Impact of surgery on immunologic function: comparison between minimally invasive techniques and conventional laparotomy for surgical resection of colorectal tumors

Background

Surgical trauma suppresses host immune function, potentially creating an environment vulnerable to tumor cell growth. This study compared immune function after laparoscopy, minilaparotomy, and conventional colorectal tumor resections.

Methods

Seventy-one patients underwent surgery (20 laparoscopy, 21 minilaparotomy, and 30 conventional). Blood samples were taken before surgery and at 3 hours, 24 hours, and 5 days after surgery. White blood cell constitution was determined using monoclonal antibodies. Levels of TH1 cytokines interferon-γ, tumor necrosis factor-α, and interleukin (IL)-2 and TH2 cytokines IL-10, -4, and -6 were measured in plasma and from supernatants of activated peripheral blood mononuclear cells.

Results

At 5 days after surgery, lymphocyte counts remained low in the conventional and minilaparotomy groups (P = .001 and P = .008) but had resolved in laparoscopic patients. Three-hour postoperative serum IL-6 concentrations were lower in laparoscopic than in conventional patients (P = .028). Production of TH1 cytokines 3 hours after surgery were significantly increased in laparoscopic patients (interferon-γ P = .018, tumor necrosis factor-α P = .011, and IL-2 P = .037).

Conclusions

TH1 lymphocyte function is improved transiently and immune homeostasis restored earlier in patients undergoing laparoscopic colorectal cancer resection, which may influence disease recurrence.     

Interferon-gamma induces caspase-8 in neuroblastomas without affecting methylation of caspase-8 promoter

Background

The expression of caspase-8, a cysteine protease that is crucial for the apoptotic cascade, is absent in a high percentage of neuroblastomas, the most frequent extracranial solid tumor of infants and children. Resistance of neuroblastomas to death-receptor (eg, tumor necrosis factor alpha (TNF-α) receptor)—mediated apoptosis is thought to be caused by loss of caspase-8 expression. Gene silencing by hypermethylation of caspase-8 promoter has been proposed for the loss of caspase-8 expression in neuroblastoma cells.

Methods

To further evaluate the role of caspase-8 in neuroblastoma, we assessed the induction of caspase-8 expression in neuroblastoma cells by treating the cells with a physiologic agent such as interferon-γ.

Results

The authors found that interferon-γ induces caspase-8 expression in neuroblastoma cells irrespective of the gene silenced by hypermethylation of caspase-8 promoter. The authors show that interferon-γ also regulates other apoptosis related gene expression. Moreover, they show that interferon-γ treatment in combination with TNF-α decreases neuroblastoma cell proliferation.

Conclusions

Interferon-γ induces procaspase-8 expression in neuroblastoma cells, and this induction is not dependent on demethylation of the caspase-8 promoter. Therapies aimed at inducing caspase-8 expression by adjunctive treatment, such as interferon-γ, may increase the effectiveness of current chemotherapeutic regimens.     

Labioscrotal island flap in feminizing genitoplasty

Background/Purpose

Stenosis of the vaginal introitus is the most frequent complication after genital reconstruction for ambiguous genitalia associated with congenital adrenal hyperplasia (CAH). With the aim of enlarging the vaginal introitus, the authors present a technical modification of the introitoplasty that uses a bilateral cutaneous island flap based on the perineal superficial branches of the internal pudendal artery.

Methods

Eleven girls with CAH and Prader III to V genital ambiguity were included. Feminizing genitoplasty was performed in 1 stage. Bilateral cutaneous labioescrotal island flaps, based on the posterior labial artery, were included in the introitoplasty. The cosmetic results of the genitoplasty were evaluated by photographic analysis of the external genitalia.

Results

Integrity of the vaginal introitus as well as excellent integration of the flap and absence of additional scars in the donor area were assessed in all girls.

Conclusions

This modified island flap is technically feasible and reproducible producing no additional sequels in the donor area. It uses perineal skin that is usually excised in other techniques avoiding the use of harvesting skin from adjacent areas. Thus, it can be a useful additional procedure in the introitoplasty in association with the currently used techniques.     

