1
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Feld LD, Sarkar M, Au JS, Flemming JA, Gripshover J, Kardashian A, Muir AJ, Nephew L, Orloff SL, Terrault N, Rabinowitz L, Volerman A, Arora V, Farnan J, Villa E. Parental leave, childcare policies, and workplace bias for hepatology professionals: A national survey. Hepatol Commun 2023; 7:e0214. [PMID: 37639705 PMCID: PMC10461944 DOI: 10.1097/hc9.0000000000000214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 05/22/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND The presence of workplace bias around child-rearing and inadequate parental leave may negatively impact childbearing decisions and sex equity in hepatology. This study aimed to understand the influence of parental leave and child-rearing on career advancement in hepatology. METHODS A cross-sectional survey of physician members of the American Association for the Study of Liver Diseases (AASLD) was distributed through email listserv in January 2021. The 33-item survey included demographic questions, questions about bias, altering training, career plans, family planning, parental leave, and work accommodations. RESULTS Among 199 US physician respondents, 65.3% were women, and 83.4% (n = 166) were attendings. Sex and racial differences were reported in several domains, including paid leave, perceptions of bias, and child-rearing. Most women (79.3%) took fewer than the recommended 12 paid weeks of parental leave for their first child (average paid leave 7.5 wk for women and 1.7 for men). A majority (75.2%) of women reported workplace discrimination, including 83.3% of Black and 62.5% of Hispanic women. Twenty percent of women were asked about their/their partners' pregnancy intentions or child-rearing plans during interviews for training. Women were more likely to alter career plans due to child-rearing (30.0% vs. 15.9%, p = 0.030). Women were also more likely to delay having children than men (69.5% vs.35.9%). CONCLUSIONS Women reported sex and maternity bias in the workplace and during training interviews, which was more frequently experienced by Black and Hispanic women. As two-thirds of women had children during training, it is a particularly influential time to reevaluate programmatic support to address long-term gender disparities in career advancement.
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Affiliation(s)
- Lauren D. Feld
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Massachusetts, Worcester, Massachusetts, USA
| | - Monika Sarkar
- Department of Medicine, Division of Gastroenterology & Hepatology, University of California San Francisco, San Francisco, California, USA
| | - Jennifer S. Au
- Department of Organ Transplant, Division of Gastroenterology and Hepatology, Scripps Clinic, La Jolla, California, USA
| | - Jennifer A. Flemming
- Department of Medicine and Public Health Sciences, Queen’s University, Ontario, Canada
| | - Janet Gripshover
- Department of Transplant Surgery, Ronald Regan UCLA Medical Center, Los Angeles, California, USA
| | - Ani Kardashian
- Department of Medicine, Division of Gastrointestinal and Liver Diseases, Keck School of Medicine of USC, Los Angeles, California, USA
| | - Andrew J. Muir
- Department of Medicine, Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Lauren Nephew
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Susan L. Orloff
- Department of Surgery, Division of Abdominal Organ Transplantation, Oregon Health & Science University School of Medicine, Portland, Oregon, USA
| | - Norah Terrault
- Department of Medicine, Division of Gastroenterology and Liver, Keck School of Medicine of USC, Los Angeles, California, USA
| | - Loren Rabinowitz
- Department of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Anna Volerman
- Departments of Medicine and Pediatrics, University of Chicago, Chicago, Illinois, USA
| | - Vineet Arora
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Jeanne Farnan
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Erica Villa
- Dipartimento di Specialità Mediche, Struttura Complessa di Gastroenterologia, Universita Degli Studi Di Modena E Reggio Emilia, Modena, Italy
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2
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Kardashian A, Kushner T, Au JS, Flemming JA, Gripshover J, Muir AJ, Orloff SL, Villa E, Sarkar M. The key role of hepatology providers in optimizing reproductive care in patients with liver disease: A call to action. Hepatology 2023; 78:363-367. [PMID: 37142412 DOI: 10.1097/hep.0000000000000275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 11/28/2022] [Indexed: 05/06/2023]
Affiliation(s)
- Ani Kardashian
- Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, California, USA
| | - Tatyana Kushner
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jennifer S Au
- Department of Organ and Cell Transplant, Scripps Clinic, La Jolla, California, USA
| | - Jennifer A Flemming
- Department of Medicine and Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Janet Gripshover
- Department of Liver and Small Bowel Transplant, University of California, Los Angeles, Los Angeles, California, USA
| | - Andrew J Muir
- Department of Medicine, Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Susan L Orloff
- Department of Surgery, Division of Abdominal Transplant Surgery, Oregon Health and Sciences University, Portland, Oregon, USA
| | - Erica Villa
- Chimomo Department, Gastroenterology Division, University of Modena and Reggio Emilia, Modena, Italy
- IRCCS Saverio de Bellis, Castellana Grotte, Italy
| | - Monika Sarkar
- Department of Medicine, Division of Gastroenterology, University of California, San Francisco, San Francisco, California, USA
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3
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Newell LF, Dunlap J, Gatter K, Bagby GC, Press RD, Cook RJ, Fletcher L, Leonard JT, Leong KM, Bubalo JS, Olyaei A, Deloughery TG, Maziarz RT, Maynard E, Orloff SL, Enestvedt CK. Graft-versus-host disease after liver transplantation is associated with bone marrow failure, hemophagocytosis, and DNMT3A mutations. Am J Transplant 2021; 21:3894-3906. [PMID: 33961341 DOI: 10.1111/ajt.16635] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/16/2021] [Accepted: 04/30/2021] [Indexed: 01/25/2023]
Abstract
Graft-versus-host disease after liver transplantation (LT-GVHD) is rare, frequently fatal, and associated with bone marrow failure (BMF), cytopenias, and hyperferritinemia. Given hyperferritinemia and cytopenias are present in hemophagocytic lymphohistiocytosis (HLH), and somatic mutations in hematopoietic cells are associated with hyperinflammatory responses (clonal hematopoiesis of indeterminate potential, CHIP), we identified the frequency of hemophagocytosis and CHIP mutations in LT-GVHD. We reviewed bone marrow aspirates and biopsies, quantified blood/marrow chimerism, and performed next-generation sequencing (NGS) with a targeted panel of genes relevant to myeloid malignancies, CHIP, and BMF. In all, 12 marrows were reviewed from 9 LT-GVHD patients. In all, 10 aspirates were evaluable for hemophagocytosis; 7 had adequate DNA for NGS. NGS was also performed on marrow from an LT cohort (n = 6) without GVHD. Nine of 10 aspirates in LT-GVHD patients showed increased hemophagocytosis. Five (71%) of 7 with LT-GVHD had DNMT3A mutations; only 1 of 6 in the non-GVHD LT cohort demonstrated DNMT3A mutation (p = .04). Only 1 LT-GVHD patient survived. BMF with HLH features was associated with poor hematopoietic recovery, and DNMT3A mutations were over-represented, in LT-GVHD patients. Identification of HLH features may guide prognosis and therapeutics. Further studies are needed to clarify the origin and impact of CHIP mutations on the hyperinflammatory state.
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Affiliation(s)
- Laura F Newell
- Knight Cancer Institute, Hematology and Medical Oncology, Oregon Health & Science University, Portland, Oregon, USA
| | - Jennifer Dunlap
- Department of Pathology, Oregon Health & Science University, Portland, Oregon, USA
| | - Ken Gatter
- Department of Pathology, Oregon Health & Science University, Portland, Oregon, USA
| | - Grover C Bagby
- Knight Cancer Institute, Hematology and Medical Oncology, Oregon Health & Science University, Portland, Oregon, USA
| | - Richard D Press
- Department of Pathology, Oregon Health & Science University, Portland, Oregon, USA
| | - Rachel J Cook
- Knight Cancer Institute, Hematology and Medical Oncology, Oregon Health & Science University, Portland, Oregon, USA
| | - Luke Fletcher
- Knight Cancer Institute, Hematology and Medical Oncology, Oregon Health & Science University, Portland, Oregon, USA
| | - Jessica T Leonard
- Knight Cancer Institute, Hematology and Medical Oncology, Oregon Health & Science University, Portland, Oregon, USA
| | - Kelli M Leong
- Department of Pharmacy, Oregon Health & Science University, Portland, Oregon, USA
| | - Joseph S Bubalo
- Department of Pharmacy, Oregon Health & Science University, Portland, Oregon, USA
| | - Ali Olyaei
- Division of Nephrology and Hypertension, Oregon Health & Science University, Portland, Oregon, USA
| | - Thomas G Deloughery
- Knight Cancer Institute, Hematology and Medical Oncology, Oregon Health & Science University, Portland, Oregon, USA
| | - Richard T Maziarz
- Knight Cancer Institute, Hematology and Medical Oncology, Oregon Health & Science University, Portland, Oregon, USA
| | - Erin Maynard
- Department of Surgery, Division of Abdominal Organ Transplantation, Oregon Health & Science University, Portland, Oregon, USA
| | - Susan L Orloff
- Department of Surgery, Division of Abdominal Organ Transplantation, Oregon Health & Science University, Portland, Oregon, USA
| | - C Kristian Enestvedt
- Department of Surgery, Division of Abdominal Organ Transplantation, Oregon Health & Science University, Portland, Oregon, USA
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4
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Turgeon MK, Shah SA, Delman AM, Tran BV, Agopian VG, Wedd JP, Magliocca JF, Kim A, Cameron A, Olyaei A, Orloff SL, Anderson MP, Kubal CA, Cannon RM, Locke JE, Simpson MA, Akoad ME, Wongjirad CP, Emamaullee J, Moro A, Aucejo F, Feizpour CA, Vagefi PA, Nguyen MH, Esquivel CO, Dhanireddy K, Subramanian V, Chavarriaga A, Kazimi MM, Anderson MS, Sonnenday CJ, Kim SC, Foley DP, Abdouljoud M, Salgia RJ, Moris D, Sudan DL, Ganesh SR, Humar A, Doyle M, Chapman WC, Maithel SK. Optimal Timing of Administration of Direct-acting Antivirals for Patients With Hepatitis C-associated Hepatocellular Carcinoma Undergoing Liver Transplantation. Ann Surg 2021; 274:613-620. [PMID: 34506316 PMCID: PMC8559662 DOI: 10.1097/sla.0000000000005070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To investigate the optimal timing of direct acting antiviral (DAA) administration in patients with hepatitis C-associated hepatocellular carcinoma (HCC) undergoing liver transplantation (LT). SUMMARY OF BACKGROUND DATA In patients with hepatitis C (HCV) associated HCC undergoing LT, the optimal timing of direct-acting antivirals (DAA) administration to achieve sustained virologic response (SVR) and improved oncologic outcomes remains a topic of much debate. METHODS The United States HCC LT Consortium (2015-2019) was reviewed for patients with primary HCV-associated HCC who underwent LT and received DAA therapy at 20 institutions. Primary outcomes were SVR and HCC recurrence-free survival (RFS). RESULTS Of 857 patients, 725 were within Milan criteria. SVR was associated with improved 5-year RFS (92% vs 77%, P < 0.01). Patients who received DAAs pre-LT, 0-3 months post-LT, and ≥3 months post-LT had SVR rates of 91%, 92%, and 82%, and 5-year RFS of 93%, 94%, and 87%, respectively. Among 427 HCV treatment-naïve patients (no previous interferon therapy), patients who achieved SVR with DAAs had improved 5-year RFS (93% vs 76%, P < 0.01). Patients who received DAAs pre-LT, 0-3 months post-LT, and ≥3 months post-LT had SVR rates of 91%, 93%, and 78% (P < 0.01) and 5-year RFS of 93%, 100%, and 83% (P = 0.01). CONCLUSIONS The optimal timing of DAA therapy appears to be 0 to 3 months after LT for HCV-associated HCC, given increased rates of SVR and improved RFS. Delayed administration after transplant should be avoided. A prospective randomized controlled trial is warranted to validate these results.
