Extrahepatic metastasis of hepatocellular carcinoma arising from a hepatic adenoma without concurrent intrahepatic recurrence

Hepatocellular carcinoma (hcc) arising from a hepatic adenoma is a rare phenomenon accounting for fewer than 5% of hcc cases; it seldom recurs after resection of the primary tumour. We report a case of extrahepatic metastasis of hcc arising from a hepatic adenoma that presented as a solitary sternal metastasis without any evidence of intrahepatic recurrence. Our patient was initially treated with radiation therapy and bland embolization, without response. Subsequently, the patient developed progressive disease while taking sorafenib. He later received chemotherapy with docetaxel and gemcitabine, with the development of multiple pulmonary and splenic nodules. However, he remained free of intrahepatic recurrence. To the best of our knowledge, this is the first case of extrahepatic metastasis of hcc arising from a hepatic adenoma without evidence of intrahepatic recurrence.

Experimental Investigation of the ^{19}Ne(p,γ)^{20}Na Reaction Rate and Implications for Breakout from the Hot CNO Cycle

The ^{19}Ne(p,γ)^{20}Na reaction is the second step of a reaction chain which breaks out from the hot CNO cycle, following the ^{15}O(α,γ)^{19}Ne reaction at the onset of x-ray burst events. We investigate the spectrum of the lowest proton-unbound states in ^{20}Na in an effort to resolve contradictions in spin-parity assignments and extract reliable information about the thermal reaction rate. The proton-transfer reaction ^{19}Ne(d,n)^{20}Na is measured with a beam of the radioactive isotope ^{19}Ne at an energy around the Coulomb barrier and in inverse kinematics. We observe three proton resonances with the ^{19}Ne ground state, at 0.44, 0.66, and 0.82 MeV c.m. energies, which are assigned 3^{+}, 1^{+}, and (0^{+}), respectively. In addition, we identify two resonances with the first excited state in ^{19}Ne, one at 0.20 MeV and one, tentatively, at 0.54 MeV. These observations allow us for the first time to experimentally quantify the astrophysical reaction rate on an excited nuclear state. Our experiment shows an efficient path for thermal proton capture in ^{19}Ne(p,γ)^{20}Na, which proceeds through ground state and excited-state capture in almost equal parts and eliminates the possibility for this reaction to create a bottleneck in the breakout from the hot CNO cycle.

Characterizing the activation of the Wnt signaling pathway in hilar cholangiocarcinoma using a tissue microarray approach

Hilar cholangiocarcinoma (HCCA) is an invasive hepatic malignancy that is difficult to biopsy; therefore, novel markers of HCCA prognosis are needed. Here, the level of canonical Wnt activation in patients with HCCA, intrahepatic cholangiocarcinoma (IHCC), and congenital choledochal cysts (CCC) was compared to understand the role of Wnt signaling in HCCA. Pathology specimens from HCCA (n=129), IHCC (n=31), and CCC (n=45) patients were used to construct tissue microarrays. Wnt2, Wnt3, β-catenin, TCF4, c-Myc, and cyclin D1 were detected by immunohistochemistry. Parallel correlation analysis was used to analyze differences in protein levels between the HCCA, IHCC, and CCC groups. Univariate and multivariate analyses were used to determine independent predictors of successful resection and prognosis in the HCCA group. The protein levels of Wnt2, β-catenin, TCF4, c-Myc, and cyclin D1 were significantly higher in HCCA compared to IHHC or CCC. Wnt signaling activation (Wnt2+, Wnt3+, nuclear β-catenin+, nuclear TCF4+) was significantly greater in HCCA tissues than CCC tissues. Univariable analyses indicated that expression of cyclin D1 as well as Wnt signaling activation, and partial Wnt activation (Wnt2+ or Wnt3+ and nuclear β-catenin+ or nuclear TCF4+) predicted successful resection, but only cyclin D1 expression remained significant in multivariable analyses. Only partial Wnt activation was an independent predictor of survival time. Proteins in the canonical Wnt signaling pathway were present at higher levels in HCCA and correlated with tumor resecility and patient prognosis. These results suggest that Wnt pathway analysis may be a useful marker for clinical outcome in HCCA.