Cytomegalovirus genotypes gB1 and gH1 are the most predominant genotypes among renal transplant recipients in Kuwait

Background

The human cytomegalovirus (HCMV) is a common pathogen responsible for asymptomatic and persistent infections in healthy individuals. However, cytomegalovirus infections are a major cause of morbidity and mortality in immunocompromised patients, especially in recipients of solid-organ transplants and AIDS patients.

Methods

HCMV DNA from 42 patients who received kidney transplants between 2004 and 2008 were subjected to polymerase chain reaction and restriction fragment length polymorphism to identify HCMV gB and gH genotypes.

Results

HCMV gB1 and gH1 genotypes were the most the predominant HCMV genotypes (P < .05, P < .05, respectively). In addition, both HCMV gB1 and gH1 genotype were significantly more often associated with the development of fever with leukopenia and severe HCMV disease than other gB or gH2 genotypes. No significant differences were observed among viral loads between the HCMV genotypes among infected individuals.

Conclusion

This study demonstrated the prevalence and role of HCMV genotypes in infection and disease in renal transplant patients in Kuwait.     

Inhibition of Inflammatory Cytokine-Induced Response in Human Islet Cells by Withaferin A

Background

After islet cell transplantation, a substantial mass of islets are lost owing to nonspecific inflammatory reactions. Cytokine exposure before or after transplantation can upregulate expression of proinflammatory genes via the nuclear factor-κB signaling pathway, eventually resulting in islet loss.

Objective

To test the effects of a naturally occurring nuclear factor-κB inhibitor, withaferin A, on regulation of inflammatory genes in human islets.

Methods

Human pancreatic islets were isolated using a modified Ricordi protocol. Purified islets were cultured for 2 days. The effect of withaferin A treatment on islet cell viability was examined using the fluorescein diacetate-propidium iodide dye exclusion test, and on function using a static glucose stimulation assay. Islet cells were treated with a cytokine mixture (50 U/mL of interleukin-1β, 1000 U/mL of tumor necrosis factor-α, and 1000 U/mL of interferon-γ) for 48 hours with or without withaferin A, 1 μg/mL. Treated islets were used for real-time polymerase chain reaction (PCR) array analysis for expression of inflammatory genes, and expression of other selected genes was analyzed using real-time PCR with single primers.

Results

Glucose stimulation and viability assays demonstrated that withaferin A was not toxic to islet cells. Of 84 inflammation-related genes examined using real-time PCR array analysis, 9 were significantly upregulated by cytokine treatment compared with the control group. However, addition of withaferin A to the culture significantly inhibited expression of all genes.

Conclusion

Withaferin A significantly inhibits the inflammatory response of islet cells with cytokine exposure.     

Hypothermic Liver Machine Perfusion With EKPS-1 Solution vs Aqix RS-I Solution: In Vivo Feasibility Study in a Pig Transplantation Model

Objective

Hypothermic machine perfusion (HMP) is superior to simple cold storage for kidney preservation. We previous observed in a porcine liver transplantation model increased tumor necrosis factor-α (TNF-α) production eventually leading to poor recipient survival after HMP using standard kidney perfusion solution (KPS-1) compared with simple cold storage. We compared two solutions for HMP preservation of the liver: enriched KPS-1 (EKPS-1) and Aqix RS-I.

Methods

Pig livers were obtained after cold flushing with histidine-tryptophan-ketoglutarate solution. Subsequently, the livers were subjected to dual-vessel perfusion with two preservation solutions: EKPS-1 (n = 6) and Aqix RS-I (n = 3). After HMP preservation and transplantation, graft and recipient survival, hepatocellular damage (aspartate aminotransferase concentration), TNF-α production, and endothelial cell damage (hyaluronic acid clearance) were recorded.

Results

No primary graft nonfunction was observed. Recipient survival at postoperative day 3 was similar in both groups (33%). Aspartate aminotransferase concentration measured in serum samples after reperfusion was similar in both groups. After reperfusion, TNF-α concentration was higher and hyaluronic acid clearance was lower in the EKPS-1 group vs the Aqix RS-I group at 60, 120, and 180 minutes (all P < .05).

Conclusion

Hypothermic machine perfusion provided adequate longer term graft survival. After reperfusion, TNF-α production seems to be reduced, and endothelial cell dysfunction remains pronounced with Aqix RS-1 solution compared with EKPS-1 solution.     