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Affiliation(s)
| | - Shimul A. Shah
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Aaron M. Delman
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Benjamin V. Tran
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | | | | | | | | | | | - Ali Olyaei
- Oregon Health and Science University, Portland, Oregon
| | | | | | | | | | - Jayme E. Locke
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | | | - Juliet Emamaullee
- Keck Hospital of University of Southern California, Los Angeles, California
| | | | | | | | | | | | | | | | | | | | | | | | | | - Steven C. Kim
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - David P. Foley
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | | | | | | | | | | | - Abhinav Humar
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Majella Doyle
- Washington University School of Medicine at St. Louis, St. Louis, Missouri
| | - William C. Chapman
- Washington University School of Medicine at St. Louis, St. Louis, Missouri
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5
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Sutton TL, Billingsley KG, Walker BS, Fung AW, Maynard E, Enestvedt CK, Dewey EN, Brinkerhoff BT, Lopez CD, Orloff SL, Mayo SC. Detection of Tumor Multifocality in Resectable Intrahepatic Cholangiocarcinoma: Defining the Optimal Pre-operative Imaging Modality. J Gastrointest Surg 2021; 25:2250-2257. [PMID: 33565011 DOI: 10.1007/s11605-021-04911-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 01/09/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Multiple tumor foci (MTF) in intrahepatic cholangiocarcinoma (ICC), including satellitosis and true multifocality, is a known negative prognostic factor and can inform pre-operative decision-making. Lack of standardized pre-operative liver staging practices may contribute to undiagnosed MTF and poor outcomes. We sought to investigate the sensitivity of different cross-sectional imaging modalities for MTF at our institution. METHODS We identified n = 52 patients with ICC who underwent curative-intent resection from 2004 to 2017 in a multidisciplinary hepato-pancreato-biliary cancer program. Timing and modality of pre-operative imaging were recorded. Blinded review of imaging was performed and modalities were evaluated for false-negative rate (FNR) in detecting MTF, satellitosis, and true multifocality. RESULTS Forty-one (79%) patients underwent CT and 20 (38%) underwent MRI prior to hepatectomy. MTF was pre-operatively identified in six (12%) patients. An additional seven patients had MTF discovered on final surgical pathology, despite a median interval from CT/MRI to surgery of 20 days. On blinded review the FNR of MRI compared to CT for multifocality was 0% vs. 38%, 50% vs 80% for satellitosis, and 22% vs 46% for MTF as a whole. CONCLUSION CT is inadequate for pre-operative diagnosis of MTF in resectable ICC, even when performed within 30 days of hepatectomy. We recommend liver-protocol MRI as the standard pre-operative imaging modality in non-metastatic ICC.
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Affiliation(s)
- Thomas L Sutton
- Department of Surgery, Division of Surgical Oncology, Oregon Heath & Science University (OHSU), 3181 SW Sam Jackson Park Rd, Mail Code: L-619, Portland, OR, 97239, USA
| | - Kevin G Billingsley
- Department of Surgery, Division of Surgical Oncology, Oregon Heath & Science University (OHSU), 3181 SW Sam Jackson Park Rd, Mail Code: L-619, Portland, OR, 97239, USA.,The Knight Cancer Institute at OHSU, Portland, OR, 97239, USA
| | - Brett S Walker
- Department of Surgery, Division of Surgical Oncology, Oregon Heath & Science University (OHSU), 3181 SW Sam Jackson Park Rd, Mail Code: L-619, Portland, OR, 97239, USA
| | - Alice W Fung
- The Knight Cancer Institute at OHSU, Portland, OR, 97239, USA.,Department of Radiology, OHSU, Portland, OR, 97239, USA
| | - Erin Maynard
- Department of Surgery, Division of Abdominal Organ Transplantation/Hepatobiliary Surgery, OHSU, Portland, OR, 97239, USA
| | - C Kristian Enestvedt
- Department of Surgery, Division of Abdominal Organ Transplantation/Hepatobiliary Surgery, OHSU, Portland, OR, 97239, USA
| | | | | | - Charles D Lopez
- The Knight Cancer Institute at OHSU, Portland, OR, 97239, USA.,Division of Hematology Oncology, OHSU, Portland, OR, 97239, USA
| | - Susan L Orloff
- Department of Surgery, Division of Abdominal Organ Transplantation/Hepatobiliary Surgery, OHSU, Portland, OR, 97239, USA
| | - Skye C Mayo
- Department of Surgery, Division of Surgical Oncology, Oregon Heath & Science University (OHSU), 3181 SW Sam Jackson Park Rd, Mail Code: L-619, Portland, OR, 97239, USA. .,The Knight Cancer Institute at OHSU, Portland, OR, 97239, USA.
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6
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Sutton TL, Walker BS, Radu S, Dewey EN, Enestvedt CK, Maynard E, Orloff SL, Nabavizadeh N, Sheppard BC, Lopez CD, Billingsley KG, Mayo SC. Degree of biliary tract violation during treatment of gallbladder adenocarcinoma is independently associated with development of peritoneal carcinomatosis. J Surg Oncol 2021; 124:581-588. [PMID: 34115368 DOI: 10.1002/jso.26569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 05/10/2021] [Accepted: 06/01/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND Gallbladder cancer (GBC) is often incidentally diagnosed after cholecystectomy. Intra-operative biliary tract violations (BTV) have been recently associated with development of peritoneal disease (PD). The degree of BTV may be associated with PD risk, but has not been previously investigated. METHODS We reviewed patients with initially non-metastatic GBC treated at our institution from 2003 to 2018. Patients were grouped based on degree of BTV during their treatment: major (e.g., cholecystotomy with bile spillage, n = 27, 29%), minor (e.g., intra-operative cholangiogram, n = 18, 19%), and no violations (n = 48, 55%). Overall survival (OS) and peritoneal disease-free survival (PDFS) were evaluated with Kaplan-Meier and Cox proportional hazards modeling. RESULTS Ninety-three patients were identified; the median age was 64 years (range 31-87 years). Seventy-six (82%) were incidentally diagnosed. The median follow-up was 23 months; 20 (22%) patients developed PD. The 3-year PDFS for patients with major, minor, and no BTV was 52%, 83%, and 98%, respectively (major vs. none: p < 0.001; minor vs. none: p < 0.01). BTV was not associated with 5-year OS (HR 1.53, p = 0.16). CONCLUSION Increasing degree of BTV is associated with higher risk of peritoneal carcinomatosis in patients with GBC and should be considered during preoperative risk stratification. Reporting biliary tract violations during cholecystectomy is encouraged.
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Affiliation(s)
- Thomas L Sutton
- Department of Surgery, Oregon Health & Science University (OHSU), Division of General Surgery, Portland, Oregon, USA
| | - Brett S Walker
- Department of Surgery, Oregon Health & Science University (OHSU), Division of General Surgery, Portland, Oregon, USA
| | | | - Elizabeth N Dewey
- Department of Surgery, Oregon Health & Science University (OHSU), Division of General Surgery, Portland, Oregon, USA
| | - C Kristian Enestvedt
- OHSU Department of Surgery, Division of Abdominal Transplant Surgery, Portland, Oregon, USA
| | - Erin Maynard
- OHSU Department of Surgery, Division of Abdominal Transplant Surgery, Portland, Oregon, USA
| | - Susan L Orloff
- OHSU Department of Surgery, Division of Abdominal Transplant Surgery, Portland, Oregon, USA
| | | | - Brett C Sheppard
- Department of Surgery, Oregon Health & Science University (OHSU), Division of General Surgery, Portland, Oregon, USA
| | - Charles D Lopez
- OHSU Department of Medicine, Division of Hematology/Oncology, Portland, Oregon, USA.,The Knight Cancer Institute at OHSU, Portland, Oregon, USA
| | | | - Skye C Mayo
- The Knight Cancer Institute at OHSU, Portland, Oregon, USA.,OHSU Department of Surgery, Division of Surgical Oncology, Portland, Oregon, USA
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7
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Sutton TL, Billingsley KG, Walker BS, Enestvedt CK, Dewey EN, Orloff SL, Mayo SC. Neoadjuvant chemotherapy is associated with improved survival in patients undergoing hepatic resection for intrahepatic cholangiocarcinoma. Am J Surg 2021; 221:1182-1187. [PMID: 33707077 DOI: 10.1016/j.amjsurg.2021.02.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 01/19/2021] [Accepted: 02/25/2021] [Indexed: 01/25/2023]
Abstract
BACKGROUND The impact of neoadjuvant chemotherapy (NAC) on overall and recurrence-free survival (OS, RFS) in resectable intrahepatic cholangiocarcinoma (ICC) is poorly characterized. We sought to investigate the association of NAC with oncologic outcomes in ICC. METHODS We identified n = 52 patients with ICC undergoing hepatectomy from 2004 to 2017. Oncologic outcomes were analyzed using Kaplan-Meier and multivariate Cox proportional hazard modeling. RESULTS The median patient age was 64-years. NAC was administered in ten (19%) patients, most commonly with gemcitabine-cisplatin (n = 8, 80%). Median RFS and OS were 15 months. and 49 months, respectively. Controlling for stage and margins, NAC was independently associated with improved OS (HR 0.16, P = 0.01) but not RFS (HR 0.54, P = 0.27). NAC was not associated with major post-operative complications (P = 0.25) or R1 margins (P = 0.58). CONCLUSION NAC in ICC may hold oncologic benefits beyond downstaging borderline resectable disease, such as identifying patients with favorable biology who are more likely to benefit from resection.
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Affiliation(s)
- Thomas L Sutton
- Oregon Heath & Science University (OHSU), Department of Surgery, Portland, OR, 97239, USA
| | | | - Brett S Walker
- Oregon Heath & Science University (OHSU), Department of Surgery, Portland, OR, 97239, USA
| | - C Kristian Enestvedt
- OHSU, Department of Surgery, Division of Abdominal Transplant, Portland, OR, 97239, USA
| | - Elizabeth N Dewey
- Oregon Heath & Science University (OHSU), Department of Surgery, Portland, OR, 97239, USA
| | - Susan L Orloff
- OHSU, Department of Surgery, Division of Abdominal Transplant, Portland, OR, 97239, USA
| | - Skye C Mayo
- The Knight Cancer Institute at OHSU, Portland, OR, 97239, USA; OHSU, Department of Surgery, Division of Surgical Oncology, Portland, OR, 97239, USA.
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8
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Gatault P, Jones IKA, Meyer C, Kreklywich C, Alexander T, Smith PP, Denton M, Powell J, Orloff SL, Streblow DN. Rat and human cytomegalovirus ORF116 encodes a virion envelope glycoprotein required for infectivity. Virology 2021; 557:23-33. [PMID: 33601113 DOI: 10.1016/j.virol.2020.12.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 12/22/2020] [Accepted: 12/23/2020] [Indexed: 11/17/2022]
Abstract
Herpesviruses encode multiple glycoproteins required for different stages of viral attachment, fusion, and envelopment. The protein encoded by the human cytomegalovirus (HCMV) open reading frame UL116 forms a stable complex with glycoprotein H that is incorporated into virions. However, the function of this complex remains unknown. Herein, we characterize R116, the rat CMV (RCMV) putative homolog of UL116. Two R116 transcripts were identified in fibroblasts with three proteins expressed with molecular weights of 42, 58, and 82 kDa. R116 is N-glycosylated, expressed with late viral gene kinetics, and is incorporated into the virion envelope. RCMV lacking R116 failed to result in productive infection of fibroblasts and siRNA knockdown of R116 substantially reduced RCMV infectivity. Complementation in trans of an R116-deficient virus restored ability of the virus to infect fibroblasts. Finally, UL116 knockdown also decreased HCMV infectivity indicating that R116 and UL116 both contribute to viral infectivity.
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Affiliation(s)
- Philippe Gatault
- Renal Transplant Unit, 10 Boulevard Tonnellé, University Hospital of Tours, France
| | - Iris K A Jones
- Vaccine & Gene Therapy Institute, Oregon Health & Science University, Portland, OR, 97239, USA
| | - Christine Meyer
- Vaccine & Gene Therapy Institute, Oregon Health & Science University, Portland, OR, 97239, USA
| | - Craig Kreklywich
- Vaccine & Gene Therapy Institute, Oregon Health & Science University, Portland, OR, 97239, USA
| | - Timothy Alexander
- Vaccine & Gene Therapy Institute, Oregon Health & Science University, Portland, OR, 97239, USA
| | - Patricia P Smith
- Vaccine & Gene Therapy Institute, Oregon Health & Science University, Portland, OR, 97239, USA
| | - Michael Denton
- Vaccine & Gene Therapy Institute, Oregon Health & Science University, Portland, OR, 97239, USA
| | - Josh Powell
- Vaccine & Gene Therapy Institute, Oregon Health & Science University, Portland, OR, 97239, USA
| | - Susan L Orloff
- Department of Surgery, Oregon Health & Science University, Portland, OR, 97239, USA
| | - Daniel N Streblow
- Vaccine & Gene Therapy Institute, Oregon Health & Science University, Portland, OR, 97239, USA.
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9
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Haese NN, Burg JM, Andoh TF, Jones IKA, Kreklywich CN, Smith PP, Orloff SL, Streblow DN. Macrophage depletion of CMV latently infected donor hearts ameliorates recipient accelerated chronic rejection. Transpl Infect Dis 2020; 23:e13514. [PMID: 33205500 DOI: 10.1111/tid.13514] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/01/2020] [Accepted: 11/08/2020] [Indexed: 12/21/2022]
Abstract
Cytomegalovirus (CMV) infection is linked to acceleration of solid organ transplant vascular sclerosis (TVS) and chronic rejection (CR). Donor latent CMV infection increases cardiac-resident macrophages and T cells leading to increased inflammation, promoting allograft rejection. To investigate the role of cardiac-resident passenger macrophages in CMV-mediated TVS/CR, macrophages were depleted from latently ratCMV (RCMV)-infected donor allografts prior to transplantation. Latently RCMV-infected donor F344 rats were treated with clodronate, PBS, or control liposomes 3 days prior to cardiac transplant into RCMV-naïve Lewis recipients. Clodronate treatment significantly increased graft survival from post-operative day (POD)61 to POD84 and decreased TVS at rejection. To determine the kinetics of the effect of clodronate treatment's effect, a time study revealed that clodronate treatment significantly decreased macrophage infiltration into allograft tissues as early as POD14; altered allograft cytokine/chemokine protein levels, fibrosis development, and inflammatory gene expression profiles. These findings support our hypothesis that increased graft survival as a result of allograft passenger macrophage depletion was in part a result of altered immune response kinetics. Depletion of donor macrophages prior to transplant is a strategy to modulate allograft rejection and reduce TVS in the setting of CMV + donors transplanted into CMV naïve recipients.
