Laparoscopic reoperation for pediatric recurrent inguinal hernia after previous laparoscopic repair.

PURPOSE: Recurrence is a concerning area in pediatric inguinal hernia repair. Various laparoscopic repair methods are available to treat recurrent pediatric inguinal hernia. We analyzed previous laparoscopic hernia repairs and report the outcomes of laparoscopic inguinal hernia reoperations in patients with recurrent inguinal hernia. METHODS: Fifty-one patients who presented for recurrent inguinal hernia after laparoscopic hernia repair from September 2012 to May 2017 were retrospectively evaluated. Previous laparoscopic procedures were analyzed with respect to sac removal (removal vs. leaving in place), suture material (absorbable vs. nonabsorbable), and high ligation method (purse string vs. multiple stitches). We removed the hernia sac from all patients and performed suture repair of the muscular arch of the internal inguinal ring using nonabsorbable material. RESULTS: All patients (38 male, 13 female) had indirect inguinal hernias. No conversion to open surgery occurred. Forty-three (84.3%) patients developed recurrence within 1 year after the previous operation [mean 8.7 ± 6.9 (range 3-33) months]. Twenty patients had concurrent hydroceles (39.2%); 16 were cord hydroceles and 4 were canal of Nuck hydroceles. In the previous operations, the hernia sac was not removed in 100% (51/51) of patients, absorbable suture material was used in 58.8% (30/51), and purse string high ligation was performed in 88.2% (45/51). No re-recurrence developed during a mean follow-up of 25.0 ± 12.6 (range 13-54) months. CONCLUSION: Laparoscopic reoperation with hernia sac removal and suture repair of the muscular arch of the internal inguinal ring with nonabsorbable material is an effective operation with few recurrences and complications.

Single-Center Experience Using Marginal Liver Grafts in Korea.

BACKGROUND: Liver transplantation (LT) is an established therapeutic modality for patients with end-stage liver disease. The use of marginal donors has become more common worldwide due to the sharp increase in recipients, with a consequent shortage of suitable organs. We analyzed our single-center experience over the last 8 years in LT to evaluate the outcomes of using so-called "marginal donors." METHODS: We retrospectively analyzed the database of all LTs performed at our institution from 2009 to 2017. Only patients undergoing deceased-donor LTs were analyzed. Marginal grafts were defined as livers from donors >60 years of age, livers from donors with serum sodium levels >155 mEq, graft steatosis >30%, livers with cold ischemia time ≥12 hours, livers from donors who were hepatitis B or C virus positive, livers recovered from donation after cardiac death, and livers split between 2 recipients. Patients receiving marginal grafts (marginal group) were compared with patients receiving standard grafts (standard group). RESULTS: A total of 106 patients underwent deceased-donor LT. There were 55 patients in the standard group and 51 patients in the marginal group. There were no significant differences in terms of age, sex, Model for End-Stage Liver Disease score, underlying liver disease, presence of hepatocellular carcinoma, and hospital stay between the 2 groups. Although the incidence of acute cellular rejection, cytomegalovirus infection, and postoperative complications was similar between the 2 groups, the incidence of early allograft dysfunction was higher in the marginal group. With a median follow-up of 26 months, the 1-, 3-, and 5-year overall and graft (death-censored) survivals in the marginal group were 85.5%, 75%, and 69.2% and 85.9%, 83.6%, and 77.2%, respectively. Patient overall survival and graft survival (death-censored) were significantly lower in the marginal group (P = .023 and P = .048, respectively). On multivariate analysis, receiving a marginal graft (hazard ratio [HR], 4.862 [95% confidence interval (CI), 1.233-19.171]; P = .024) and occurrence of postoperative complications (HR, 4.547 [95% CI, 1.279-16.168]; P = .019) were significantly associated with worse patient overall survival. Also, when factors associated with marginal graft were analyzed separately, graft steatosis >30% was independently associated with survival (HR, 5.947 [95% CI, 1.481-23.886]; P = .012). CONCLUSIONS: Patients receiving marginal grafts showed lower but acceptable overall survival and graft survival. However, because graft steatosis >30% was independently associated with worse survival, caution must be exercised when using this type of marginal graft by weighing the risk and benefits.

Loss of serum response factor induces microRNA-mediated apoptosis in intestinal smooth muscle cells.