The Effect of Recipient Hepatitis C Virus Infection on Outcomes Following Heart Transplantation

Background

Insufficient data exist on the clinical course of hepatitis C virus (HCV) infection in heart transplant (HT) recipients. Our study reports the outcomes of heart transplantation in pretransplantation HCV-positive (HCV+) recipients.

Methods

A retrospective analysis of the heart transplantation database at our institution was performed to identify HT recipients who were HCV+ prior to transplantation. Chart reviews yielded demographic features, liver function tests, graft function, incidence of posttransplantation acute hepatitis and transplant coronary artery disease, and patient survival data.

Results

Between 1995 and 2006, 10 HCV+ patients underwent cardiac transplantation. The recipient mean age was 47 years (range, 23-69). Seven recipients were males and 3 were females. At listing 9 patients had no cirrhosis. One patient with Child-B cirrhosis was listed for combined heart-liver transplantation. Two of 10 donors were known to be HCV carriers. Posttransplantation in-hospital survival rate was 100%. At a mean follow-up of 58 months (range, 1.6-145), 3 deaths occurred, yielding an overall survival rate of 70%. Only 1 death (10%) was linked to accelerated acute hepatitis. Transplant coronary artery disease was detected in 2 patients (20%). Echocardiograms of survivors at last follow-up revealed normal ejection fractions. In addition, there were no cases of hepatocellular carcinoma; all survivors were without evidence of hepatic dysfunction.

Conclusions

Transplanting recipients known to have HCV did not seem to affect overall posttransplantation survival or to increase the risk of liver dysfunction or graft-related complications.     

Valvular procedures during ventricular assist device implantation

Background

Increased experience and success with ventricular asist devices (VAD) has permitted more aggressive use in patients formerly believed to be inappropriate for mechanical circulatory support (MCS). There is no clearly proven policy to manage end-stage heart failure patients with valvular pathologies. The aim of this report was to analysis our experience with combined approach of VAD implantation and valvular procedures among patients with valvular heart disease and end-stage heart failure.

Methods

We evaluated the clinical records of 67 patients who underwent MCS from April 2007 to September 2011. We identified 12 patients (17.9%) who received concomitant valvular procedures, four of whom had significant aortic insufficiency and received a simple coaptation stitch at the center to approximate the fibrous nodules of Arantius. The mechanical aortic valve was replaced with a stentless bioprosthesis in three patients. Mitral valve commissurotomy was performed in one patient with mitral stenosis and seven patients underwent tricuspit valve repair using an annuloplasty ring.

Results

All 12 patients were males, of mean age 50.3 ± 11.5 years (range = 25-66). Eleven of them (91.6%) survived the early and late postoperative periods. Ten subjects (83.3%) continue to be supported with VAD; 1 (8.3%) was successfully bridged to transplantation. Each study participant regression of the valvular pathologies by early echocardiography demonstrated.

Conclusion

Concomitant valve surgery during VAD implantation appeared to be a reasonable option in end-stage heart failure patients with valvular heart disease.     

Th1/Th2 Cytokines and Soluble CD30 Levels in Kidney Allograft Patients With Donor Bone Marrow Cell Infusion

Objective

We investigated the relevance of donor bone marrow cell infusion (DBMI) and serum levels of interferon-γ (IFN-γ), interleukin-10 (IL-10), and soluble CD30 (sCD30) in kidney recipients.

Patients and Methods

We analyzed the allograft outcomes correlated with sCD30, IFN-γ, and IL-10 levels using pre- and posttransplantation sera from 40 live donor renal transplants (20 patients with DBMI [2.1 × 10⁹ ± 1.3 × 10⁹ mononuclear cells/body] and 20 controls).

Results

Patients with acute rejection episodes (ARE)—3/20 DBMI and 6/20 controls—showed increased sCD30 and IFN-γ as well as decreased IL-10 posttransplantation compared with nonrejectors. Significant differences were observed for sCD30 and IFN-γ levels: 59.54 vs 30.92 ng/mL (P = .02) and 11.91 vs 3.01 pg/mL (P = .01), respectively. Comparison of pre- and posttransplant levels of IFN-γ, IL-10, and sCD30 in ARE patients showed higher levels in posttransplant sera except for IFN-γ in controls (6.37 vs 11.93; P = .01). Increased IFN-γ and IL-10 were correlated with rejection (r = .93; P = .008). sCD30 correlated with serum creatinine among ARE patients in control and DBMI groups (r = .89; P = .019; and r = 1.00; P < .0001, respectively).