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Affiliation(s)
- Nicole N Haese
- Vaccine and Gene Therapy Institute, Oregon Health Sciences University, Beaverton, OR, USA
| | - Jennifer M Burg
- Department of Surgery, Oregon Health Sciences University, Portland, OR, USA
| | - Takeshi F Andoh
- Vaccine and Gene Therapy Institute, Oregon Health Sciences University, Beaverton, OR, USA
| | - Iris K A Jones
- Vaccine and Gene Therapy Institute, Oregon Health Sciences University, Beaverton, OR, USA
| | - Craig N Kreklywich
- Vaccine and Gene Therapy Institute, Oregon Health Sciences University, Beaverton, OR, USA
| | - Patricia P Smith
- Vaccine and Gene Therapy Institute, Oregon Health Sciences University, Beaverton, OR, USA
| | - Susan L Orloff
- Department of Surgery, Oregon Health Sciences University, Portland, OR, USA.,Department of Molecular Microbiology & Immunology, Oregon Health Sciences University, Portland, OR, USA
| | - Daniel N Streblow
- Vaccine and Gene Therapy Institute, Oregon Health Sciences University, Beaverton, OR, USA
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10
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Jones IKA, Haese NN, Gatault P, Streblow ZJ, Andoh TF, Denton M, Streblow CE, Bonin K, Kreklywich CN, Burg JM, Orloff SL, Streblow DN. Rat Cytomegalovirus Virion-Associated Proteins R131 and R129 Are Necessary for Infection of Macrophages and Dendritic Cells. Pathogens 2020; 9:E963. [PMID: 33228102 PMCID: PMC7699341 DOI: 10.3390/pathogens9110963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/05/2020] [Accepted: 11/17/2020] [Indexed: 12/15/2022] Open
Abstract
Cytomegalovirus (CMV) establishes persistent, latent infection in hosts, causing diseases in immunocompromised patients, transplant recipients, and neonates. CMV infection modifies the host chemokine axis by modulating chemokine and chemokine receptor expression and by encoding putative chemokine and chemokine receptor homologues. The viral proteins have roles in cellular signaling, migration, and transformation, as well as viral dissemination, tropism, latency and reactivation. Herein, we review the contribution of CMV-encoded chemokines and chemokine receptors to these processes, and further elucidate the viral tropism role of rat CMV (RCMV) R129 and R131. These homologues of the human CMV (HCMV)-encoded chemokines UL128 and UL130 are of particular interest because of their dual role as chemokines and members of the pentameric entry complex, which is required for entry into cell types that are essential for viral transmission and dissemination. The contributions of UL128 and UL130 to acceleration of solid organ transplant chronic rejection are poorly understood, and are in need of an effective in vivo model system to elucidate the phenomenon. We demonstrated similar molecular entry requirements for R129 and R131 in the rat cells, as observed for HCMV, and provided evidence that R129 and R131 are part of the viral entry complex required for entry into macrophages, dendritic cells, and bone marrow cells.
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Affiliation(s)
- Iris K. A. Jones
- Vaccine & Gene Therapy Institute, Oregon Health & Science University, Portland, OR 97239, USA; (I.K.A.J.); (N.N.H.); (Z.J.S.); (T.F.A.); (M.D.); (C.E.S.); (K.B.); (C.N.K.)
| | - Nicole N. Haese
- Vaccine & Gene Therapy Institute, Oregon Health & Science University, Portland, OR 97239, USA; (I.K.A.J.); (N.N.H.); (Z.J.S.); (T.F.A.); (M.D.); (C.E.S.); (K.B.); (C.N.K.)
| | - Philippe Gatault
- Renal Transplant Unit, 10 Boulevard Tonnellé, University Hospital of Tours, 37032 Tours, France;
| | - Zachary J. Streblow
- Vaccine & Gene Therapy Institute, Oregon Health & Science University, Portland, OR 97239, USA; (I.K.A.J.); (N.N.H.); (Z.J.S.); (T.F.A.); (M.D.); (C.E.S.); (K.B.); (C.N.K.)
| | - Takeshi F. Andoh
- Vaccine & Gene Therapy Institute, Oregon Health & Science University, Portland, OR 97239, USA; (I.K.A.J.); (N.N.H.); (Z.J.S.); (T.F.A.); (M.D.); (C.E.S.); (K.B.); (C.N.K.)
- Department of Surgery, Oregon Health & Science University, Portland, OR 97239, USA; (J.M.B.); (S.L.O.)
| | - Michael Denton
- Vaccine & Gene Therapy Institute, Oregon Health & Science University, Portland, OR 97239, USA; (I.K.A.J.); (N.N.H.); (Z.J.S.); (T.F.A.); (M.D.); (C.E.S.); (K.B.); (C.N.K.)
| | - Cassilyn E. Streblow
- Vaccine & Gene Therapy Institute, Oregon Health & Science University, Portland, OR 97239, USA; (I.K.A.J.); (N.N.H.); (Z.J.S.); (T.F.A.); (M.D.); (C.E.S.); (K.B.); (C.N.K.)
| | - Kiley Bonin
- Vaccine & Gene Therapy Institute, Oregon Health & Science University, Portland, OR 97239, USA; (I.K.A.J.); (N.N.H.); (Z.J.S.); (T.F.A.); (M.D.); (C.E.S.); (K.B.); (C.N.K.)
| | - Craig N. Kreklywich
- Vaccine & Gene Therapy Institute, Oregon Health & Science University, Portland, OR 97239, USA; (I.K.A.J.); (N.N.H.); (Z.J.S.); (T.F.A.); (M.D.); (C.E.S.); (K.B.); (C.N.K.)
| | - Jennifer M. Burg
- Department of Surgery, Oregon Health & Science University, Portland, OR 97239, USA; (J.M.B.); (S.L.O.)
| | - Susan L. Orloff
- Department of Surgery, Oregon Health & Science University, Portland, OR 97239, USA; (J.M.B.); (S.L.O.)
- Department of Molecular Microbiology & Immunology, Oregon Health & Science University, Portland, OR 97239, USA
| | - Daniel N. Streblow
- Vaccine & Gene Therapy Institute, Oregon Health & Science University, Portland, OR 97239, USA; (I.K.A.J.); (N.N.H.); (Z.J.S.); (T.F.A.); (M.D.); (C.E.S.); (K.B.); (C.N.K.)
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11
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Naugler WE, Orloff SL. Sex Does Matter in Liver Allocation-Time to Address Existing Sex-Based Disparities. JAMA Surg 2020; 155:e201130. [PMID: 32432662 DOI: 10.1001/jamasurg.2020.1130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Willscott E Naugler
- Division of Gastrointestinal and Hepatology, Department of Medicine, Oregon Health and Science University, Portland
| | - Susan L Orloff
- Division of Abdominal Organ Transplant, Department of Surgery, Oregon Health and Science University, Portland.,Department of Molecular Microbiology and Immunology, Oregon Health & Science University, Portland
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12
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Zu Q, Schenning RC, Jahangiri Y, Tomozawa Y, Kolbeck KJ, Kaufman JA, Al-Hakim R, Naugler WE, Nabavizadeh N, Kardosh A, Billingsley KG, Mayo SC, Orloff SL, Enestvedt CK, Maynard E, Ahn J, Lhewa D, Farsad K. Correction to: Yttrium-90 Radioembolization for BCLC Stage C Hepatocellular Carcinoma Comparing Child-Pugh A Versus B7 Patients: Are the Outcomes Equivalent? Cardiovasc Intervent Radiol 2020; 43:1425-1426. [PMID: 32548673 DOI: 10.1007/s00270-020-02554-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The name of one of the co-authors was slightly misspelled. Kristian Enestvedt is listed currently as "Kristian K. Enestvedt" and should be listed instead as "C. Kristian Enestvedt."
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Affiliation(s)
- Qingquan Zu
- Dotter Department of Interventional Radiology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L-605, Portland, OR, 97239, USA.,Department of Interventional Radiology, The First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), Nanjing, China
| | - Ryan C Schenning
- Dotter Department of Interventional Radiology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L-605, Portland, OR, 97239, USA
| | - Younes Jahangiri
- Dotter Department of Interventional Radiology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L-605, Portland, OR, 97239, USA
| | - Yuki Tomozawa
- Dotter Department of Interventional Radiology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L-605, Portland, OR, 97239, USA
| | - Kenneth J Kolbeck
- Dotter Department of Interventional Radiology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L-605, Portland, OR, 97239, USA
| | - John A Kaufman
- Dotter Department of Interventional Radiology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L-605, Portland, OR, 97239, USA
| | - Ramsey Al-Hakim
- Dotter Department of Interventional Radiology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L-605, Portland, OR, 97239, USA
| | - Willscott E Naugler
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L-605, Portland, OR, 97239, USA
| | - Nima Nabavizadeh
- Radiation Oncology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L-605, Portland, OR, 97239, USA
| | - Adel Kardosh
- Medical Oncology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L-605, Portland, OR, 97239, USA
| | - Kevin G Billingsley
- Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L-605, Portland, OR, 97239, USA
| | - Skye C Mayo
- Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L-605, Portland, OR, 97239, USA
| | - Susan L Orloff
- Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L-605, Portland, OR, 97239, USA
| | - C Kristian Enestvedt
- Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L-605, Portland, OR, 97239, USA
| | - Erin Maynard
- Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L-605, Portland, OR, 97239, USA
| | - Joseph Ahn
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L-605, Portland, OR, 97239, USA
| | - Dekey Lhewa
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L-605, Portland, OR, 97239, USA
| | - Khashayar Farsad
- Dotter Department of Interventional Radiology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L-605, Portland, OR, 97239, USA.
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13
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Zarour LR, Billingsley KG, Walker BS, Enestvedt CK, Orloff SL, Maynard E, Mayo SC. Hepatic resection of solitary HCC in the elderly: A unique disease in a growing population. Am J Surg 2019; 217:899-905. [PMID: 30819401 DOI: 10.1016/j.amjsurg.2019.01.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 12/11/2018] [Accepted: 01/14/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Management of elderly patients with solitary hepatocellular carcinoma (sHCC) is challenging with perceived clinicopathologic differences driving treatment options. We sought to determine factors predictive of disease control and survival after hepatic resection of sHCC in elderly patients. METHODS We identified n = 45 elderly patients (³≥65 yo) with sHCC treated with hepatic resection alone from our prospective database from 2003-16. Clinicopathologic data were analyzed and survival was assessed from the time of hepatic resection. RESULTS The median age was 75-years-old. Less than half of patients (47%) had viral hepatitis. At resection, the median Child-Pugh score was A6, median tumor size 5 cm, and mean AFP of 1050 (ng/mL). Major hepatectomy was performed in 23 patients (51%) with R0 resection achieved in 96%. Two patients (4%) had Grade III complications with no mortalities at 30 days and one death (2%) at 90-days. After R0 resection 44% (n = 20) had intrahepatic recurrence at a median of 32 months (95% CI: 15-46) with 20% (n = 9) developing extrahepatic recurrence at a median of 78 months (95% CI: 78-.). The median survival was 72 months (95% CI: 30-108 months). For patients with at least 3 years of follow-up, the 1-, 3-, and 5-year overall survival was 74%, 59%, and 50%, respectively. Mortality was associated with higher AFP and lower Prognostic Nutritional Index (PNI). CONCLUSION Carefully selected elderly patients with sHCC appear to have unique disease that is amenable to hepatic resection with low morbidity and mortality with excellent overall and recurrence-free survival.
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Affiliation(s)
- Luai R Zarour
- Oregon Heath & Science University (OHSU), Department of Surgery, Division of Surgical Oncology, Portland, OR, 97239, USA
| | - Kevin G Billingsley
- Oregon Heath & Science University (OHSU), Department of Surgery, Division of Surgical Oncology, Portland, OR, 97239, USA; The Knight Cancer Institute at OHSU, Portland, OR, 97239, USA
| | - Brett S Walker
- Oregon Heath & Science University (OHSU), Department of Surgery, Division of Surgical Oncology, Portland, OR, 97239, USA
| | - C Kristian Enestvedt
- OHSU, Department of Surgery, Division of Transplant Surgery, Portland, OR, 97239, USA
| | - Susan L Orloff
- OHSU, Department of Surgery, Division of Transplant Surgery, Portland, OR, 97239, USA
| | - Erin Maynard
- OHSU, Department of Surgery, Division of Transplant Surgery, Portland, OR, 97239, USA
| | - Skye C Mayo
- Oregon Heath & Science University (OHSU), Department of Surgery, Division of Surgical Oncology, Portland, OR, 97239, USA; The Knight Cancer Institute at OHSU, Portland, OR, 97239, USA.
