancer. Whether cancer incidence is increased in haemophiliacs remains uncertain; thus, we aimed to further examine this issue. By using data from the National Health Insurance Research Database in Taiwan, we obtained a cohort of 683 patients with haemophilia A, and compared the incidence rate ratio (IRR) of cancer in this cohort with an age- and sex-matched control of 6830 patients. The log-rank test was used to compare Kaplan-Meier curve of the cumulative cancer incidence between two cohorts. Cox regressions were used to identify independent risk factors of cancer in the study patients. The cancer incidence of patients with haemophilia A was significantly higher compared to the control group (IRR 1.95, 95% CI 1.18-3.09, P = 0.008) during the 14-year follow-up period. The non-lymphoma and non-liver cancer incidence in the haemophilia A cohort remained higher than that of the matched control (P = 0.050 by the log-rank test). The multivariate Cox proportional hazards analysis indicated that age (per year, HR 1.09, 95% CI 1.06-1.12, P < 0.001) was the only significant risk factor for cancer development in haemophilia patients. Patients with haemophilia A had higher cancer incidence than the age- and sex-matched patients, especially for the elderly. With increasing life expectancy for haemophiliacs, physicians should be aware of their cancer development.

Impact of pulmonary and extrapulmonary tuberculosis infection in kidney transplantation: a nationwide population-based study in Taiwan.

BACKGROUND: Tuberculosis (TB) has been reported to increase morbidity after kidney transplantation and pose a therapeutic challenge. However, population-based research, specifically focused on the association between kidney transplantation and subsequent pulmonary or extrapulmonary TB, is lacking. METHODS: A nationwide population-based study was conducted using Taiwan's National Health Insurance Research Database, which provided claims data belonging to kidney transplant recipients during 1997-2006. Multivariate analysis was used to identify independent risk factors for TB after kidney transplantation. Kaplan-Meier survival analysis was used to assess the outcome of patients with TB. RESULTS: Among 4554 kidney transplant recipients over the 10-year period, 109 (2.4%) patients with newly diagnosed TB were identified: 75 patients with only pulmonary involvement, and 34 with extrapulmonary spread. The incidence of kidney transplant recipients developing TB was 638 per 100,000 person-years. The independent risk factors for post-transplant TB included cyclosporine-based immunosuppressant agents during the first year after kidney transplantation (odds ratio [OR]: 1.98, P = 0.001), hepatitis C infection (OR: 1.79, P = 0.024), and chronic obstructive pulmonary disease (OR: 1.50, P = 0.041). Kidney transplant recipients who developed TB had a lower 5-year survival rate than those who did not (78.6% vs. 93.4%, P = 0.001). CONCLUSIONS: Kidney transplant recipients in Taiwan did have a high risk of TB infection, with high proportion of extrapulmonary spread. Physicians need to be vigilant in surveying for TB in kidney transplantation, especially in high-risk patients.

Risk of extrathymic cancer in patients with myasthenia gravis in Taiwan: a nationwide population-based study.

BACKGROUND AND PURPOSE: The relationship between myasthenia gravis (MG) and extrathymic malignancies has not been determined. This study aimed to explore the risk of extrathymic malignancy in patients with MG based on a nationwide population-based dataset. METHODS: We identified 2614 patients with MG from the Taiwan National Health Insurance database between 1997 and 2005 and compared the incidence rates of extrathymic malignancies with 15, 684 randomly selected age-, sex-, and comorbidity-matched subjects without MG. Both cohorts were followed until the end of 2009. Cox proportional hazard model was used to evaluate the predictors of extrathymic malignancy in the MG cohort, including age, sex, comorbidities, and prescription drugs. RESULTS: After an average follow-up of 8 years, the MG cohort had a higher risk of extrathymic cancers with an incidence rate ratio (IRR) of 1.38 (95% CI 1.12-1.68, P = 0.002) than the control cohort. Although breast cancer was the most common cancer found, no statistically significant relationship between MG and any specific malignancy was observed. Cox multivariate proportional hazards analysis showed that only age (HR = 1.05, 95% CI 1.04-1.06, P < 0.001) and liver cirrhosis (IRR = 3.85, 95% CI 1.22-12.14, P = 0.021) were predictors of extrathymic cancers in the MG cohort. CONCLUSIONS: Our study showed that patients with MG had an increased risk of extrathymic malignancy in a follow-up of 8 years, but no specific susceptibility to certain malignancies was found.