Conclusions

Higher levels of sCD30, IFN-γ, and IL-10 posttransplantation in rejecting patients provided evidence for coexistence of cellular and humoral responses in ARE. There appeared to be a down-regulatory effect of infusion on alloresponses.     

Low Levels of Th1-Type Cytokines and Increased Levels of Th2-Type Cytokines in Kidney Transplant Recipients With Active Cytomegalovirus Infection

Background

Cytomegalovirus (CMV) infection is a major complication after kidney transplantation. It is clear that Th1 and Th2 cell subsets are of major importance in determining the class of immunoprotective function in infectious diseases. Given the strong influence exerted by Th1- and Th2-type immunity on the outcome of infections, we felt it important to elucidate the levels of Th1- and Th2-type cytokines to CMV-related antigens in kidney recipients and to identify antigens that play an essential role in preventing the development of CMV infection and/or disease.

Methods

One hundred twenty subjects were followed for CMV infection by the antigenemia assay. We investigated peripheral blood mononuclear cells (PBMCs) responses to five CMV-related peptide antigens (pp65, gB, pp150, pp28, and pp38). Stimulation index was determined by radioactive thymidine uptake, while the production of Th1-type cytokines (interferon-γ and tumor necrosis factor-α) and Th2-type cytokines (interleukins-4 and -10) were measured by enzyme-linked immunosorbent assay.

Results

The levels of Th1-type cytokine production after stimulating PBMCs with CMV-related antigens gB and pp150 resulted in significant decreases in the levels of interferon-γ, while pp65, pp150, and pp38 produced significant decreases in the level of tumor necrosis factor-α between the two groups (P < .05). For Th2-type cytokines only pp28 produced a significant increase in the level of interleukin-10 between the two groups (P < .05). Regarding the Th1:Th2 ratios, a lower Th1-bias was observed among the CMV-positive patients for PBMCs stimulated with three CMV-related antigens (pp65, pp38, and pp28).

Conclusion

Low levels of Th1-type cytokines and increased levels of Th2-type cytokines upon stimulation with CMV-related peptide antigens were associated with reduced cell-mediated immunity to CMV, thus seeming to correlate with active CMV infections.     

Pretransplantation Cellular Alloreactivity Is Predictive of Acute Graft Rejection and 1-Year Graft Function in Kidney Transplant Recipients

Objective

To study cellular alloimmunity in kidney allograft recipients using an interferon-γ enzyme-linked immunosorbent spot assay (ELISPOT).

Material and Methods

Donor splenocyte peripheral blood mononuclear cells were obtained during kidney recovery in 53 kidney recipients including 11 with positive panel-reactive antibodies pretransplantation. For ELISPOT data analysis, the spot number, size, and intensity were calculated, reflecting the volume of cytokine secretion at the single-cell level. Results were recalculated as the ratio of the values observed for donor-stimulated to unstimulated recipient cells corrected for residual donor activity.

Results

Significantly greater pretransplantation donor-stimulated activity was observed in recipients who experienced an acute rejection episode (ARE) within 1 year (P < .05). Mean change in spot number, size, and intensity in patients without or with AREs was 0.99 vs 3.33, 1.60 vs 6.05, and 1.40 vs 6.31, respectively. The assessed parameters were prognostic of high risk of ARE: 1.5-fold increase in spot number (ARE incidence, 52% vs 9%), 2.5-fold increase in spot size (ARE incidence, 53% vs 13%), and 2.7-fold increase in spot intensity (ARE incidence, 52% vs 9%). The 3 parameters correlated with 1-year serum creatinine concentration (P < .05). In 14 recipients, AREs could have been predicted in 11 using pretransplantation ELISPOT results, and in only 2 on the basis of panel-reactive antibodies.

Conclusion

The ELISPOT-determined capacity of donor-induced reactivity observed in recipient cells obtained just before transplantation is predictive of risk of graft rejection and 1-year allograft function.     