Analysis of alterations to the transcriptome of Loquat (Eriobotrya japonica Lindl.) under low temperature stress via de novo sequencing

Loquat (Eriobotrya japonica Lindl.), which originates from the cooler hill regions of southwestern China, is a typical subtropical evergreen tree. Loquat is one of the most important economic crops in China, but the available genomic information is very limited. Here, we present the first deep transcriptomic analysis of loquat. De novo assembly generated 116,723 contigs and 64,814 unigenes using Illumina sequencing technology. A total of 45,739 unigenes were annotated by Nr, GO, and COG datasets. In addition, we analyzed the gene expression profiles of loquat fruit under low temperature stress and 4017 differential expressed genes were identified. We found that the unigenes involved in the brassinosteroid biosynthesis and phosphatidylinositol signaling systems were upregulated, indicating that they have an important role in the resistance of plants to low temperature. Our results provide an invaluable resource for identification of specific genes and proteins involved in loquat development and response to low temperatures.

RNF126 promotes homologous recombination via regulation of E2F1-mediated BRCA1 expression

RNF126 is an E3 ubiquitin ligase. The deletion of RNF126 gene was observed in a wide range of human cancers and is correlated with improved disease-free and overall survival. These data highlights the clinical relevance of RNF126 in tumorigenesis and cancer therapy. However, the specific functions of RNF126 remain largely unknown. Homologous recombination (HR)-mediated DNA double-strand break repair is important for tumor suppression and cancer therapy resistance. Here, we demonstrate that RNF126 facilitates HR by promoting the expression of BRCA1, in a manner independent of its E3 ligase activity but depending on E2F1, a well-known transcription factor of BRCA1 promoter. In support of this result, RNF126 promotes transactivation of BRCA1 promoter by directly binding to E2F1. Most importantly, an RNF126 mutant lacking 11 amino acids that is responsible for the interaction with E2F1 has a dominant-negative effect on BRCA1 expression and HR by suppressing E2F1-mediated transactivation of BRCA1 promoter and blocking the enrichment of E2F1 on BRCA1 promoter. Lastly, RNF126 depletion leads to the increased sensitivity to ionizing radiation (IR) and poly (ADP-ribose) polymerase (PARP) inhibition. Collectively, our results suggest a novel role of RNF126 in promoting HR-mediated repair through positive regulation on BRCA1 expression by direct interaction with E2F1. This study not only offers novel insights into our current understanding of the biological functions of RNF126 but also provides a potential therapeutic target for cancer treatment.

Clinical and laboratory characteristics of systemic sclerosis patients with pulmonary arterial hypertension in China

OBJECTIVES

Pulmonary arterial hypertension (PAH) is associated with significant morbidity and mortality, especially in systemic sclerosis (SSc). Since there was no published study regarding PAH in the Chinese SSc population, we aimed to describe a cohort to provide some data for early diagnosis.

METHODS

We evaluated 236 systemic sclerosis patients prospectively registered in the EUSTAR (European League Against Rheumatism Scleroderma Trial and Research Group) database from the Peking Union Medical College Hospital from 2009 to 2012. Among them, 33 individuals received right heart catheterisations (RHC) while the remaining patients were grouped by echocardiographic data. These patients were classified into two groups, PAH and non-PAH group. Their clinical and laboratory features were statistically analysed to identify possible risk factors for PAH in Chinese SSc population.

RESULTS

The possible prevalence of PAH in SSc patients was approximately 11% in our study. Digital ulcers (52.0% vs. 31.2%), telangiectasias (64.0% vs. 37.6%) and gastroesophageal reflux disease (GERD) (60.0% vs. 36.2%) were more common in SSc patients with PAH. Some laboratory results were also proved to be significantly correlated with it. Logistic regression analysis showed that telangiectasias (OR=2.888, 95% CI=1.176-7.093), presence of GERD (OR=2.592, 95% CI=1.067-6.296), anti-RNP positivity (OR=24.384, 95% CI=1.978-36.651), IgA level elevation (OR=8.745, 95% CI 4.838-122.896) and FVC/TLCO ratio (OR=97.067, 95% CI 12.475-755.271) were associated with an increased odds for PAH in SSc patients.

CONCLUSIONS

This study described possible predictors of PAH in Chinese SSc population, which have been supported by similar studies in other ethnic groups.