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14
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Walcott-Sapp S, Naugler S, Lim JY, Wagner J, Orloff SL, Farsad K, Kolbeck KJ, Kaufman J, Maynard E, Enestvedt CK, Mayo SC, Billingsley KG. Tailored treatment of patients with hepatocellular carcinoma with portal vein invasion: experience from a multidisciplinary hepatobiliary tumor program within a NCI comprehensive cancer center. J Gastrointest Oncol 2018; 9:1074-1083. [PMID: 30603126 DOI: 10.21037/jgo.2018.08.11] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background Hepatocellular carcinoma (HCC) with portal vein invasion (PVI) has a poor prognosis with limited treatment options. Intra-arterial brachytherapy (IAB) and transarterial chemoembolization (TACE) yield local control but risk accelerating liver dysfunction. The outcomes, survival, and safety of selective liver-directed treatment are reported. Methods Thirty-seven consecutive patients with HCC and PVI treated between 2009 and 2015 were reviewed from a prospectively collected database. Univariate analysis, Kaplan-Meier plots using the log-rank method, and multivariate analyses were performed. Statistical significance was defined as P<0.05. Overall survival was reported in months (median; 95% CI). Results Most patients (59%) had PVI identified at initial HCC diagnosis. The liver-directed therapy group (n=22) demonstrated a survival advantage versus the systemic/supportive care group (n=14) [23.6 (5.8, 30.9) vs. 6.0 (3.5, 8.8) months]. Patients indicated for liver directed therapy had unilateral liver involvement (100% vs. 43%, P<0.0001), lower median alkaline phosphatase (105.5 vs. 208.0, P=0.002), and lower mean Child-Turcotte-Pugh (CTP) score (5.9 vs. 7.2, P=0.04) and tolerated treatment without serious complications. Conclusions In HCC patients presenting with PVI, liver-directed therapy was safely performed in patients with limited venous involvement and preserved liver function. Liver-directed therapy extended survival for these patients indicated for palliative chemotherapy by traditional guidelines.
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Affiliation(s)
- Sarah Walcott-Sapp
- Division of Surgical Oncology, Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Scott Naugler
- Division of Gastroenterology, Department of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Jeong Youn Lim
- Division of Biostatistics, Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA
| | - Jesse Wagner
- Division of Surgical Oncology, Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Susan L Orloff
- Abdominal Transplant Division, Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Khashayar Farsad
- Charles T. Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, OR, USA
| | - Kenneth J Kolbeck
- Charles T. Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, OR, USA
| | - John Kaufman
- Charles T. Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, OR, USA
| | - Erin Maynard
- Abdominal Transplant Division, Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - C Kristian Enestvedt
- Abdominal Transplant Division, Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Skye C Mayo
- Division of Surgical Oncology, Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Kevin G Billingsley
- Division of Surgical Oncology, Department of Surgery, Oregon Health and Science University, Portland, OR, USA
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15
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Affiliation(s)
- Willscott E Naugler
- Liver Transplantation and the Multidisciplinary Liver Tumor Group, Department of Medicine/GI and Hepatology, Oregon Health and Sciences University, Portland, OR
| | - Susan L Orloff
- Division of Abdominal Organ Transplantation/Hepatobiliary Surgery, Department of Surgery, Oregon Health and Sciences University, Portland, OR
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16
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Krishnaswami S, Stephens CQ, Yang GP, Nwomeh BC, Swaroop M, Nadler EP, Holterman AX, Simeone DM, Kingham TP, Merchant N, Orloff SL. An academic career in global surgery: a position paper from the Society of University Surgeons Committee on Academic Global Surgery. Surgery 2017; 163:954-960. [PMID: 29254606 DOI: 10.1016/j.surg.2017.10.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 10/02/2017] [Accepted: 10/14/2017] [Indexed: 02/07/2023]
Abstract
In recent years, as the high burden of surgical disease and poor access to surgical care in low- and middle-income countries have gained recognition as major public health problems, interest in global health has surged among surgical trainees and faculty. Traditionally, clinical volunteerism was at the forefront of the high-income country response to the significant burden of surgical disease in low- and middle-income countries. However, sustainable strategies for providing surgical care in low- and middle-income countries increasingly depend on bilateral clinical, research, and education collaborations to ensure effective resource allocation and contextual relevance. Academic global surgery creates avenues for interested surgeons to combine scholarship and education with their clinical global surgery passions through incorporation of basic/translational, education, clinical outcomes, or health services research with global surgery. Training in global health, either within residency or through advanced degrees, can provide the necessary skills to develop and sustain such initiatives. We further propose that creating cross-continental, bidirectional collaborations can maximize funding opportunities. Academic institutions are uniquely positioned to lead longitudinal and, importantly, sustainable global surgery efforts. However, for the individual global surgeon, the career path forward may be unclear. This paper reviews the development of academic global surgery, delineates the framework and factors critical to training global surgeons, and proposes models for establishing an academic career in this field. Overall, with determination, the academic global surgeon will not only carve out a niche of expertise but will define this critical field for future generations.
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Affiliation(s)
- Sanjay Krishnaswami
- Department of Surgery, Division of Pediatric Surgery, Oregon Health & Science University, Portland, OR, USA.
| | - Caroline Q Stephens
- Department of Surgery, Division of Pediatric Surgery, Oregon Health & Science University, Portland, OR, USA
| | - George P Yang
- Department of Surgery, Stanford University, Stanford, CA, USA; Palo Alto VA Health Care System, Palo Alto, CA, USA
| | - Benedict C Nwomeh
- Department of Pediatric Surgery, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Mamta Swaroop
- Division of Trauma & Critical Care, Department of Surgery, Northwestern University, Chicago, IL, USA
| | - Evan P Nadler
- Department of Surgery, Division of Pediatric Surgery, Children's National Medical Center, Washington, DC, WA, USA
| | - Ai-Xuan Holterman
- Department of Surgery/Pediatric Surgery, Children's Hospital of Illinois, University of Illinois College of Medicine at Peoria, IL, USA
| | - Diane M Simeone
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - T Peter Kingham
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Nipun Merchant
- Department of Surgery, Division of Surgical Oncology, University of Miami, Miami, FL, USA
| | - Susan L Orloff
- Department of Surgery, Division of Abdominal Organ Transplantation/Hepatobiliary Surgery, Oregon Health & Science University, Portland, OR, USA
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17
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Wong LL, Lacar L, Roytman M, Orloff SL. Urgent Liver Transplantation for Dietary Supplements: An Under-Recognized Problem. Transplant Proc 2017; 49:322-325. [PMID: 28219592 DOI: 10.1016/j.transproceed.2016.11.041] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Accepted: 11/16/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND The recent outbreak of acute liver failure caused by herbal/dietary supplements (HDS) in Hawaii prompted evaluation of those patients who underwent emergency liver transplantation (LT) for HDS in the United States. METHODS We queried the Scientific Registry of Transplant Recipients (2003-2015) to identify patients who underwent urgent LT for acute hepatic necrosis (AHN) and identified those with HDS use. This group of patients was then characterized. RESULTS Of 2408 adult cases, 625 were characterized as a drug-induced liver injury. The majority of cases (n = 300) were due to acetaminophen toxicity, but the fourth highest category was due to HDS (n = 21). Of these 21 cases caused by HDS, 13 did not list the specific agent responsible, mean age was 36 years, and all cases occurred after 2007. There probably are more cases because 25% of all LT cases in the study did not list a specific reason for liver failure and 20% of all drug-induced liver failure did not list a specific drug. CONCLUSIONS Herbal/supplement use is the fourth most common cause of drug-induced AHN requiring LT, albeit an underestimation of the problem. Detailed questioning of patients and their support systems regarding herbal/supplement use and better reporting are imperative to further define this problem and identify products that have the potential to lead to liver failure.
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Affiliation(s)
- L L Wong
- Department of Surgery, University of Hawaii, John A. Burns School of Medicine, Honolulu, Hawaii.
| | - L Lacar
- University of Hawaii, Honolulu, Hawaii
| | - M Roytman
- Liver Center, Queens Medical Center, Honolulu, Hawaii
| | - S L Orloff
- Division of Abdominal Organ Transplantation/Hepatobiliary Surgery, Oregon Health and Sciences University, Portland VA Medical Center, Portland, Oregon
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18
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Affiliation(s)
- Barry Schlansky
- Division of Gastroenterology and Hepatology, Department of Medicine, Oregon Health & Science University, Portland
| | - Susan L Orloff
- Division of Abdominal Organ Transplantation/Hepatobiliary Surgery, Department of Surgery, Oregon Health & Science University, Portland3Portland Veterans Administration Medical Center Transplant Program, Portland, Oregon
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19
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O'Leary JG, Orloff SL, Levitsky J, Martin P, Foley DP. Keeping high model for end-stage liver disease score liver transplantation candidates alive. Liver Transpl 2015; 21:1428-37. [PMID: 26335696 DOI: 10.1002/lt.24329] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Revised: 07/14/2015] [Accepted: 08/11/2015] [Indexed: 02/07/2023]
Abstract
As the mean Model for End-Stage Liver Disease (MELD) score at time of liver transplantation continues to increase, it is crucial to implement preemptive strategies to reduce wait-list mortality. We review the most common complications that arise in patients with a high MELD score in an effort to highlight strategies that can maximize survival and successful transplantation.
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Affiliation(s)
- Jacqueline G O'Leary
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX.,Liver Intestine Community of Practice, American Society of Transplantation, Mount Laurel, NJ
| | - Susan L Orloff
- Liver Intestine Community of Practice, American Society of Transplantation, Mount Laurel, NJ.,Department of Surgery, Oregon Health and Sciences University, Portland, OR
| | - Josh Levitsky
- Liver Intestine Community of Practice, American Society of Transplantation, Mount Laurel, NJ.,Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Paul Martin
- Liver Intestine Community of Practice, American Society of Transplantation, Mount Laurel, NJ.,Department of Medicine, University of Miami School of Medicine, Miami, FL
| | - David P Foley
- Liver Intestine Community of Practice, American Society of Transplantation, Mount Laurel, NJ.,Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI.,Veterans Administration Surgical Services, William S. Middleton Memorial Hospital, Madison, WI
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20
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Affiliation(s)
- Jennifer Tseng
- Department of General Surgery, Oregon Health and Science University, Portland
| | - Susan L Orloff
- Division of Abdominal Organ Transplantation/Hepatobiliary Surgery, Oregon Health and Science University, Portland
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21
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Louis SG, Barton JS, Riha GM, Orloff SL, Sheppard BC, Pommier RF, Underwood SJ, Differding JA, Schreiber MA, Billingsley KG. The international normalized ratio overestimates coagulopathy in patients after major hepatectomy. Am J Surg 2014; 207:723-7; discussion 727. [DOI: 10.1016/j.amjsurg.2013.12.021] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Revised: 12/17/2013] [Accepted: 12/21/2013] [Indexed: 12/21/2022]
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22
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Gur I, Diggs BS, Orloff SL. Surgical portosystemic shunts in the era of TIPS and liver transplantation are still relevant. HPB (Oxford) 2014; 16:481-93. [PMID: 23961811 PMCID: PMC4008167 DOI: 10.1111/hpb.12163] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Accepted: 06/10/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND The surgical portosystemic shunts (PSS) are a time-proven modality for treating portal hypertension. Recently, in the era of liver transplantation and the transjugular intrahepatic portosystemic shunts (TIPS), use of the PSS has declined. OBJECTIVES This study was conducted to evaluate changes in practice, referral patterns, and short- and longterm outcomes of the use of the surgical PSS before and after the introduction of the Model for End-stage Liver Disease (MELD). METHODS A retrospective analysis of 47 patients undergoing PSS between 1996 and 2011 in a single university hospital was conducted. RESULTS Subgroups of patients with cirrhosis (53%), Budd-Chiari syndrome (13%), portal vein thrombosis (PVT) (26%), and other pathologies (9%) differed significantly with respect to shunt type, Child-Pugh class, MELD score and perioperative mortality. Perioperative mortality at 60 days was 15%. Five-year survival was 68% (median: 70 months); 5-year shunt patency was 97%. Survival was best in patients with PVT and worst in those with Budd-Chiari syndrome compared to other subgroups. Patency was better in the subgroups of patients with cirrhosis and other pathologies compared with the PVT subgroup. Substantial changes in referral patterns coincided with the adoption of the MELD in 2002, with decreases in the incidence of cirrhosis and variceal bleeding, and increases in non-cirrhotics and hypercoagulopathy. CONCLUSIONS Although the spectrum of diseases benefiting from surgical PSS has changed, surgical shunts continue to constitute an important addition to the surgical armamentarium. Selected subgroups with variceal bleeding in well-compensated cirrhosis and PVT benefit from the excellent longterm patency offered by the surgical PSS.