Serum response factor (SRF) is a transcription factor known to mediate phenotypic plasticity in smooth muscle cells (SMCs). Despite the critical role of this protein in mediating intestinal injury response, little is known about the mechanism through which SRF alters SMC behavior. Here, we provide compelling evidence for the involvement of SRF-dependent microRNAs (miRNAs) in the regulation of SMC apoptosis. We generated SMC-restricted Srf inducible knockout (KO) mice and observed both severe degeneration of SMCs and a significant decrease in the expression of apoptosis-associated miRNAs. The absence of these miRNAs was associated with overexpression of apoptotic proteins, and we observed a high level of SMC death and myopathy in the intestinal muscle layers. These data provide a compelling new model that implicates SMC degeneration via anti-apoptotic miRNA deficiency caused by lack of SRF in gastrointestinal motility disorders.

A small subunit processome protein promotes cancer by altering translation.

Dysregulation of ribosome biogenesis or translation can promote cancer, but the underlying mechanisms remain unclear. UTP18 is a component of the small subunit processome, a nucleolar multi-protein complex whose only known function is to cleave pre-ribosomal RNA to yield the 18S ribosomal RNA component of 40S ribosomal subunits. Here, we show that UTP18 also alters translation to promote stress resistance and growth, and that UTP18 is frequently gained and overexpressed in cancer. We observed that UTP18 localizes to the cytoplasm in a subset of cells, and that serum withdrawal increases cytoplasmic UTP18 localization. Cytoplasmic UTP18 associates with the translation complex and Hsp90 to upregulate the translation of IRES-containing transcripts such as HIF1a, Myc and VEGF, thereby inducing stress resistance. Hsp90 inhibition decreases cytoplasmic UTP18 and UTP18-induced increases in translation. Importantly, elevated UTP18 expression correlates with increased aggressiveness and decreased survival in numerous cancers. Enforced UTP18 overexpression promotes transformation and tumorigenesis, whereas UTP18 knockdown inhibits these processes. This stress adaptation mechanism is thus co-opted for growth by cancers, and its inhibition may represent a promising new therapeutic target.

Does procurement technique affect posttransplant graft function in deceased donor liver transplantation?

INTRODUCTION: Various techniques have been described deceased donor liver transplantation (DDLT) procurement. One is a technique whereby almost total dissection is done in the porta hepatis and perihepatic detachment is carried out before cross-clamping the donor aorta. In another approach, after the donor aorta is cross-clamped, rapid and minimal en bloc dissection is performed with minimal manipulation. We evaluated early posttransplant graft function among liver procurement techniques. METHOD: Between January 2008 and August 2012, we performed 45 consecutive adult DDLTs. One patient was excluded from this analysis due to early death from sepsis after transplantation. The 44 included patients were divided into two cohorts according to the procurement technique: A warm dissection (n = 23; 52%) and a cold dissection group (n = 21; 48%). We compared early posttransplant graft function using the aspartate aminotransferase (AST), alanine aminotransferase (ALT), total bilirubin (T-bil), and prothrombin time (PT) values of the two groups from the first to seventh postoperative day. RESULT: The AST values in the warm group were significantly greater than those in the cold group on postoperative days 3 and 5. In addition, the ALT values in the warm group were greater than those in the cold group on postoperative days 4, 5, and 6. Moreover, the T-bil values in the warm group were greater than those in the cold group on postoperative days 2, 3, 4, 5, 6, and 7. However, there were no differences in PT values. CONCLUSION: During liver procurement for DDLT, rapid en bloc procurement with minimal manipulation after clamping the donor aorta achieved better early graft function posttransplantation.

Differential function of natural killer cells in the liver graft perfusate of Korean population.