Variability in free 25(OH) vitamin D levels in clinical populations

Our goal was to determine total and directly measured free 25-hydroxy vitamin D (25(OH)D) serum levels in humans with a range of 25(OH)D levels and clinical conditions associated with low and high vitamin D binding protein levels. Serum samples and clinical data were collected from 106 subjects: 62 without cirrhosis or pregnancy, 24 cirrhotic patients with albumin <2.9g/dL, and 20 pregnant women. Total 25(OH)D (LC/MS/MS) and "free" 25(OH)D (immunoassay) were measured. Total 25(OH)D was significantly lower in liver disease patients but free 25(OH)D concentrations were significantly higher in this group (p<.001). Neither total nor free 25(OH)D concentrations were significantly different in pregnant women vs. the comparator group. There were significant direct positive relationships between free 25(OH)D and total 25(OH)D concentrations for the entire dataset and for each group (p<.0001), however slopes of relationships differed in the cirrhotic group compared to pregnant women or the comparator group. In cirrhotics: y (free 25(OH)D)=2.52+0.29×X(total 25 (OH)D), r(2)=.51, p<.001; y=1.45+0.09×X; r(2)=.77, p<.0001 for pregnant women; and y=1.11+0.12×X; r(2)=.72, p<.0001 for the comparator group).

CONCLUSIONS

directly measured free 25(OH)D serum concentrations and relationships between total and free 25(OH)D vary with clinical conditions, and may differ from those predicted by indirect estimation methods. This article is part of a Special Issue entitled 'Vitamin D Workshop'.

Measurements of fusion reactions of low-intensity radioactive carbon beams on 12C and their implications for the understanding of X-ray bursts

The interaction between neutron-rich nuclei plays an important role for understanding the reaction mechanism of the fusion process as well as for the energy production through pycnonuclear reactions in the crust of neutron stars. We have performed the first measurements of the total fusion cross sections in the systems (10,14,15)C+(12)C using a new active target-detector system. In the energy region accessible with existing radioactive beams, a good agreement between the experimental and theoretical cross sections is observed. This gives confidence in our ability to calculate fusion cross sections for systems which are outside the range of today's radioactive beam facilities.

A comparison of measured and calculated free 25(OH) vitamin D levels in clinical populations

OBJECTIVE

Our goal was to compare direct quantitation of circulating free 25-hydroxyvitamin D (25(OH)D)levels to calculated free 25(OH)D levels and their relationships to intact PTH (iPTH), a biomarker of 25(OH)D effect, in humans with a range of clinical conditions.

PATIENTS AND METHODS

Serum samples and clinical data were collected from 155 people: 111 without cirrhosis or pregnancy (comparison group), 24 cirrhotic patients with albumin <2.9 g/dL, and 20 pregnant women (second and third trimester). Total 25(OH)D (LC/MS/MS), free 25(OH)D (immunoassay), vitamin D binding protein (DBP) (immunoassay), albumin, and iPTH (immunoassay) were measured.

RESULTS

Total 25(OH)D, DBP, and albumin were lowest in patients with cirrhosis, but measured free 25(OH)D was highest in this group (P < .001). DBP was highest in pregnant women (P < .001), but measured free 25(OH)D did not differ from the comparison group. Calculated free 25(OH)D was positively correlated with measured free 25(OH)D (P < .0001) but explained only 13% of the variability with calculated values higher than measured. African Americans had lower DBP than other ethnic populations within all clinical groups (P < .03), and differences between measured and calculated free 25(OH)D were greatest in African Americans (P < .001). Measured free 25(OH)D was correlated with total 25(OH)D (P < .0001; r(2) = 0.51), but calculated free 25(OH)D was not. Similarly, both measured free 25(OH)D (P < .02) and total 25(OH)D (P < .05) were correlated with iPTH, but calculated free 25(OH)D was not.

CONCLUSIONS

Calculated free 25(OH)D levels varied considerably from direct measurements of free 25(OH)D with discrepancies greatest in the data for African Americans. Differences in DBP binding affinity likely contributed to estimation errors between the races. Directly measured free 25(OH)D concentrations were related to iPTH, but calculated estimates were not. Current algorithms to calculate free 25(OH)D may not be accurate. Further evaluation of directly measured free 25(OH)D levels to determine its role in research and clinical management of patients is needed.