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Affiliation(s)
- Ilia Gur
- Division of Surgical Oncology, Oregon Health and Science UniversityPortland, OR, USA,Correspondence Ilia Gur, General Surgery, Sutter Gould Medical Foundation, 2545 W. Hammer Lane, STE 2200, Stockton, CA, 95209 USA. Tel: +209 941 0127. Fax: + 209 951 2438.
| | - Brian S Diggs
- Division of General Surgery, Oregon Health and Science UniversityPortland, OR, USA
| | - Susan L Orloff
- Division of Abdominal Organ Transplant, Oregon Health and Science UniversityPortland, OR, USA
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Naugler WE, Schlansky B, Orloff SL. Who should undergo liver transplantation for hepatocellular carcinoma? Ablate, wait … and see! Hepat Oncol 2014; 1:165-168. [PMID: 30190949 PMCID: PMC6095151 DOI: 10.2217/hep.14.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Willscott E Naugler
- Division of Gastroenterology & Hepatology, Oregon Health & Science University, Portland, OR 97239, USA
| | - Barry Schlansky
- Division of Gastroenterology & Hepatology, Oregon Health & Science University, Portland, OR 97239, USA
| | - Susan L Orloff
- Division of Abdominal Organ Transplantation, Oregon Health & Science University, Portland, OR 97239, USA
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Kreklywich CN, Smith PP, Jones CB, Cornea A, Orloff SL, Streblow DN. Fluorescence-based laser capture microscopy technology facilitates identification of critical in vivo cytomegalovirus transcriptional programs. Methods Mol Biol 2014; 1119:217-37. [PMID: 24639226 PMCID: PMC4347879 DOI: 10.1007/978-1-62703-788-4_13] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Cytomegalovirus gene expression in highly permissive, cultured fibroblasts occurs in three kinetic classes known as immediate early, early, and late. Infection of these cells results in a predictable transcriptional program leading to high levels of virus production. Infection of other, so-called, nonpermissive cell types results in a transcriptional program that either fails to produce virus particles or production is substantially reduced compared to fibroblasts. We have found that CMV gene expression profiles in tissues from infected hosts differ greatly from those observed in infected tissue culture cells. The number of viral genes expressed in tissues is much more limited, and the number of highly active genes does not correlate with viral DNA load. Additionally, viral gene expression in vivo is tissue selective with no two tissues expressing the exact same viral gene profile. Thus, in vivo CMV gene expression appears to be governed by mechanisms that are still uncharacterized. Cytomegalovirus remains in a persistent phase for the lifetime of the host. During this phase only a limited number of host cells are infected, and it is very difficult to detect CMV gene expression in whole tissues without sub-fractionating infected vs. uninfected cells. Herein, we describe the development of a fluorescence-based laser capture microscopy technique coupled with small sample size microarray analysis to determine the viral gene expression in 50-100 infected cells isolated from frozen RCMV-infected tissue sections.
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Affiliation(s)
- Craig N. Kreklywich
- Department of Molecular Microbiology & Immunology and The Vaccine & Gene Therapy Institute, Oregon Health & Science University, Portland OR 97239
- Department of Surgery, Oregon Health & Science University, Portland OR 97239
- Portland VA Medical Center, Portland OR 97239
| | - Patricia P. Smith
- Department of Molecular Microbiology & Immunology and The Vaccine & Gene Therapy Institute, Oregon Health & Science University, Portland OR 97239
| | - Carmen Baca Jones
- Department of Molecular Microbiology & Immunology and The Vaccine & Gene Therapy Institute, Oregon Health & Science University, Portland OR 97239
| | - Anda Cornea
- Oregon National Primate Research Center, Oregon Health & Science University, Beaverton, OR 97006
| | - Susan L. Orloff
- Department of Molecular Microbiology & Immunology and The Vaccine & Gene Therapy Institute, Oregon Health & Science University, Portland OR 97239
- Department of Surgery, Oregon Health & Science University, Portland OR 97239
- Portland VA Medical Center, Portland OR 97239
| | - Daniel N. Streblow
- Department of Molecular Microbiology & Immunology and The Vaccine & Gene Therapy Institute, Oregon Health & Science University, Portland OR 97239
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25
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Gur I, Diggs BS, Wagner JA, Vaccaro GM, Lopez CD, Sheppard BC, Orloff SL, Billingsley KG. Safety and outcomes following resection of colorectal liver metastases in the era of current perioperative chemotherapy. J Gastrointest Surg 2013; 17:2133-42. [PMID: 24091909 DOI: 10.1007/s11605-013-2295-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 07/16/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Preoperative chemotherapy is increasingly utilized in the treatment of colorectal liver metastases (CRLM). Although this strategy may improve resectability, long-term advantages of preoperative chemotherapy for resectable CRLM are less clear. The objective of this study is to report safety and outcomes when perioperative chemotherapy is routinely added to surgery for CRLM. METHODS A retrospective review of patients undergoing liver resections for CRLM during 2003-2011 in single academic oncology center. Demographic data, tumor characteristics, chemotherapy, surgical details, complications and survival were analyzed. RESULTS The study included 157 patients that underwent 168 liver operations. One hundred eighteen patients (70 %) underwent preoperative chemotherapy (75 % oxaliplatin-based). Preoperative portal vein embolization was utilized in 16 (10.1 %) patients. Overall survival (OS) was 89, 57, and 27 % at 1, 3, and 5 years, respectively (median survival-42.8 months). Eleven (7 %) patients had repeat resections for liver recurrence. Thirty-day mortality was 1.26 %, morbidity-24 % (6 %-liver related). Complications were not significantly different in patients that had preoperative chemotherapy. On a multivariate analysis advanced age and >3 lesions predicted poor OS, while advanced age, lesions >5 cm, synchronous lesions, margin-positivity and resection less than hepatectomy were associated with decreased DFS. CONCLUSIONS Our results suggest that even with chemotherapy and resection only a subset of patients remain disease-free after 5 years. However, even in a high-risk patient with multiple lesions, preoperative chemotherapy can be administered safely without apparent increase in postoperative complications. Perioperative chemotherapy should be considered particularly in patients with multifocal or large lesions, synchronous disease and short disease-free interval.
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Affiliation(s)
- Ilia Gur
- Division of Surgical Oncology, Oregon Health and Science University, Portland, OR, USA,
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26
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Barton JS, Riha GM, Differding JA, Underwood SJ, Curren JL, Sheppard BC, Pommier RF, Orloff SL, Schreiber MA, Billingsley KG. Coagulopathy after a liver resection: is it over diagnosed and over treated? HPB (Oxford) 2013; 15:865-71. [PMID: 23458574 PMCID: PMC4503284 DOI: 10.1111/hpb.12051] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Accepted: 10/17/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Prothrombin time-international normalized ratio (PT-INR) is widely utilized to guide plasma therapy and initiation of thromboprophylaxis after a hepatectomy. Thrombelastography (TEG) monitors shear elasticity, which is sensitive to cellular and plasma components in blood, allowing for functional assessment of the life of the clot. The objective of this study was to prospectively compare PT-INR and TEG in liver resection patients. METHODS Forty patients were enrolled before undergoing an elective hepatectomy. Patients underwent a liver resection utilizing a low central venous pressure (CVP) anaesthetic technique and intermittent Pringle manoeuver. PT-INR and TEG were drawn prior to incision, post-operatively, and post-operative days 1, 3 and 5. RESULTS All post-operative PT-INR values increased significantly when compared with pre-operative PT-INR (P < 0.01). The time of onset to clot (R-value) decreased significantly at the post-operative time point (P = 0.04), consistent with a relative hypercoagulability. Subsequent R-values were not different compared with the pre-operative R-value. The strength of the clot (maximum amplitude, MA) was unchanged when comparing pre- and post-operative time points. DISCUSSION In spite of an elevation in PT-INR, patients undergoing a liver resection demonstrated a brief hypercoagulable state, followed by normal coagulation function based on TEG. These data call into question the practice of utilizing PT-INR to guide plasma transfusion and timing of prophylactic anticoagulation after a liver resection.
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Affiliation(s)
- Jeffrey S Barton
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Oregon Health & Science UniversityPortland, OR, USA
| | - Gordon M Riha
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Oregon Health & Science UniversityPortland, OR, USA
| | - Jerome A Differding
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Oregon Health & Science UniversityPortland, OR, USA
| | - Samantha J Underwood
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Oregon Health & Science UniversityPortland, OR, USA
| | - Jodie L Curren
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Oregon Health & Science UniversityPortland, OR, USA
| | - Brett C Sheppard
- Division of General Surgery, Department of Surgery, Oregon Health & Science UniversityPortland, OR, USA
| | - Rodney F Pommier
- Division of Surgical Oncology, Department of Surgery, Oregon Health & Science UniversityPortland, OR, USA
| | - Susan L Orloff
- Division of Liver and Pancreas Transplantation, Department of Surgery, Oregon Health & Science UniversityPortland, OR, USA
| | - Martin A Schreiber
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Oregon Health & Science UniversityPortland, OR, USA
| | - Kevin G Billingsley
- Division of Surgical Oncology, Department of Surgery, Oregon Health & Science UniversityPortland, OR, USA,Correspondence, Kevin G. Billingsley, Oregon Health & Science University, Division of Surgical Oncology, L619, 3181 S.W. Sam Jackson Park Rd, Portland, OR 97239, USA. Tel: +1 503 494 5501. Fax: +1 503 494 1211. E-mail:
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Eil R, Hansen PD, Cassera M, Orloff SL, Sheppard BC, Diggs B, Billingsley KG. Bile duct involvement portends poor prognosis in resected gallbladder carcinoma. Gastrointest Cancer Res 2013; 6:101-105. [PMID: 24147157 PMCID: PMC3782874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Accepted: 07/23/2013] [Indexed: 06/02/2023]
Abstract
BACKGROUND Gallbladder cancer (GBC) carries an unfavorable prognosis with high mortality. This retrospective study was conducted to identify prognostic factors after resection of GBC, to assist in selecting appropriate surgical and adjuvant therapy. METHODS Sixty-two patients from two institutions were identified with GBC by pathology. In 25, the cancer was unresectable at presentation. The remaining 37 patients comprised the study population. Log-rank analysis was used to assess univariate association with disease-free survival (DFS) and disease-specific survival (DSS). Cox regression was used for multivariate analysis. RESULTS Median DFS and DSS were 22.6 and 28.5 months respectively, with a median follow-up of 44.2 months. On univariate analysis, bile duct (BD) involvement was significantly associated with decreased DFS (P ≤ .001) and DSS (P = .004). BD involvement was uniformly fatal. LN involvement was not significantly associated with DFS or DSS (P = .85, P = .54). CONCLUSIONS All patients with BD involvement in our population died of the disease. The subset of patients with resectable GBC and BD involvement is a group that is at high risk for recurrence and should be treated as such. In our small population, preoperative and intraoperative methods evaluating BD involvement were unreliable.
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Affiliation(s)
- Robert Eil
- Division of Surgical Oncology Oregon Health and Sciences University Portland, OR
| | - Paul D. Hansen
- Hepatobiliary and Pancreatic Surgery Program Providence Portland Medical Center Portland, OR
| | - Maria Cassera
- Hepatobiliary and Pancreatic Surgery Program Providence Portland Medical Center Portland, OR
| | - Susan L. Orloff
- Division of Surgical Oncology Oregon Health and Sciences University Portland, OR
| | - Brett C. Sheppard
- Division of Surgical Oncology Oregon Health and Sciences University Portland, OR
| | - Brian Diggs
- Division of Surgical Oncology Oregon Health and Sciences University Portland, OR
| | - Kevin G. Billingsley
- Division of Surgical Oncology Oregon Health and Sciences University Portland, OR
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Affiliation(s)
- Myrddin Rees
- Basingstoke and North Hampshire Foundation TrustBasingstoke, UK
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Wong LL, Naugler WE, Schwartz J, Scott DL, Bhattacharya R, Reyes J, Orloff SL. Impact of locoregional therapy and alpha-fetoprotein on outcomes in transplantation for liver cancer: a UNOS Region 6 pooled analysis. Clin Transplant 2012; 27:E72-9. [PMID: 23278701 DOI: 10.1111/ctr.12056] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2012] [Indexed: 12/15/2022]
Abstract
Liver transplantation (LT) provides optimal long-term disease-free survival for hepatocellular carcinoma (HCC). High pre-LT alpha-fetoprotein (AFP) has been associated with HCC recurrence, but it is unclear whether a drop in AFP or locoregional therapy impacts survival/recurrence after LT. LT-recipients transplanted for HCC in three centers (UNOS Region 6) were reviewed (2006-2009) for demographics, tumor characteristics, locoregional therapy, AFP, recurrence, and survival. Among 211 LT recipients (mean age 56.4 yr, 83% male, mean MELD 12.2), 94% met Milan criteria and 61% received locoregional therapy. Mean disease-free survival (DFS) was 1549.7 d, and 84% are currently alive. Factors affecting DFS included recurrence (RR, 0.074; 95% CI, 0.038-0.14), normal peak AFP (29.6, 95% CI, 2.96-296.3), peak AFP >400 (RR, 0.15; 95% CI, 0.03-0.73) and AFP at LT >400 (RR, 15.5; 95% CI, 2.4-100.5). Twenty-one patients had recurrence and were more likely beyond Milan criteria (5/23(21%) vs. 8/220 (4%), p = 0.0038), with peak AFP >400 and AFP at LT >400 (p = 0.001). Locoregional therapy did not affect mean DFS (1458.0 vs. 1603.8 d, p = 0.05) or recurrence (12.5% vs. 6%). Predictors of recurrence were similar to previous studies, including high AFP and tumor outside Milan criteria. While locoregional therapy itself did not affect DFS/recurrence, a decrease in AFP pre-transplant appears to positively influence outcomes in those who received locoregional therapy.