BACKGROUND: Liver perfusate (LP) lymphocytes show unique subsets compared with peripheral blood (PB) lymphocytes. LP natural killer (NK) and NKT cells may display unique cytotoxicity and cytokine production, thus leading to distinct roles in liver transplantation. In this study, we sought to evaluate the functions of graft perfusate NK and NKT cells in clinical liver transplantation. METHODS: The living donor right lobe graft was initially washed with 1 L of histidine-tryptophan-ketoglutarate solution to collect the perfusate. We also collected donor PB. Lymphocytes separated by the Ficoll-Hypaque density gradient method underwent immunophenotyping using multicolor flow cytometry. To assess cytokine secretion, we performed the enzyme-linked immunosorbent assay. RESULTS: There were more NK and NKT cells in LP confirming previous reports. In particular, CD56(bright)CD16(low) NK cells accounted for approximately 50% of total NK cells compared with 5% to 10% among PB NK cells. In response to cytokine stimulation LP NK cells produce tumor necrosis factor-α at different levels and less interleukin-10 compared with PB NK cells. The major source of interferon-γ production upon stimulation with liver caner cells were CD56(dim) NK cells and CD56(-)CD3(-) cells rather than NKT or T cells. Unlike PB NK cells, LP CD56(bright)CD16(low) NK cells along with CD56(dim)CD16(high) NK cells and NKT cells were efficient killers against Korean liver cancer cells. CONCLUSION: LP NK and NKT cells showed unique functions in cytotoxicity and cytokine production.

Comment on "Drosophila dosage compensation involves enhanced Pol II recruitment to male X-linked promoters".

Conrad et al. (Reports, 10 August 2012, p. 742) reported a doubling of RNA polymerase II (Pol II) occupancy at X-linked promoters to support 5' recruitment as the key mechanism for dosage compensation in Drosophila. However, they employed an erroneous data-processing step, overestimating Pol II differences. Reanalysis of the data fails to support the authors' model for dosage compensation.

Serum biomarker panels for the diagnosis of gastric adenocarcinoma.

BACKGROUND: Currently, serum biomarkers, which are sufficiently sensitive and specific for early detection and risk classification of gastric adenocarcinoma do not exist. Therefore, this study identified a panel of serum biomarkers for the diagnosis of gastric adenocarcinoma. METHODS: A 29-plex array platform with 29 biomarkers, consisting of 11 proteins discovered through proteomics and 18 previously known to be cancer-associated, was constructed. A test/training set consisting of 120 gastric adenocarcinoma and 120 control samples were examined. After 13 proteins were selected as candidate biomarkers, multivariate classification analyses were used to identify algorithms for diagnostic biomarker combinations. These algorithms were independently validated using a set of 95 gastric adenocarcinoma and 51 control samples. RESULTS: Epidermal growth factor receptor (EGFR), pro-apolipoprotein A1 (proApoA1), apolipoprotein A1, transthyretin (TTR), regulated upon activation, normally T-expressed and presumably secreted (RANTES), D-dimer, vitronectin (VN), interleukin-6, α-2 macroglobulin, C-reactive protein and plasminogen activator inhibitor-1 were selected as classifiers in the two algorithms. These algorithms differentiated between the majority of gastric adenocarcinoma and control serum samples in the training/test set with high accuracy (>88%). These algorithms also accurately classified in the validation set (>85%). CONCLUSION: Two panels of combinatorial biomarkers, including EGFR, TTR, RANTES, and VN, are developed, which are less invasive method for the diagnosis of gastric adenocarcinoma. They could supplement clinical gastroscopic evaluation of symptomatic patients to enhance diagnostic accuracy.

StratomeX: Visual Analysis of Large-Scale Heterogeneous Genomics Data for Cancer Subtype Characterization.

Identification and characterization of cancer subtypes are important areas of research that are based on the integrated analysis of multiple heterogeneous genomics datasets. Since there are no tools supporting this process, much of this work is done using ad-hoc scripts and static plots, which is inefficient and limits visual exploration of the data. To address this, we have developed StratomeX, an integrative visualization tool that allows investigators to explore the relationships of candidate subtypes across multiple genomic data types such as gene expression, DNA methylation, or copy number data. StratomeX represents datasets as columns and subtypes as bricks in these columns. Ribbons between the columns connect bricks to show subtype relationships across datasets. Drill-down features enable detailed exploration. StratomeX provides insights into the functional and clinical implications of candidate subtypes by employing small multiples, which allow investigators to assess the effect of subtypes on molecular pathways or outcomes such as patient survival. As the configuration of viewing parameters in such a multi-dataset, multi-view scenario is complex, we propose a meta visualization and configuration interface for dataset dependencies and data-view relationships. StratomeX is developed in close collaboration with domain experts. We describe case studies that illustrate how investigators used the tool to explore subtypes in large datasets and demonstrate how they efficiently replicated findings from the literature and gained new insights into the data.