Noise temperature improvement for magnetic fusion plasma millimeter wave imaging systems

Significant progress has been made in the imaging and visualization of magnetohydrodynamic and microturbulence phenomena in magnetic fusion plasmas [B. Tobias et al., Plasma Fusion Res. 6, 2106042 (2011)]. Of particular importance have been microwave electron cyclotron emission imaging and microwave imaging reflectometry systems for imaging T(e) and n(e) fluctuations. These instruments have employed heterodyne receiver arrays with Schottky diode mixer elements directly connected to individual antennas. Consequently, the noise temperature has been strongly determined by the conversion loss with typical noise temperatures of ~60,000 K. However, this can be significantly improved by making use of recent advances in Monolithic Microwave Integrated Circuit chip low noise amplifiers to insert a pre-amplifier in front of the Schottky diode mixer element. In a proof-of-principle design at V-Band (50-75 GHz), significant improvement of noise temperature from the current 60,000 K to measured 4000 K has been obtained.

Covalent amphiphilic polyoxometalates for the design of biphasic microemulsion systems

Unprecedented stabilization of a Winsor I microemulsion has been achieved using a covalent polyoxotungstate amphiphile.

Gene expression signature analysis and protein-protein interaction network construction of spinal cord injury

BACKGROUND

The aim of this study was to investigate the gene expression profile of thoracic propriospinal neurons between post-injury rat and controls.

MATERIALS AND METHODS

Microarray dataset GSE20907 was downloaded from GEO database, including 12 Spinal Cord Injury (SCI) rat and 12 controls. Student's t test was employed to identified differentially expressed genes with a fold-change > 1.2. Then, we used DAVID to perform functional enrichment analysis to uncover dysfunctional biological processes and molecular signatures database (MsigDB) to find any potential relationship between SCI gene expression signature and other published gene expression signature. Protein-Protein interaction (PPI) network was constructed by STRING and visualized in Cytoscape. Functional analysis of the hub protein was performed by BinGO.

RESULTS

The maximum change of gene expression profile was found at 3-days post injury and immune response was found upregulated all tested time points. Interestingly, genes upregulated 2-weeks post injury was found significantly overlapped with genes upregulated in brains from Alzheimer's disease patients. Protein interaction network analysis found that LYN, PTPN6 and SMAD1 could be of great value for further investigation.

CONCLUSIONS

It could be inferred that understanding the underlying molecular mechanism post injury, especially at early moment, may provide novel insight for development of therapeutics strategy.

Vulval cancer incidence, mortality and survival in England: age-related trends

OBJECTIVE

To explore the trends and age characteristics of vulval cancer incidence, mortality, survival and stage of disease.

DESIGN

Retrospective population-based observational study based on cancer registry and Office for National Statistics data.

SETTING

England.

POPULATION

All women diagnosed with vulval cancer, defined by the site of the tumour (ICD-10 code C51).

METHODS

Including all C51 cases, Poisson regression was used to test for trends in incidence and mortality rates, and generalised linear modelling was used to test for trends in relative survival. Excluding women with melanomas, basal cell carcinomas and Paget disease, stage was investigated as a percentage of staged data by age.

MAIN OUTCOME MEASURES

Age-standardised incidence and mortality rates, relative survival rates and stage of disease at diagnosis.

RESULTS

From 1990, there was a statistically significant increase in overall incidence (P = 0.018) and decrease in mortality (P < 0.001). In addition, there were statistically significant increases in overall survival (1-year, P < 0.001; 5-year, P < 0.001). However, from 1990, incidence increased in women aged 20-39 years (P = 0.002), 40-49 and 50-59 years (both P < 0.001) and 60-69 years (P = 0.030) and decreased in women aged 80 years and above (P < 0.001). There were statistically significant decreases in mortality in women aged ≥60 years (P < 0.001), and statistically significant increases in 1-year survival in women aged ≥40 years (P ≤ 0.047) and in 5-year survival in women aged 40-49 and ≥60 years (P ≤ 0.011). Stage patterns by age highlight diagnosis at an earlier stage in younger women and more advanced stage diagnosis in older women.

CONCLUSION

Survival from vulval cancer has improved and mortality has decreased since 1990. The overall incidence of disease has increased as a result of more new diagnoses in the under 70-year age group.

Dietary patterns as compared with physical activity in relation to metabolic syndrome among Chinese adults

AIMS

To examine the nationally-representative dietary patterns and their joint effects with physical activity on the likelihood of metabolic syndrome (MS) among 20,827 Chinese adults.