The ortho-plastic management of Gustilo grade IIIB fractures of the tibia in children: A systematic review of the literature

Background

The challenges of managing Gustilo IIIB tibial fractures in children are unique. A multi-disciplinary, evidence based approach is needed. We aimed to evaluate the evidence for the ortho-plastic management of Gustilo grade IIIB open tibial shaft fractures in children based on a review of all published data in order to rationalise the orthopaedic and plastic surgical approach to these complex injuries.

Method

A systematic review of the literature was performed. Gustilo grade IIIB tibial shaft fractures in pre-adolescent and adolescent children were identified and evaluated with regard to both the skeletal and soft tissue management, and the outcome.

Results

Of 54 children with grade IIIB tibial fractures, a mean union time of 31 weeks included 33 weeks for 42 adolescents and 23 weeks for 12 pre-adolescents. Faster union time in pre-adolescents tended towards significance. Delayed union occurred in 22%, nonunion in 13%, mostly in adolescents. Two of 45 covered by vascularised flaps and 3 of 9 treated without flaps developed deep infection (p = 0.028). There was no correlation between method of skeletal fixation and union time.

Conclusion

Gustilo IIIB tibial shaft fractures in pre-adolescents tended towards faster healing with fewer complications, irrespective of the method of skeletal fixation. In adolescents, healing times were similar to adults. Soft tissue closure without flaps was associated with deep infection in one-third of patients, requiring debridement and flap cover. Adequate debridement and flap cover is suggested in all cases, irrespective of age.     

A Rare Case of Colic Thrombotic Microangiopathy in Renal Transplantation

Introduction

We report a case of thrombotic microangiopathy (TM) in patient with UC and kidney transplantation.

Case Report

A 59-year-old Caucasian may with a renal transplant, with atrial fibrillation and ulcerative colitis (UC), was referred for asthenia, fever (38°C), anemia, colicky pain, and bloody diarrhea. The maintenance therapy consisted of CSA, sodium mycophenolate, steroids, ticlopidine, and mesalazine. Laboratory data, colonscopy, and colic mucosal biopsy revealed de novo colic TM. We administered antibiotics and antishock therapy, reducing CSA, withdrawing ticlopedine and maintaining mesalazine with the resolution of the problem.

Conclusion

Posttransplantation TM is an uncommon but severe complication of kidney transplantation associated with reduced graft survival and a high risk for death. Only an early, accurate diagnosis with optimal treatment permits resolution of the problem.     

First Year Renal Function as a Predictor of Kidney Allograft Outcome

Background

Several factors are known to have detrimental effects on kidney allograft function in the first year posttransplantation, which has been reported to be an important factor influencing long-term graft survival.

Objectives

The objectives of this study were to evaluate risk factors for lower estimated glomerular filtration rate (eGFR) at 3 and 12 months posttransplantation and analyze the influence of first year allograft function on graft and patient survivals.

Patients

We performed a retrospective review of the clinical data from 433 cadaveric donor kidney transplantations in adults performed in our unit from May 1989 to May 2007.

Results

Donor female gender and nontraumatic cause of death, panel-reactive antibody (PRA) titer ≥50%, acute rejection episodes, and delayed graft function (DGF) were significant risk factors for a decreased eGFR at one year posttransplantation. Recipient and donor age showed negative correlations with eGFR at 3 and 12 months. A logistic regression model showed acute rejection episodes, DGF, donor age ≥55 years, donor female gender, and nontraumatic cause of donor death to be independent adverse risk factors for eGFR <60 mL/min at 3 and 12 months. Lower eGFRs at 3 and 12 months were associated with poorer allograft survival when data were censored for death with a functioning graft and patient survival. Multivariate analysis revealed that PRA titer ≥50%, acute rejection episodes, and eGFR <30mL/min at 12 months had adverse effects on allograft survival.

Conclusion

Several factors influence kidney allograft function in the first year after transplantation. Kidney allograft function at 12 months predicted long-term graft survival.     

Hemodynamic characteristics of midazolam, propofol, and dexmedetomidine in healthy volunteers

Study Objective

To study the effect of intravenous (IV) sedation on blood pressure (BP), heart rate (HR), and respiratory rates (RR) to determine if IV sedatives differ with respect to their effect on BP, HR, and RR.