Safety of ultra-rapid intravenous infusion of hepatitis B immunoglobulin in liver transplant recipients.

PURPOSE: To evaluate the safety of institutional protocol for ultra-rapid hepatitis B immunoglobulin (HBIG) infusion (10,000 IU in 30 minutes) for hepatitis B virus prophylaxis in adult liver transplant recipients. METHODS: In this case-controlled study, prospectively recruited liver transplant recipients received ultra-rapid infusions of HBIG (10,000 units in 30 minutes) for 6 months. The historical control group consisted of patients who had received 1-hour HBIG infusions (conventional rapid infusion) for the precedent 6 months. RESULTS: We found that 1472 patients had received 5744 ultra-rapid HBIG infusions, whereas 1343 patients had received 5200 conventional rapid HBIG infusions. Adverse side-effects were observed after 7 (0.13%) and 9 (0.16%) infusions, respectively (P = .763). The number of infusions per month increased significantly, from 878 ± 34 before the introduction of ultra-rapid infusion to 957 ± 29 afterwards (P < .001), an increase of 10.5%. The maximal capacity of HBIG infusions per day in the outpatient clinic increased from 53 for conventional rapid infusion to 65 for ultra-rapid infusion, without expansion of the outpatient facility or equipment. CONCLUSIONS: Nearly all adult liver recipients able to tolerate 1-hour infusions of HBIG can also tolerate ultra-rapid infusions well. Thus, it seems to be reasonable to perform ultra-rapid infusion protocol widely for patient convenience.

Intractable recurrent hepatitis A virus infection requiring repeated liver transplantation: a case report.

Although hepatitis A virus (HAV) infection is usually self-limited, it may induce fulminant hepatitis. We present an unusual case of a 40-year-old, otherwise healthy man with intractable recurrent HAV infection requiring retransplantation after primary liver transplantation for HAV-associated fulminant liver failure. After the first living-donor liver transplantation, allograft function recovered uneventfully; however, beginning at 35 days, his serum total bilirubin concentration increased, reaching 40 mg/dL, with a slight increase in liver enzymes. Detection of genomic HAV RNA in serum at the time of graft dysfunction led to a diagnosis of recurrent HAV infection. Fifty-one days after the first transplant, he underwent a deceased donor retransplantation. His allograft function recovered; the patient was discharged from the hospital. Sixty-five days later, however, he was readmitted for colitis-like symptoms and was again treated for acute rejection, but died owing to overwhelming sepsis and persistence of HAV infection. These findings indicate that patients who undergo liver transplantation for HAV-associated liver disease may be at risk of HAV reinfection, particularly if they require anti-rejection therapy. Routine measurements of anti-HAV immunoglobulin M and HAV RNA during the early posttransplant period in HAV-associated liver transplant recipients may differentiate reinfection from an acute cellular rejection episode.

Peritransplant monitoring of immune cell function in adult living donor liver transplantation.

PURPOSE: We evaluated the clinical utility of peritransplant in vitro assays of immune cell function in adult living donor liver transplant (LDLT) recipients. METHODS: In particular, we measured immune cell function, using the ImmuKnow assay, in 107 adult LDLT recipients and 200 potential living liver donors (control group) admitted to our center between July 2008 and January 2009. RESULTS: In the control group, the mean proportion of T-helper/inducer cells was 36.8% ± 8.2%. The degree of immune response was strong in 12%, moderate in 77%, and low in 11%. In the study group, the degree of immune response within the first month was strong in 4.6%, moderate in 38.2%, and low in 57.2%, thus significantly lower than in the control group (P < .001). ImmuKnow results and tacrolimus levels did not show a significant correlation (r(2) = .002, P = .392). Although six patients showed biopsy-proven acute cellular rejection, none showed a strong immune response. Patients with overt infection showed a lower immune response. CONCLUSIONS: These results indicate that peritransplant assessment of immune response using the ImmuKnow assay does not reliably predict the occurrence of acute rejection. Additional studies are necessary to accurately assess the clinical utility of immune response monitoring.

An increase in deceased donor incidence alleviated the need for urgent adult living donor liver transplantation in a Korean high-volume center.