METHODS AND RESULTS

CNNHS was a nationally representative cross-sectional observational study. Metabolic syndrome was defined according to the Joint Interim Statement definition. The "Green Water" dietary pattern, characterized by high intakes of rice and vegetables and moderate intakes in animal foods was related to the lowest prevalence of MS (15.9%). Compared to the "Green Water" dietary pattern, the "Yellow Earth" dietary pattern, characterized by high intakes of refined cereal products, tubers, cooking salt and salted vegetable was associated with a significantly elevated odds of MS (odds ratio 1.66, 95%CI: 1.40-1.96), after adjustment of age, sex, socioeconomic status and lifestyle factors. The "Western/new affluence" dietary pattern characterized by higher consumption of beef/lamb, fruit, eggs, poultry and seafood also significantly associated with MS (odds ratio: 1.37, 95%CI: 1.13-1.67). Physical activity showed significant interactions with the dietary patterns in relation to MS risk (P for interaction = 0.008). In the joint analysis, participants with the combination of sedentary activity with the "Yellow Earth" dietary pattern or the "Western/new affluence" dietary pattern both had more than three times (95%CI: 2.8-6.1) higher odds of MS than those with active activity and the "Green Water" dietary pattern.

CONCLUSIONS

Our findings from the large Chinese national representative data indicate that dietary patterns affect the likelihood of MS. Combining healthy dietary pattern with active lifestyle may benefit more in prevention of MS.

Prevalence and antimicrobial resistance of Enterococcus species of food animal origin from Beijing and Shandong Province, China

AIMS

To evaluate the prevalence and antimicrobial resistance of Enterococcus species from chickens and pigs in Beijing and Shandong Province, China.

METHODS AND RESULTS

Swab samples were collected from four farms in Beijing and two in Shandong Province in 2009 and tested for Enterococcus. Minimum inhibitory concentrations of antimicrobial agents were determined using broth microdilution or agar screening methods. A total of 453 Enterococcus isolates were recovered, belonging to six different Enterococcus species. All isolates were sensitive to vancomycin. Resistance to tetracycline (92.5%), amikacin (89.4%), erythromycin (72.8%) and rifampin (58.1%), and high-level streptomycin resistance (HLSR, 50.3%) were prevalent, while resistance to penicillins (7.9% to penicillin and 4.2% to ampicillin) was rare. The resistance rates to phenicols (chloramphenicol and florfenicol) and enrofloxacin, and high-level gentamicin resistance (HLGR) were approximately 30%. The vast majority of the Enterococcus isolates were classified as multidrug-resistant organisms.

CONCLUSIONS

Resistance of Enterococcus sp. to most antimicrobials was more prevalent in China than in European or other Asian countries.

SIGNIFICANCE AND IMPACT OF THE STUDY

Our findings reveal a high level of antimicrobial resistance in Enterococcus isolates from food animals in China and underline the need for prudent use of antibiotics in chicken and pig production to minimize the spread of antibiotic-resistant enterococci.

Endovascular treatment for the spontaneous rupture of a non-aneurysmal subdiaphragmatic aorta

The case of a patient who underwent an endovascular aortic repair for a spontaneous rupture of a non-aneurysmal subdiaphragmatic aorta without trauma, infection, or inflammation is reported. The patient is a 51-year-old male diagnosed with subdiaphragmatic aortic rupture and was in a state of hemorrhagic shock upon admission to the hospital. Intraoperative aortography revealed the abdominal aortic rupture site located above the celiac artery. A coated thoracic stent graft was used. Completion angiography showed a total exclusion with no endoleaks. After six months of follow-up, computed tomographic scans confirmed the absence of endoleaks or graft displacements.