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Affiliation(s)
- Linda L Wong
- Hawaii Medical Center-East, Transplant Institute, Honolulu, HI 96813, USA.
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30
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Orloff MJ, Isenberg JI, Wheeler HO, Haynes KS, Jinich-Brook H, Rapier R, Vaida F, Hye RJ, Orloff SL. Disability index in a randomized controlled trial of emergency sclerotherapy versus portacaval shunt for bleeding varices in cirrhosis. Am J Surg 2012; 204:157-66. [PMID: 22575398 DOI: 10.1016/j.amjsurg.2011.09.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2011] [Revised: 09/04/2011] [Accepted: 09/04/2011] [Indexed: 01/23/2023]
Abstract
BACKGROUND Disability has not been studied after emergency treatment of bleeding esophageal varices (BEV). We created a disability index (DI) in a randomized controlled trial comparing emergency endoscopic therapy (EST) versus emergency portacaval shunt (EPCS). METHODS There were 211 unselected, consecutive patients with cirrhosis and acute BEV who were randomized to EST (n = 106) or EPCS (n = 105). Diagnostic work-up and treatment were performed within 8 hours. Ninety-six percent underwent more than 10 years follow-up evaluation. Disability was measured by assessing 9 factors to create a DI. RESULTS Ten-year survival was 8% after EST versus 51% after EPCS (P < .001). EPCS had a significantly better DI. The EST and EPCS values were as follows: liver function improvement: not applicable and ++; worsening liver function, ++ and not applicable; portal-systemic encephalopathy (PSE) incidence, 36 and 15; PSE episodes, 179 and 94; packed red blood cell units, 1,005 and 320; hospital readmissions, 387 and 292; and number of readmission days, 9.6 and 4.7. All of the P values were less than .001. CONCLUSIONS EPCS resulted in a markedly better DI than EST, a significantly higher survival rate, better control of bleeding, and a lower incidence of PSE. EPCS is an effective first-line emergency treatment of BEV.
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Affiliation(s)
- Marshall J Orloff
- Department of Surgery, University of California San Diego Medical Center, 200 West Arbor Dr., San Diego, CA 92103-8999, USA.
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31
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Orloff MJ, Isenberg JI, Wheeler HO, Haynes KS, Jinich-Brook H, Rapier R, Vaida F, Hye RJ, Orloff SL. A randomized controlled trial of emergency treatment of bleeding esophageal varices in cirrhosis for hepatocellular carcinoma. Am J Surg 2011; 203:182-90. [PMID: 21679921 DOI: 10.1016/j.amjsurg.2011.02.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Revised: 02/10/2011] [Accepted: 02/10/2011] [Indexed: 12/21/2022]
Abstract
BACKGROUND Ninety percent of patients with hepatocellular carcinoma (HCC) have cirrhosis. Bleeding esophageal varices (BEV) is a frequent complication of cirrhosis. Detection of HCC in cirrhotic patients with BEV has not been studied. METHODS Two hundred eleven unselected patients with cirrhosis and BEV were randomized to endoscopic sclerotherapy (n = 106) or emergency portacaval shunt (n = 105). Diagnostic workup and treatment were initiated within 8 hours. Ninety-six percent had >10 years of follow-up. HCC screening involved serum α-fetoprotein (AFP) every 3 months, ultrasonography every 6 months, and selective computed tomography (CT). RESULTS HCC occurred in 15 patients, all incurable, a mean of 2.94 years after entry. They died a mean 1.33 years after discovery. Serial AFP and ultrasound examinations were unrevealing over a mean of 2.3 years. The mean model of end-stage liver disease score was 12.7 at entry and 17.4 at HCC diagnosis. CONCLUSIONS Long-term screening by AFP and ultrasound plus selective CT failed to detect HCC at a curable stage. The detection of HCC in cirrhotic patients with BEV remains a serious, unsolved problem. The use of CT for routine screening warrants consideration despite increased costs.
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Affiliation(s)
- Marshall J Orloff
- Department of Surgery, University of California, San Diego, Medical Center, USA.
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Sun HY, Alexander BD, Lortholary O, Dromer F, Forrest GN, Lyon GM, Somani J, Gupta KL, del Busto R, Pruett TL, Sifri CD, Limaye AP, John GT, Klintmalm GB, Pursell K, Stosor V, Morris MI, Dowdy LA, Munoz P, Kalil AC, Garcia-Diaz J, Orloff SL, House AA, Houston SH, Wray D, Huprikar S, Johnson LB, Humar A, Razonable RR, Fisher RA, Husain S, Wagener MM, Singh N. Unrecognized pretransplant and donor‐derived cryptococcal disease in organ transplant recipients. Clin Infect Dis 2011; 51:1062-9. [PMID: 20879857 DOI: 10.1086/656584] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Cryptococcosis occurring ≤30 days after transplantation is an unusual event, and its characteristics are not known. METHODS Patients included 175 solid-organ transplant (SOT) recipients with cryptococcosis in a multicenter cohort. Very early-onset and late-onset cryptococcosis were defined as disease occurring ≤30 days or >30 days after transplantation, respectively. RESULTS Very early-onset disease developed in 9 (5%) of the 175 patients at a mean of 5.7 days after transplantation. Overall, 55.6% (5 of 9) of the patients with very early-onset disease versus 25.9% (43 of 166) of the patients with late-onset disease were liver transplant recipients (P = .05). Very early cases were more likely to present with disease at unusual locations, including transplanted allograft and surgical fossa/site infections (55.6% vs 7.2%; P < .001). Two very early cases with onset on day 1 after transplantation (in a liver transplant recipient with Cryptococcus isolated from the lung and a heart transplant recipient with fungemia) likely were the result of undetected pretransplant disease. An additional 5 cases involving the allograft or surgical sites were likely the result of donor‐acquired infection. CONCLUSIONS A subset of SOT recipients with cryptococcosis present very early after transplantation with disease that appears to occur preferentially in liver transplant recipients and involves unusual sites, such as the transplanted organ or the surgical site. These patients may have unrecognized pretransplant or donor-derived cryptococcosis.
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Affiliation(s)
- Hsin-Yun Sun
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania 15240, USA
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Orloff SL, Hwee YK, Kreklywich C, Andoh TF, Hart E, Smith PA, Messaoudi I, Streblow DN. Cytomegalovirus latency promotes cardiac lymphoid neogenesis and accelerated allograft rejection in CMV naïve recipients. Am J Transplant 2011; 11:45-55. [PMID: 21199347 PMCID: PMC3454525 DOI: 10.1111/j.1600-6143.2010.03365.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Human cytomegalovirus (HCMV) infection is associated with the acceleration of transplant vascular sclerosis (TVS) and chronic allograft rejection (CR). HCMV-negative recipients of latently HCMV infected donor grafts are at highest risk for developing CMV disease. Using a rat heart transplant CR model, we have previously shown that acute rat CMV (RCMV) infection following transplantation significantly accelerates both TVS and CR. Here, we report that RCMV-naïve recipients of heart allografts from latently RCMV-infected donors undergo acceleration of CR with similar kinetics as acutely infected recipients. In contrast to acutely infected recipients, treatment of recipients of latently infected donor hearts with ganciclovir did not prevent CR or TVS. We observed the formation of tertiary lymphoid structures (TLOs) containing macrophages and T cells in latently infected hearts prior to transplantation but not in uninfected rats. Moreover, pathway analysis of gene expression data from allografts from latently infected donors indicated an early and sustained production of TLO-associated genes compared to allografts from uninfected donors. We conclude that RCMV-induced TLO formation and alteration of donor tissue T cell profiles prior to transplantation in part mediate the ganciclovir-insensitive rejection of latently infected donor allografts transplanted into naïve recipients by providing a scaffold for immune activation.
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Affiliation(s)
- Susan L. Orloff
- Portland Veterans Affairs Medical Center, Portland, OR 97239
,Departments of Surgery, and The Vaccine and Gene Therapy Institute, Oregon Health Sciences University, Portland, OR 97006
,Molecular Microbiology and Immunology, and The Vaccine and Gene Therapy Institute, Oregon Health Sciences University, Portland, OR 97006
| | - Yin-Kan Hwee
- Portland Veterans Affairs Medical Center, Portland, OR 97239
,Departments of Surgery, and The Vaccine and Gene Therapy Institute, Oregon Health Sciences University, Portland, OR 97006
| | - Craig Kreklywich
- Portland Veterans Affairs Medical Center, Portland, OR 97239
,Departments of Surgery, and The Vaccine and Gene Therapy Institute, Oregon Health Sciences University, Portland, OR 97006
,Molecular Microbiology and Immunology, and The Vaccine and Gene Therapy Institute, Oregon Health Sciences University, Portland, OR 97006
| | - Takeshi F. Andoh
- Portland Veterans Affairs Medical Center, Portland, OR 97239
,Departments of Surgery, and The Vaccine and Gene Therapy Institute, Oregon Health Sciences University, Portland, OR 97006
| | - Elaine Hart
- Portland Veterans Affairs Medical Center, Portland, OR 97239
| | | | - Ilhem Messaoudi
- Molecular Microbiology and Immunology, and The Vaccine and Gene Therapy Institute, Oregon Health Sciences University, Portland, OR 97006
| | - Daniel N. Streblow
- Portland Veterans Affairs Medical Center, Portland, OR 97239
,Molecular Microbiology and Immunology, and The Vaccine and Gene Therapy Institute, Oregon Health Sciences University, Portland, OR 97006
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Abstract
BACKGROUND Intrahepatic cholangiocarcinoma (ICC) remains a rare tumour, although its incidence is increasing. Surgical resection is the mainstay of treatment. Published data regarding prognostic factors and optimal patient selection for resection are scant. We sought to determine the clinicopathologic characteristics of resectable ICC and outcomes following surgical treatment. METHODS We reviewed prospectively collected clinical data including patient, pathologic and operative details. Survival and recurrence outcomes were analysed using Cox hazard models and the Kaplan-Meier method. RESULTS We identified 31 surgically treated patients. Their 3-year overall survival rate (OS) was 40.1%; median follow-up was 16.2 months (range: 0.2-86.9 months). R0 resection was associated with significantly improved OS compared with R1/R2 resection (3-year OS was 68.6% in R0 vs. 24.0% in R1/R2; P= 0.042). The postoperative complication rate was 58.1%. Two patients died of postoperative liver failure within 30 days. Preoperative hypoalbuminaemia was significantly associated with worse survival. CONCLUSIONS Surgical therapy for ICC is associated with longterm survival in the subset of nutritionally replete patients in whom an R0 resection can be achieved. Surgical mortality is significant in patients undergoing extended resection. The margin involvement rate is high and surgeons should consider the infiltrative nature of the disease in operative planning.
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Affiliation(s)
| | - Maria A Cassera
- Hepatobiliary and Pancreatic Surgery Program, Providence Portland Medical CenterPortland, OR, USA
| | | | - Susan L Orloff
- Division of Abdominal Transplantation, Oregon Health and Science UniversityPortland, OR, USA
| | - Paul D Hansen
- Hepatobiliary and Pancreatic Surgery Program, Providence Portland Medical CenterPortland, OR, USA
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Enestvedt BK, Enestvedt CK, Diggs B, Orloff SL. Hypercoagulability in Liver Transplant Recipients: Does Portal Vein Thrombosis Predict Post-Operative Thrombotic Complications? ACTA ACUST UNITED AC 2011. [DOI: 10.4236/ojots.2011.11001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Orloff MJ, Isenberg JI, Wheeler HO, Haynes KS, Jinich-Brook H, Rapier R, Vaida F, Hye RJ, Orloff SL. Alcoholic versus nonalcoholic cirrhosis in a randomized controlled trial of emergency therapy of bleeding varices. J Surg Res 2010; 174:98-105. [PMID: 21195430 DOI: 10.1016/j.jss.2010.11.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2010] [Revised: 10/28/2010] [Accepted: 11/03/2010] [Indexed: 12/11/2022]
Abstract
BACKGROUND It has been proposed that portal-systemic shunts be avoided in alcoholic cirrhotics because survival rate is allegedly lower in alcoholics than in nonalcoholics. We examined this issue in a randomized controlled trial. METHODS Two hundred eleven unselected, consecutive patients with cirrhosis and bleeding esophageal varices were randomized to endoscopic sclerotherapy (EST) (n = 106) or emergency portacaval shunt (EPCS) (105). Treatment was initiated within 8 h. EST failure was treated by rescue portacaval shunt (PCS). Ten-year follow-up was 96%. RESULTS Results strongly favored EPCS over EST (P < 0.001). Among EPCS patients, 83% were alcoholic and 17% nonalcoholic. Outcomes were (1) permanent control of bleeding 100% versus 100%; (2) 5-y survival 71% versus 78%; (3) encephalopathy 14% versus 19%; (4) yearly charges $38,300 versus $43,000. CONCLUSIONS EPCS results were similar in alcoholic and nonalcoholic cirrhotics. EPCS is an effective first line emergency treatment in all forms of cirrhosis, including alcoholic.