PURPOSE: This study analyzed the effects of a recent increase in deceased donors on the pattern of adult liver transplantation (OLT) in a high-volume center in Korea. METHODS: OLT patterns relative to pretransplant recipient status were analyzed for 112 deceased donor LTs (DDLT) and 743 living donor OLT (LDLT) in a single center as compared to nationwide Korean data over 3 years from 2006 to 2008. RESULTS: During the study period, the annual proportion of institutional urgent OLT was relatively invariable (20% to 25.2%), but the annual proportion of DDLTs to all OLT increased from 8.9% to 19.9%, as did the annual rate of DDLTs among those undergoing urgent OLT, from 18.6% to 65.8%, with a reciprocal decrease in the proportion of urgent LDLTs. Korean nationwide data also showed a noticeable increase in deceased liver graft allocation for urgency from 39.8% to 62.2% over the same time period. CONCLUSION: An increase in deceased donors up to 5 per million enabled an increase in urgent adult DDLTs, alleviating the need for urgent adult LDLTs in Korea.

Bioelectrical impedance analysis for evaluation of donor hepatic steatosis in living-donor liver transplantation.

OBJECTIVE: To assess whether bioelectrical impedance analysis (BIA) can be used to evaluate the degree of hepatic steatosis in potential living liver donors. MATERIAL AND METHODS: From May 2008 to April 2009, BIA was measured in 302 living donor candidates. Correlations among body mass index (BMI; calculated as weight in kilograms divided by height in meters squared), total fatty changes at percutaneous needle liver biopsy, and BIA-derived fat composition were assessed. RESULTS: The median (range) BIA-derived fat proportion was 19.4% (4.8%-35.3%), BMI was 24 (17-39), and hepatic steatosis at liver biopsy was 2% (0%-75%). Crude correlations were observed between BIA-derived fat proportion and hepatic steatosis (r(2) = 0.14; P = .000), between BMI and hepatic steatosis (r(2) = 0.27; P = .000), and between BMI and BIA-derived fat proportion (r(2) = .25; P = .000). Receiver operating characteristic curve analysis revealed that the area under the curve of BIA-derived fat proportion was smaller than that of BMI, and no significant cutoff value was identified. CONCLUSIONS: These results suggest that BIA-derived fat composition alone cannot be used to accurately determine the degree of hepatic steatosis. However, a combination of BMI and BIA-derived fat composition may increase clinical ability to assess hepatic steatosis.

A permutation test for determining significance of clusters with applications to spatial and gene expression data.

Hierarchical clustering is a common procedure for identifying structure in a data set, and this is frequently used for organizing genomic data. Although more advanced clustering algorithms are available, the simplicity and visual appeal of hierarchical clustering has made it ubiquitous in gene expression data analysis. Hence, even minor improvements in this framework would have significant impact. There is currently no simple and systematic way of assessing and displaying the significance of various clusters in a resulting dendrogram without making certain distributional assumptions or ignoring gene-specific variances. In this work, we introduce a permutation test based on comparing the within-cluster structure of the observed data with those of sample datasets obtained by permuting the cluster membership. We carry out this test at each node of the dendrogram using a statistic derived from the singular value decomposition of variance matrices. The p-values thus obtained provide insight into the significance of each cluster division. Given these values, one can also modify the dendrogram by combining non-significant branches. By adjusting the cut-off level of significance for branches, one can produce dendrograms with a desired level of detail for ease of interpretation. We demonstrate the usefulness of this approach by applying it to illustrative data sets.

MSL complex associates with clusters of actively transcribed genes along the Drosophila male X chromosome.

Dosage compensation in Drosophila serves as a model system for understanding the targeting of chromatin-modifying complexes to their sites of action. The MSL (male-specific lethal) complex up-regulates transcription of the single male X chromosome, thereby equalizing levels of transcription of X-linked genes between the sexes. Recruitment of the MSL complex to its binding sites on the male X chromosome requires each of the MSL proteins and at least one of the two large noncoding roX RNAs. To better understand how the MSL complex specifically targets the X chromosome, we have defined the binding using high-resolution genomic tiling arrays. Our results indicate that the MSL complex largely associates with transcribed genes that are present in clusters along the X chromosome. We hypothesize that after initial recruitment of the MSL complex to the X chromosome by unknown mechanisms, nascent transcripts or chromatin marks associated with active transcription attract the MSL complex to its final targets. Defining MSL-complex-binding sites will provide a tool for understanding functions of large noncoding RNAs that have remained elusive.