There were no differences in serum HBV DNA level between HBeAg-positive and HBeAg-negative chronic hepatitis B with same liver histological necroinflammation grade but differences among grades 1, 2, 3 and 4 apportioned by the same hepatic parenchyma cell volume

Hepatitis B virus (HBV) DNA levels and liver histological necroinflammation grades are correlated with the antiviral efficacy. It is necessary to clarify the relationship between HBV replication levels apportioned by the same hepatic parenchyma cell volume and severity of liver histological necroinflammation grades in both hepatitis B e antigen (HBeAg)-positive and HBeAg-negative chronic hepatitis B. The serum HBV DNA levels apportioned by the same hepatic parenchyma cell volume were compared between HBeAg-positive and HBeAg-negative chronic hepatitis B as well as among liver histological necroinflammation grades 1, 2, 3 and 4, respectively. There were no differences in the serum HBV DNA levels between HBeAg-positive and HBeAg-negative chronic hepatitis B as well as among liver histological necroinflammation grades 1, 2, 3 and 4. However, there were differences in the serum HBV DNA levels apportioned by the same hepatic parenchyma cell volume among liver histological necroinflammation grades 1, 2, 3 and 4 in both HBeAg-positive and HBeAg-negative chronic hepatitis B, respectively. There were no differences in HBV DNA levels with the same liver histological necroinflammation grade activated by HBV wild-type and variant strains. After the differences in hepatic parenchyma cell volume for HBV replication of the same liver histological necroinflammation grade accompanied by different hepatic fibrosis stages were adjusted, the serum HBV DNA level apportioned by the same hepatic parenchyma cell volume was correlated with the severity of liver histological necroinflammation grade.

Spinal or systemic TY005, a peptidic opioid agonist/neurokinin 1 antagonist, attenuates pain with reduced tolerance

BACKGROUND AND PURPOSE

The use of opioids in treating pain is limited due to significant side effects including somnolence, constipation, analgesic tolerance, addiction and respiratory depression. Pre-clinical studies have shown that neurokinin 1 (NK(1) ) receptor antagonists block opioid-induced antinociceptive tolerance and may inhibit opioid-induced rewarding behaviours. Here, we have characterized a bifunctional peptide with both opioid agonist and NK(1) antagonist pharmacophores in a rodent model of neuropathic pain.

EXPERIMENTAL APPROACH

Rats were evaluated for behavioural responses to both tactile and thermal stimuli in either an uninjured, sham- or nerve-injured state. TY005 (Tyr-DAla-Gly-Phe-Met-Pro-Leu-Trp-O-3,5-Bn(CF(3) )(2) ) was delivered spinally or systemically to assess the antinociceptive effects after acute exposure. Motor skills were evaluated using the rotarod test to determine potential sedative effects. Spinal TY005 was given chronically to sham- or nerve-injured animals to determine the development of tolerance.

KEY RESULTS

Bolus injections of TY005 produced dose-dependent antinociception in non-injured animals and alleviated nerve injury-induced thermal and tactile hypersensitivities (i.e. antihyperalgesia) more effectively than morphine. Sedative effects were not evident from the rotarod test at doses that were antihyperalgesic, nor at doses threefold higher. Repeated administration of TY005 did not lead to the development of antihyperalgesic tolerance or alter sensory thresholds.

CONCLUSIONS AND IMPLICATIONS

Collectively, the data suggest that opioid agonist/NK(1) antagonist bifunctional peptides represent a promising novel approach to the management of chronic pain without the development of tolerance, reducing the need for escalation of doses and unwanted side effects associated with opiates alone.

CCR2 regulates monocyte recruitment as well as CD4 T1 allorecognition after lung transplantation

Graft rejection remains a formidable problem contributing to poor outcomes after lung transplantation. Blocking chemokine pathways have yielded promising results in some organ transplant systems. Previous clinical studies have demonstrated upregulation of CCR2 ligands following lung transplantation. Moreover, lung injury is attenuated in CCR2-deficient mice in several inflammatory models. In this study, we examined the role of CCR2 in monocyte recruitment and alloimmune responses in a mouse model of vascularized orthotopic lung transplantation. The CCR2 ligand MCP-1 is upregulated in serum and allografts following lung transplantation. CCR2 is critical for the mobilization of monocytes from the bone marrow into the bloodstream and for the accumulation of CD11c(+) cells within lung allografts. A portion of graft-infiltrating recipient CD11c(+) cells expresses both recipient and donor MHC molecules. Two-photon imaging demonstrates that recipient CD11c(+) cells are associated with recipient T cells within the graft. While recipient CCR2 deficiency does not prevent acute lung rejection and is associated with increased graft infiltration by T cells, it significantly reduces CD4(+) T(h)1 indirect and direct allorecognition. Thus, CCR2 may be a potential target to attenuate alloimmune responses after lung transplantation.