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Affiliation(s)
- Marshall J Orloff
- Department of Surgery, University of California, San Diego Medical Center, 200West Arbor Drive, San Diego, CA 92103-8999, USA.
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Orloff MJ, Isenberg JI, Wheeler HO, Haynes KS, Jinich-Brook H, Rapier R, Vaida F, Hye RJ, Orloff SL. Liver transplantation in a randomized controlled trial of emergency treatment of acutely bleeding esophageal varices in cirrhosis. Transplant Proc 2010; 42:4101-8. [PMID: 21168637 PMCID: PMC3032417 DOI: 10.1016/j.transproceed.2010.09.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Accepted: 09/03/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND Bleeding esophageal varices (BEV) in cirrhosis has been considered an indication for liver transplantation (LT). This issue was examined in a randomized controlled trial (RCT) of unselected, consecutive patients with advanced cirrhosis and BEV that compared endoscopic sclerotherapy (EST; n = 106) to emergency direct portacaval shunt (EPCS; n = 105). METHODS Diagnostic work-up and treatment were initiated within 8 hours. Patients were evaluated for LT on admission and repeatedly thereafter; 96% underwent over 10 years of regular follow-up. The analysis was supplemented by 1300 unrandomized cirrhotic patients who previously underwent portacaval shunt (PCS) with 100% follow-up. RESULTS In the RCT long-term bleeding control was 100% following EPCS, only 20% following EST. Also, 3-, 5-, 10-, and 15-year survival rates were 75%, 73%, 46%, and 46%, respectively, following EPCS compared with 44%, 21%, 9%, and 9% following EST, respectively (P < .001). Only 13 RCT patients (6%) were ultimately referred for LT mainly because of progressive liver failure; only 7 (3%) were approved for LT and only 4 (2%) underwent LT. The 1- and 5-year LT survival rates were 0.68% and 0, respectively, compared with 81% and 73%, respectively, after EPCS. In the 1300 unrandomized PCS patients, 50 (3.8%) were referred and 19 (1.5%) underwent LT. The 5-year survival rate was 53% compared with 72% for all 1300 patients. CONCLUSIONS If bleeding is permanently controlled, as occurred invariably following EPCS, cirrhotic patients with BEV seldom require LT. PCS is effective first-line and long-term treatment. Should LT be required in patients with PCS, although technically more demanding, numerous studies have shown that PCS does not increase mortality or complications. EST is not effective emergency or long-term therapy.
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Affiliation(s)
- M J Orloff
- Department of Surgery, University of California, San Diego Medical Center, San Diego, California 92103-8999, USA.
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Sun HY, Alexander BD, Lortholary O, Dromer F, Forrest GN, Lyon GM, Somani J, Gupta KL, Del Busto R, Pruett TL, Sifri CD, Limaye AP, John GT, Klintmalm GB, Pursell K, Stosor V, Morris MI, Dowdy LA, Muñoz P, Kalil AC, Garcia-Diaz J, Orloff SL, House AA, Houston SH, Wray D, Huprikar S, Johnson LB, Humar A, Razonable RR, Fisher RA, Husain S, Wagener MM, Singh N. Cutaneous cryptococcosis in solid organ transplant recipients. Med Mycol 2010; 48:785-91. [PMID: 20100136 DOI: 10.3109/13693780903496617] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Clinical manifestations, treatment, and outcomes of cutaneous cryptococcosis in solid organ transplant (SOT) recipients are not fully defined. In a prospective cohort comprising 146 SOT recipients with cryptococcosis, we describe the presentation, antifungal therapy, and outcome of cutaneous cryptococcal disease. Cutaneous cryptococcosis was documented in 26/146 (17.8%) of the patients and manifested as nodular/mass (34.8%), maculopapule (30.4%), ulcer/pustule/abscess (30.4%), and cellulitis (30.4%) with 65.2% of the skin lesions occurred in the lower extremities. Localized disease developed in 30.8% (8/26), and disseminated disease in 69.2% (18/26) with involvement of the central nervous system (88.9%, 16/18), lung (33.3%, 6/18), or fungemia (55.6%, 10/18). Fluconazole (37.5%) was employed most often for localized and lipid formulations of amphotericin B (61.1%) for disseminated disease. Overall mortality at 90 days was 15.4% (4/26) with 16.7% in disseminated and 12.5% in localized disease (P = 0.78). SOT recipients who died were more likely to have renal failure (75.0% vs. 13.6%, P = 0.028), longer time to onset of disease after transplantation (87.5 vs. 22.6 months, P = 0.023), and abnormal mental status (75% vs. 13.6%, P = 0.028) than those who survived. Cutaneous cryptococcosis represents disseminated disease in most SOT recipients and preferentially involves the extremities. Outcomes with appropriate management were comparable between SOT recipients with localized and disseminated cryptococcosis.
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Affiliation(s)
- Hsin-Yun Sun
- VA Pittsburgh Healthcare System, University Drive C, Pittsburgh, PA 15240, USA
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Osawa R, Alexander BD, Forrest GN, Lyon GM, Somani J, del Busto R, Pruett TL, Sifri CD, Limaye AP, Klintmalm GB, Pursell K, Stosor V, Morris MI, Dowdy LA, Kalil AC, Garcia-Diaz J, Orloff SL, Houston SH, Wray D, Huprikar S, Johnson LB, Razonable RR, Fisher RA, Wagener MM, Husain S, Singh N. Geographic differences in disease expression of cryptococcosis in solid organ transplant recipients in the United States. Ann Transplant 2010; 15:77-83. [PMID: 21183881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023] Open
Abstract
BACKGROUND Whether there are geographic differences in clinical presentation of cryptococcosis in solid organ transplant (SOT) recipients in the United States (US) is not known. MATERIAL/METHODS Patients comprised a cohort of 120 SOT recipients from US transplant centers who fulfilled the EORTC/MSG criteria for cryptococcal disease. RESULTS Central nervous system, pulmonary, and cutaneous cryptococcal disease were observed in 51% (61/120), 64% (77/120), and 15% (18/120) of the patients, respectively. Cutaneous disease was documented in 9% (3/32) of the patients from South Atlantic region, 19% (6/32) from Mid Atlantic, 26% (6/23) from Southern, 7% (2/29) from Midwestern, and in 1 of 4 patients from the Northwestern region of the US. When controlled for age, immunosuppressive regimen, type of transplant, and renal failure at baseline, patients from the Southern compared with other regions of the US were significantly more likely to have cutaneous cryptococcal disease (OR 3.8, 95% CI 1.1-14, P=0.045). CONCLUSIONS Post-transplant cryptococcosis is more likely to present with cutaneous disease in the Southern region compared with other regions in the US. This predilection for cutaneous cryptococcosis could not be explained on the basis of differences in immunosuppression or the type of transplant. Whether our findings are related to strain-related variations in characteristics of the yeast or other transplant variables remains to be determined.
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Affiliation(s)
- Ryosuke Osawa
- University of Buffalo, State University of New York, Buffalo, NY, U.S.A
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40
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Caposio P, Orloff SL, Streblow DN. The role of cytomegalovirus in angiogenesis. Virus Res 2010; 157:204-11. [PMID: 20869406 DOI: 10.1016/j.virusres.2010.09.011] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2010] [Revised: 09/17/2010] [Accepted: 09/17/2010] [Indexed: 01/02/2023]
Abstract
Human cytomegalovirus (HCMV) infection has been associated with the acceleration of vascular disease including atherosclerosis and transplant associated vasculopathy in solid organ transplants. HCMV promotes vascular disease at many of the different stages of the disease development. These include the initial injury phase, enhancing the response to injury and inflammation, as well as by increasing SMC hyperplasia and foamy macrophage cell formation. Angiogenesis is a critical process involved in the development of vascular diseases. Recently, HCMV has been shown to induce angiogenesis and this process is thought to contribute to HCMV-accelerated vascular disease and may also be important for HCMV-enhanced tumor formation. This review will highlight the role of HCMV in promoting angiogenesis.
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Affiliation(s)
- Patrizia Caposio
- Department of Molecular Microbiology & Immunology and The Vaccine & Gene Therapy Institute, Oregon Health & Science University, Portland, OR 97239, USA
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41
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O’Glasser AY, Scott DL, Corless CL, Zaman A, Sasaki A, Gopal DV, Rayhill SC, Orloff SL, Ham JM, Rabkin JM, Flora K, Davies CH, Broberg CS, Schwartz JM. Hepatic and cardiac iron overload among patients with end-stage liver disease referred for liver transplantation. Clin Transplant 2009; 24:643-51. [DOI: 10.1111/j.1399-0012.2009.01136.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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42
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McGuire BM, Rosenthal P, Brown CC, Busch AMH, Calcatera SM, Claria RS, Hunt NK, Korenblat KM, Mazariegos GV, Moonka D, Orloff SL, Perry DK, Rosen CB, Scott DL, Sudan DL. Long-term management of the liver transplant patient: recommendations for the primary care doctor. Am J Transplant 2009; 9:1988-2003. [PMID: 19563332 DOI: 10.1111/j.1600-6143.2009.02733.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
No official document has been published for primary care physicians regarding the management of liver transplant patients. With no official source of reference, primary care physicians often question their care of these patients. The following guidelines have been approved by the American Society of Transplantation and represent the position of the association. The data presented are based on formal review and analysis of published literature in the field and the clinical experience of the authors. These guidelines address drug interactions and side effects of immunosuppressive agents, allograft dysfunction, renal dysfunction, metabolic disorders, preventive medicine, malignancies, disability and productivity in the workforce, issues specific to pregnancy and sexual function, and pediatric patient concerns. These guidelines are intended to provide a bridge between transplant centers and primary care physicians in the long-term management of the liver transplant patient.
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Affiliation(s)
- B M McGuire
- University of Alabama at Birmingham, Birmingham, AL, USA.
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Baca Jones CC, Kreklywich CN, Messaoudi I, Vomaske J, McCartney E, Orloff SL, Nelson JA, Streblow DN. Rat cytomegalovirus infection depletes MHC II in bone marrow derived dendritic cells. Virology 2009; 388:78-90. [PMID: 19349057 DOI: 10.1016/j.virol.2009.02.050] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2008] [Revised: 12/22/2008] [Accepted: 02/28/2009] [Indexed: 01/10/2023]
Abstract
While cytomegalovirus (CMV) infects and replicates in a multitude of cell types, the ability of the virus to replicate in antigen presenting cells (APCs) is believed to play a critical role in the viral dissemination and latency. CMV infection of APCs and manipulation of their function are important areas of investigation. CMV down regulation of MHC II is reportedly mediated by the HCMV proteins US2, US3, UL83, UL111a (vIL10) or through the induction of cellular IL10. In this study, we demonstrate that rat CMV (RCMV) significantly reduces MHC II expression neither by mechanisms that do not involve orthologues of the known HCMV genes nor by an increase in cellular IL10. Rat bone marrow derived dendritic cells (BMDC) were highly susceptible to infection with RCMV and a recombinant RCMV expressing eGFP. RCMV infection of BMDCs depleted both surface and intracellular MHC II to nearly undetectable levels as well as reduced surface expression of MHC I. The effect on MHC II only occurred in the infected GFP positive cells and is mediated by an immediate early or early viral gene product. Furthermore, treatment of uninfected immature DCs with virus-free conditioned supernatants from infected cells failed to down regulate MHC II. RCMV depletion of MHC II was sensitive to treatment with lysosomal inhibitors but not proteasomal inhibitors suggesting that the mechanism of RCMV-mediated down regulation of MHC II occurs through endocytic degradation. Since RCMV does not encode homologues of US2, US3, UL83 or UL111a, these data indicate a novel mechanism for RCMV depletion of MHC II.