The performance of a risk score in predicting undiagnosed hyperglycemia.

OBJECTIVE: Type 2 diabetes is a serious disease that is commonly undetected and for which screening is sometimes advocated. A number of risk factors are associated with prevalent undiagnosed diabetes. The use of routinely available information on these factors has been proposed as a simple and effective way of identifying individuals at high risk for having the disease. The objective of this study was to assess the effectiveness of the Cambridge risk score in a large and representative population. RESEARCH DESIGN AND METHODS: A risk score derived from data in a previous study was tested for its ability to detect prevalent undiagnosed hyperglycemia as measured by a GHb > or = 6.0, 6.5, or 7% in 6,567 subjects aged 39-78 years in the European Prospective Investigation of Cancer-Norfolk cohort. RESULTS: For a specificity of 78%, the risk score predicted a GHb of > or = 7.0% in subjects aged 39-78 years, with a sensitivity of 51% (95% CI 40-62). The areas under the receiver-operating characteristic (ROC) curve for GHb > or = 6.0, 6.5, and 7% were 65.7% (63.8-67.6), 71.2% (68.4-75.2), and 74.2% (69.5-79.0), respectively. The area under the ROC curve was not significantly reduced if data on family and smoking history were unavailable for any of the cut-offs for GHb. CONCLUSIONS: The risk score performed as well as other previously reported models in all age groups. We concluded that a simple risk score using data routinely available in primary care can identify people with an elevated GHb with reasonable sensitivity and specificity, and it could therefore form part of a strategy for early detection of type 2 diabetes.

Subacute toxicity of chitosan oligosaccharide in Sprague-Dawley rats.

A subacute oral toxicity study of chitosan oligosaccharide was performed in Sprague-Dawley rats of both sexes. Each 36 male and female rats were administered by gavage with 500, 1,000 and 2,000 mg/kg/day for 4 weeks (7 days/week), respectively. Examinations regarding clinical signs, body weights, hematological and biochemical parameters, and histopathological examinations were carried out. There were no significant differences in behavior or external appearance, body weight and food consumption between control and treated rats. In addition, no significant differences in urinalysis, hematology, blood biochemistry, relative organ weights and histopathological findings were found in both control and treated rats. In conclusion, it was suggested that subacute toxicity of chitosan oligosaccharide was low and the no-observed adverse effect level was considered to be over 2,000 mg/kg in rats.

Angiotensin I converting enzyme inhibitory peptides purified from bovine skin gelatin hydrolysate.

Bovine skin gelatin was hydrolyzed with sequential protease treatments in the order of Alcalase, Pronase E, and collagenase using a three-step ultrafiltration membrane reactor. The molecular weight distributions of the first, second, and third hydrolysates were 4.8-6.6, 3.4-6.6, and 0.9-1.9 kDa, respectively. The angiotensin I converting enzyme (ACE) inhibitory activity of the third hydrolysate (IC(50) = 0.689 mg/mL) was higher than that of the first and second hydrolysates. Two different peptides showing strong ACE inhibitory activity were isolated from the hydrolysate using consecutive chromatographic methods including gel filtration chromatography, ion-exchange chromatography, and reversed-phase high-performance liquid chromatography. The isolated peptides were composed of Gly-Pro-Leu and Gly-Pro-Val and showed IC(50) values of 2.55 and 4.67 microM, respectively.

A nonparametric scoring algorithm for identifying informative genes from microarray data.

Microarray data routinely contain gene expression levels of thousands of genes. In the context of medical diagnostics, an important problem is to find the genes that are correlated with given phenotypes. These genes may reveal insights to biological processes and may be used to predict the phenotypes of new samples. In most cases, while the gene expression levels are available for a large number of genes, only a small fraction of these genes may be informative in classification with statistical significance. We introduce a nonparametric scoring algorithm that assigns a score to each gene based on samples with known classes. Based on these scores, we can find a small set of genes which are informative of their class, and subsequent analysis can be carried out with this set. This procedure is robust to outliers and different normalization schemes, and immediately reduces the size of the data with little loss of information. We study the properties of this algorithm and apply it to the data set from cancer patients. We quantify the information in a given set of genes by comparing its distribution of the score statistics to a set of distributions generated by permutations that preserve the correlation structure among the genes.