Design

Prospective, randomized, single-blinded, placebo-controlled study.

Setting

Monitored patient care room at a clinical research center.

Subjects

60 healthy ASA physical status 1 volunteers.

Interventions

Subjects were randomized to receive, in increasing doses, one of three IV sedatives: propofol, midazolam, or dexmedetomidine; or saline control.

Measurements

Blood pressure (systolic, diastolic), HR, and RR were recorded.

Main Results

A significant dose-dependent BP reduction occurred with dexmedetomidine and, to a lesser degree, with propofol; and there was good agreement of predicted versus measured drug concentrations for all sedatives. Blood pressure and HR of participants who received midazolam did not change.

Conclusions

When administered in sedative doses, dexmedetomidine and, to a lesser extent, midazolam, reduces BP in a dose-dependent fashion. Dexmedetomidine also reduces HR. Midazolam does not affect BP or HR.     

Anti-γ Chain and Anti-IL-2Rβ mAbs in Combination With Donor Splenocyte Transfusion Induce H-Y Skin Graft Acceptance in Murine Model

Background

The common cytokine receptor γ chain signals regulate proliferation, differentiation, and apoptosis of peripheral T cells.

Objective

To investigate whether simultaneous blockade of IL-2Rβ and γ chain signaling in combination with donor splenocyte transfusion (DST) induces transplant tolerance.

Materials and Methods

C57BL/6 (H-2b) mice were randomly divided into 5 groups. In group 1, female mice received only H-Y skin grafts. In group 2, female mice received transfused splenocytes (5 × 10⁶ cells) from syngeneic male mice on day 7 before H-Y skin grafting. In group 3, on days 2 and 4 after DST, female mice received intraperitoneal injections of a mixture of anti-IL-2Rβ monoclonal antibody (mAb) and anti-γ chain mAbs (4G3, 3E12, and TUGm2; 0.5 mg). After DST, group 4 received an intraperitoneal injection of the mixture of anti-γ chain mAbs, and group 5 received intraperitoneal injection of anti-IL-2Rβ mAb (TM-β1). On day 7, H-Y skin grafting was performed.

Results

Group 3 recipients accepted H-Y skin grafts for more than 100 days compared with group 1 (mean survival time [MST], 33.42 days), group 2 (MST, 14.71 days), group 4 (MST, 58.71 days), and group 5 (MST, 17.29 days). Statistical differences (P < .05) were observed between any 2 groups except groups 2 and 5.

Conclusion

Blockade of γ chain signaling rather than IL-2Rβ signaling combined with DST prolongs H-Y skin graft survival. Simultaneous blockade of IL-2Rβ and γ chain signaling may strengthen this effect.     

Patterns of postoperative enterocolitis in children with Hirschsprung's disease combined with hypoganglionosis

Objective

The relationship between postoperative enterocolitis (EC) and Hirschsprung's disease (HD) combined with hypoganglionosis (HYP) has not been thoroughly reported elsewhere. The aim of this study was to investigate the incidence of EC after operation in children with HD combined with HYP and to identify new strategies to prevent postoperative EC.

Methods

From 1998 to 2005, 97 children with HD underwent the modified Swenson's procedure in this institute. They were classified into 2 groups based on pathologic investigation as follows: group A contained 70 patients with HD and group B contained 27 patients with HD complicated with HYP. The mean follow-up time from the time of the operation was 3.4 years (range, 1.5-8 years). The incidence of postoperative EC and anorectal functions were evaluated and compared between these 2 groups.

Results

Eight cases (11.4%) in group A developed postoperative EC, whereas 11 (40.7%) in group B did so. The incidence of postoperative EC in group A was significantly lower than that in group B (P < .005). According to the Rintala scoring system, the percentage of patients with an excellent score in group A (85.7%) was significantly higher than that in group B (P < .05). The recurrence rate of constipation in group B was 14.8% (4/27), whereas it was 2.8% (2/70) in group A.

Conclusions

Postoperative EC is associated with retained proximal HYP, which suggests that HYP could be, at minimum, a predictive marker for this complication. Complete resection of HYP segment could potentially minimize the incidence of postoperative EC and alleviate the severity of EC.     