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Affiliation(s)
- Carmen C Baca Jones
- Department of Molecular Microbiology and Immunology, Oregon Health and Science University, Portland, OR 97239, USA
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Streblow DN, Dumortier J, Moses AV, Orloff SL, Nelson JA. Mechanisms of cytomegalovirus-accelerated vascular disease: induction of paracrine factors that promote angiogenesis and wound healing. Curr Top Microbiol Immunol 2008; 325:397-415. [PMID: 18637518 DOI: 10.1007/978-3-540-77349-8_22] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Human cytomegalovirus (HCMV) is associated with the acceleration of a number of vascular diseases such as atherosclerosis, restenosis, and transplant vascular sclerosis (TVS). All of these diseases are the result of either mechanical or immune-mediated injury followed by inflammation and subsequent smooth muscle cell (SMC) migration from the vessel media to the intima and proliferation that culminates in vessel narrowing. A number of epidemiological and animal studies have demonstrated that CMV significantly accelerates TVS and chronic rejection (CR) in solid organ allografts. In addition, treatment of human recipients and animals alike with the antiviral drug ganciclovir results in prolonged survival of the allograft, indicating that CMV replication is a requirement for acceleration of disease. However, although virus persists in the allograft throughout the course of disease, the number of directly infected cells does not account for the global effects that the virus has on the acceleration of TVS and CR. Recent investigations of up- and downregulated cellular genes in infected allografts in comparison to native heart has demonstrated that rat CMV (RCMV) upregulates genes involved in wound healing (WH) and angiogenesis (AG). Consistent with this result, we have found that supernatants from HCMV-infected cells (HCMV secretome) induce WH and AG using in vitro models. Taken together, these findings suggest that one mechanism for HCMV acceleration of TVS is mediated through induction of secreted cytokines and growth factors from virus-infected cells that promote WH and AG in the allograft, resulting in the acceleration of TVS. We review here the ability of CMV infection to alter the local environment by producing cellular factors that act in a paracrine fashion to enhance WH and AG processes associated with the development of vascular disease, which accelerates chronic allograft rejection.
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Affiliation(s)
- D N Streblow
- Vaccine and Gene Therapy Institute and Department of Molecular Microbiology and Immunology, Oregon Health and Science University, Portland, OR 97201, USA.
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45
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Streblow DN, Kreklywich CN, Andoh T, Moses AV, Dumortier J, Smith PP, Defilippis V, Fruh K, Nelson JA, Orloff SL. The role of angiogenic and wound repair factors during CMV-accelerated transplant vascular sclerosis in rat cardiac transplants. Am J Transplant 2008; 8:277-87. [PMID: 18093265 DOI: 10.1111/j.1600-6143.2007.02062.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Human cytomegalovirus (HCMV) accelerates transplant vascular sclerosis (TVS), a consequence of angiogenesis (AG) and wound repair (WR). While HCMV can be localized to TVS lesions, the low number of infected cells suggests a global effect on target tissues. We used microarray analysis followed by real-time-polymerase chain reaction (RT-PCR) in an RCMV-accelerated TVS rat cardiac transplant model to determine whether CMV activates host WR and AG factors. Dysregulated cellular genes in allografts from RCMV-infected recipients were compared to those from uninfected recipients and native hearts. We demonstrated that RCMV upregulates the genes involved in WR and AG, which was highest during the critical time of TVS acceleration (21-28 days). Using a standard in vitro AG assay, virus and serum-free supernatants collected at 48 h postinfection significantly induced endothelial cell (EC) migration, branching and tubule formation compared to supernatants from mock-infected cells. Supernatants from ultraviolet (UV)-inactivated RCMV-infected cells failed to induce AG, indicating that virus replication is required. Upregulation of WR and AG genes occurs during the critical period of CMV-accelerated TVS. Targeting these genes may prevent this process and improve allograft survival.
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Affiliation(s)
- D N Streblow
- Vaccine and Gene Therapy Institute, Oregon Health and Science University, Portland, OR, USA
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Abstract
A number of human herpesviruses are important opportunistic pathogens that have been associated with increased morbidity and mortality in transplant recipients including human cytomegalovirus (HCMV), HHV6, HHV7, HHV8 as well as HSV-1, VZV. However, HCMV has been linked both epidemiologically and through the use of animal models to the acceleration of acute and chronic allograft rejection. This review will cover the pathophysiology, epidemiology, and mechanisms of CMV-associated disease in the setting of transplantation.
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Affiliation(s)
| | - Susan L. Orloff
- Veterans Affairs, Portland VAMC, Portland, OR
- MMI, OHSU, Portland, OR
| | - Jay A. Nelson
- MMI, OHSU, Portland, OR
- Department of Surgery, OHSU, Portland, OR
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47
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Soule JL, Streblow DN, Andoh TF, Kreklywich CN, Orloff SL. Cytomegalovirus accelerates chronic allograft nephropathy in a rat renal transplant model with associated provocative chemokine profiles. Transplant Proc 2007; 38:3214-20. [PMID: 17175227 DOI: 10.1016/j.transproceed.2006.10.187] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND Studies have shown that rat cytomegalovirus (RCMV) infection accelerates transplant vascular sclerosis (TVS) in rat heart and small bowel allotransplants. In these models, RCMV-accelerated TVS results from increased graft infiltration of inflammatory cells through up-regulation of chemokine expression. The aim of this study was to determine if RCMV infection accelerates renal transplant chronic allograft nephropathy (CAN), and the role of chemokines in this process. METHODS F344 kidneys were transplanted into Lewis recipients with and without RCMV infection. To monitor CAN, serum creatinine (Cr) levels were measured starting at 4 weeks posttransplantation. At 7 and 21 days, and at terminal rejection, grafts were examined for histologic changes, inflammatory cell infiltrates, viral load, and chemokine expression profiles. RESULTS By week 8, serum Cr showed significant elevation (P < .01) in the RCMV-infected group vs uninfected group, and remained significantly elevated through the end of the study. RCMV+ renal allografts had significant inflammatory cell infiltration and increased CAN at postoperative day (POD) 28. The CC chemokines RANTES, MCP-1, and MIP-1alpha, and the CXC chemokine IP-10 were up-regulated in RCMV-infected vs uninfected allografts. IP-10 was significantly up-regulated early in the process, whereas RANTES and MCP-1 were induced at a later time. CONCLUSIONS RCMV infection accelerates CAN, with associated graft inflammatory infiltrates, which is paralleled by an increase in expression of CC and CXC chemokines. Our findings suggest that the early induction of IP-10 in the infected allografts promotes alterations in T-cell and monocyte migration to the graft, which initiates accelerated inflammatory and fibrotic changes associated with CAN.
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Affiliation(s)
- J L Soule
- Department of Surgery, Oregon Health and Science University, Portland, Oregon 97239, USA
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48
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Streblow DN, van Cleef KWR, Kreklywich CN, Meyer C, Smith P, Defilippis V, Grey F, Früh K, Searles R, Bruggeman C, Vink C, Nelson JA, Orloff SL. Rat cytomegalovirus gene expression in cardiac allograft recipients is tissue specific and does not parallel the profiles detected in vitro. J Virol 2007; 81:3816-26. [PMID: 17251289 PMCID: PMC1866122 DOI: 10.1128/jvi.02425-06] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Rat cytomegalovirus (RCMV) is a beta-herpesvirus with a 230-kbp genome containing over 167 open reading frames (ORFs). RCMV gene expression is tightly regulated in cultured cells, occurring in three distinct kinetic classes (immediate early, early, and late). However, the extent of viral-gene expression in vivo and its relationship to the in vitro expression are unknown. In this study, we used RCMV-specific DNA microarrays to investigate the viral transcriptional profiles in cultured, RCMV-infected endothelial cells, fibroblasts, and aortic smooth muscle cells and to compare these profiles to those found in tissues from RCMV-infected rat heart transplant recipients. In cultured cells, RCMV expresses approximately 95% of the known viral ORFs with few differences between cell types. By contrast, in vivo viral-gene expression in tissues from rat heart allograft recipients is highly restricted. In the tissues studied, a total of 80 viral genes expressing levels twice above background (5,000 to 10,000 copies per mug total RNA) were detected. In each tissue type, there were a number of genes expressed exclusively in that tissue. Although viral mRNA and genomic DNA levels were lower in the spleen than in submandibular glands, the number of individual viral genes expressed was higher in the spleen (60 versus 41). This finding suggests that the number of viral genes expressed is specific to a given tissue and is not dependent upon the viral load or viral mRNA levels. Our results demonstrate that the profiles, as well as the amplitude, of viral-gene expression are tissue specific and are dramatically different from those in infected cultured cells, indicating that RCMV gene expression in vitro does not reflect viral-gene expression in vivo.
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MESH Headings
- Animals
- Aorta/virology
- Cells, Cultured
- DNA, Viral/analysis
- Endothelial Cells/virology
- Fibroblasts/virology
- Gene Expression
- Gene Expression Profiling
- Heart Transplantation
- Herpesviridae Infections/virology
- Muromegalovirus/genetics
- Muromegalovirus/growth & development
- Muscle, Smooth, Vascular/cytology
- Muscle, Smooth, Vascular/virology
- Myocytes, Smooth Muscle/virology
- Oligonucleotide Array Sequence Analysis
- Organ Specificity
- RNA, Messenger/biosynthesis
- RNA, Viral/biosynthesis
- Rats
- Rats, Inbred F344
- Spleen/virology
- Submandibular Gland/virology
- Transplantation, Homologous
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Affiliation(s)
- Daniel N Streblow
- Department of Molecular Microbiology and Immunology, The Vaccine and Gene Therapy Institute, Oregon Health and Science University, 505 SW 185th St., Beaverton, OR 97006, USA.
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Melnychuk RM, Smith P, Kreklywich CN, Ruchti F, Vomaske J, Hall L, Loh L, Nelson JA, Orloff SL, Streblow DN. Mouse cytomegalovirus M33 is necessary and sufficient in virus-induced vascular smooth muscle cell migration. J Virol 2005; 79:10788-95. [PMID: 16051870 PMCID: PMC1182681 DOI: 10.1128/jvi.79.16.10788-10795.2005] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Mouse cytomegalovirus (MCMV) encodes two potential seven-transmembrane-spanning proteins with homologies to cellular chemokine receptors, M33 and M78. While these virus-encoded chemokine receptors are necessary for the in vivo pathogenesis of MCMV, the function of these proteins is unknown. Since vascular smooth muscle cell (SMC) migration is of critical importance for the development of atherosclerosis and other vascular diseases, the ability of M33 to promote SMC motility was assessed. Similar to human CMV, MCMV induced the migration of mouse aortic SMCs but not mouse fibroblasts. To demonstrate whether M33 was required for MCMV-induced SMC migration, we employed interfering-RNA technology to specifically knock down M33 expression in the context of viral infection. The knockdown of M33 resulted in the specific reduction of M33 protein expression and ablation of MCMV-mediated SMC migration but failed to reduce viral growth in cultured cells. Adenovirus vector expression of M33 was sufficient to promote SMC migration, which was enhanced in the presence of recombinant mouse RANTES (mRANTES). In addition, M33 promoted the activation of Rac1 and extracellular signal-related kinase 1/2 upon stimulation with mRANTES. These findings demonstrate that mRANTES is a ligand for this chemokine receptor and that the activation of M33 occurs in a ligand-dependent manner. Thus, M33 is a functional homologue of US28 that is required for MCMV-induced vascular SMC migration.
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Affiliation(s)
- Ryan M Melnychuk
- Department of Molecular Microbiology and Immunology, Oregon Health Sciences University, Portland, OR 97239, USA
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50
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Wang PL, Meyer MM, Orloff SL, Anderson S. Bone resorption and "relative" immobilization hypercalcemia with prolonged continuous renal replacement therapy and citrate anticoagulation. Am J Kidney Dis 2005; 44:1110-4. [PMID: 15558534 DOI: 10.1053/j.ajkd.2004.09.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Regional citrate anticoagulation is an alternative to heparin in patients with bleeding diatheses who require continuous renal replacement therapy (CRRT). The short-term metabolic consequences that occur with citrate anticoagulation are well described and usually manageable if established protocols are followed vigilantly. Because of its customary short-term nature, the long-term consequences of CRRT with citrate are less often considered and have not been reported. The authors present the case of a woman with multisystem organ failure and prolonged acute renal failure who required CRRT for 120 days. Throughout her hospital course, adequate regional anticoagulation was achieved by blocking the coagulation cascade via the chelation of calcium by citrate. Despite an appropriate drop in the postfilter ionized calcium level, by 8 weeks after the initiation of CRRT, the patient was able to normalize serum calcium levels without the customary calcium infusion. Bone resorption owing to prolonged immobilization leading to hypercalcemia is a known complication of critically ill patients. This problem is more pronounced in patients with high bone turnover rates owing to conditions such as secondary hyperparathyroidism. In this particular case, the chelation of calcium by citrate masked the ensuing immobilization hypercalcemia, resulting in marked bone loss and bilateral spontaneous femoral fractures in the context of normal calcium levels. In critically ill patients sustained with prolonged CRRT with citrate anticoagulation, bone resorption and "relative" immobilization hypercalcemia may manifest as normal serum calcium levels in the face of falling calcium infusion rate requirements.
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Affiliation(s)
- Pei-Li Wang
- Division of Nephrology and Hypertension, Department of Medicine Oregon Health and Science University, Portland, OR 97239, USA
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