The use of bupropion in the treatment of restlessness after a traumatic brain injury.

The occurrence of restlessness after a traumatic brain injury (TBI) is common. Severe restlessness can be a barrier in the multidisciplinary treatment of patients with TBI. The following case describes a patient with restlessness after a head-on motor vehicle accident. The patient was tachycardic, diaphoretic, demonstrating decerebrate posturing and a Rancho Los Amigos Stage II--III. Significant left lower leg restlessness was severe enough to cause bruising and ulceration. A multidisciplinary look was taken at the effects of using different neurotransmitter modulators in the treatment of restlessness after a TBI. Current biology treatment options include the use of medications that either modulate dopamine or noradrenaline alone. Bupropion effects both the dopaminergic and noradrenergic pathways. In the following case, the patient's restlessness was resistant to almost every medication employed. The only medication that proved to be effective in significantly reducing the patient's restlessness was bupropion. The evidence for the use of bupropion in the treatment of restlessness after a TBI has never been discussed previously, aside from anecdotal accounts. It is hoped that this case will prove insight into another treatment option for patients who have severe restlessness.

Necrotizing bowel lesions complicated by Pseudomonas septicaemia in previously healthy infants.

UNLABELLED: Two previously healthy infants with Pseudomonas septicaemia presented with necrotizing bowel lesions. Necrotizing bowel lesions should be suspected when infants presenting with a history of diarrhoea, develop abdominal distension and toxic signs. Pseudomonas aeruginosa should be regarded as one of the important aetiologies in such disorders, especially if there is associated neutropenia and ecthyma gangrenosum-like lesions. Antibiotics must be able to cover this pathogen to avert a catastrophic outcome. CONCLUSION: The intestine should be considered a possible site of involvement in Pseudomonas sepsis and special attention should be paid to examination of the abdomen.

Characterization of the tissue regression process in the uterus of older mice as apoptotic by the presence of Tp30, an isoform of terminin.

Whether old uteri that have undergone involution do so by an apoptotic mechanism was examined by the presence of known biochemical and morphological markers for programmed cell death. Terminin, a protein identified by an unique monoclonal antibody, has three forms, Tp-90, Tp-60, and Tp-30: Tp-90 (the 90 kDa form) is only present in growing and quiescent non-growing cells; Tp-60 (the 60 kDa form) is found in senescent cells; and finally, Tp-30 (the 30 kDa form) is found in cells committed to apoptotic death. Biochemical analysis of a protein, Tp30, previously identified as a marker for the commitment to programmed cell death, was performed with both young (5-month-old) and old (24-month-old) C57BL/6J mouse uteri. In addition to biochemical analysis of Tp30 presence in uterine tissue, propidium iodide (PI) staining and DNA framentation by nick-end labelling with fluorescence-conjugated UTP were used to characterize apoptosis-related changes in the chromatin organization of the nucleus. Results indicate that within the old uterus Tp-30 is indeed detected in the tissue extracts and was the major terminin band, while Tp-90 and Tp-60 were the major bands observed in extracts of the younger mouse uterus. The presence of Tp30 in the older uterine tissue suggests that the tissue regression which has occurred in the uterus of older mice may be apoptotic in nature. This suggestion is further supported by the demonstration of increases in the number of cells showing apoptotic morphology, i.e. positive staining with UTP reflecting the presence of nuclei with nicked DNA, localized exclusively in the uterine stroma of older females. The presence of DNA fragmentation, as reflected by UTP staining, was virtually absent from the young uteri. These data suggest that apoptosis may be a part of the cellular mechanism contributing to the regression of uterine tissue in the older female during involution, appearing as an age-dependent event.