Presence of pneumomediastinum after blunt trauma in children: what does it really mean?

Background

Pneumomediastinum after blunt thoracic trauma is often considered a marker of serious aerodigestive injury that leads to invasive testing. However, the efficacy of such testing in otherwise stable children remains unknown. We hypothesize that pneumomediastinum after blunt trauma in clinically stable children is rarely associated with significant underlying injury.

Methods

We reviewed all patients in our pediatric trauma database (1997-2007) for pneumomediastinum after blunt injury. Patients were then subdivided into 2 groups: group I, isolated thoracic and group II, thoracic and additional injuries. Procedures and imaging were recorded, and outcomes were assessed.

Results

Thirty-two children with blunt thoracic trauma were included as follows: group I (n = 14) and group II (n = 18). In all patients, there were 28 diagnostic procedures performed resulting in only 1 positive test—a bronchial tear found on bronchoscopy in association with obvious respiratory distress. Group I was more than twice as likely to undergo invasive procedures as group II (P < .0001), resulting in significantly greater costs (?$13683 ± 2520 vs $5378 ± 1000; P < .002). Patients in group I also received more diagnostic imaging to assess pneumomediastinum (1.89 vs 1.08 studies/patient per day; P < .05). More than 28% of all patients were completely asymptomatic and had pneumomediastinum as their only marker of injury. Strikingly, these patients received more than 46% of the procedures.

Conclusions

Children with pneumomediastinum from blunt trauma often receive invasive and expensive testing with low yield, especially those with isolated thoracic trauma.     

Intestine as Source of Cytokines and Growth Factors

Background

The activation status of intestinal immune system cells is much higher than that of analogous peripheral cells. Increased serum concentrations of proinflammatory cytokines have been reported in various pathologic conditions; however, the source of these mediators has not been elucidated.

Objective

To assess the role of the human intestine and its lymphatic system in production of growth factors and proinflammatory cytokines.

Material and Methods

Twenty liver transplant recipients and 20 donors were included in the study. Blood samples were obtained from the artery supplying the intestine, the portal vein, and a peripheral vein during liver harvesting in donors and after transplantation in recipients. An enzyme-linked immunosorbent assay was used to assess serum concentrations of IL-6, tumor necrosis factor-α (TNF-α), transforming growth factor-β (TGF-β), and hepatocyte growth factor (HGF).

Results

In transplant recipients, IL-6 concentration in arterial blood was lower than that in portal blood (P < .049), whereas in donors, there was no significant difference in these concentrations. Neither recipients nor donors demonstrated significant differences in arterial or portal blood concentrations of TNF-α, TGF-β, or HGF.

Conclusions

In healthy human beings, the intestine is not a substantial source of IL-6, TNF-α, TGF-β, or HGF. However, in patients with liver cirrhosis, the intestine is an important source of IL-6 but not of the other studied growth factors and cytokines.     

Augmentor of liver regeneration ameliorates renal tubular epithelial cell injury after rat liver transplantation

Background

Acute renal insufficiency and dysfunction are common complications after clinical liver transplantation. This study examined whether augmentor of liver regeneration (ALR) played a significant role to ameliorate renal tubular epithelial cell injury after liver transplantation.

Methods

Orthotopic liver transplantation was performed from Sprague-Dawley (SD) to SD rats. Twelve recipients were randomly divided into two groups: ALR group (with recombinated human ALR 100 μg/kg  ·  d intramuscular injection postoperation) versus normal saline-treated group (with the same volume of normal saline injected intramuscularly postoperation). Rats were sacrificed at day 3 posttransplantation. Renal morphological changes in recipients were assessed with light microscopy. The expressions of tumor necrosis factor-α (TNF-α), proliferating cell nuclear antigen (PCNA) and caspase-3 protein and mRNA in the kidney were evaluated by real-time polymerase chain reaction and immunohistochemical staining.

Results

Morphological changes in renal tubular epithelial cells were not significant in either group at day 3 posttransplantation. The intragraft expression of TNF-α and caspase-3 was strikingly promoted in the normal saline-treated group and PCNA attenuated compared to the ALR group.

Conclusion

These data suggested that ALR may play a role to reduce renal damage in liver transplant recipients.