Hungry bone syndrome in peritoneal dialysis patients after parathyroid surgery

Secondary hyperparathyroidism (SHPT) is a common complication of end-stage kidney disease (ESKD). Hungry bone syndrome (HBS) occurs frequently in patients on maintenance dialysis receiving parathyroidectomy for refractory SHPT. However, there is scanty study investigating the clinical risk factors that predict postoperative HBS, and its outcome in peritoneal dialysis (PD) patients. We conducted a single-center retrospective study to analyze 66 PD patients who had undergone parathyroidectomy for secondary hyperparathyroidism at Chang Gung Memorial Hospital between 2009 and 2019. The patients were stratified into two groups based on the presence (n=47) or absence (n=19) of HBS after parathyroidectomy. Subtotal parathyroidectomy was the most common surgery performed (74.2%), followed by total parathyroidectomy with autoimplantation (25.8%). Pathological examination of all surgical specimens revealed parathyroid hyperplasia (100%). Patients with HBS had lower levels of postoperative nadir corrected calcium, higher alkaline phosphate (ALP), and higher potassium levels compared with patients without HBS (all P<0.05). A multivariate logistic regression model confirmed that lower preoperative serum calcium level (OR 0.354, 95% CI 0.133-0.940, P=0.037), higher ALP (OR 1.026, 95% CI 1.008-1.044, P=0.004), and higher potassium level (OR 6.894, 95% CI 1.806-26.317, P=0.005) were associated with HBS after parathyroidectomy. Patients were followed for 58.2±30.8 months after the surgery. There was no significant difference between HBS and non-HBS groups in persistence (P=0.496) or recurrence (P=1.000) of hyperparathyroidism. The overall mortality rate was 10.6% with no significant difference found between both groups (P=0.099). We concluded that HBS is a common complication (71.2%) of parathyroidectomy for SHPT and should be managed appropriately.

Wound Infection of Snakebite from Venomous Protobothrops mucrosquamatus, Viridovipera stejnegeri and Naja atra in Taiwan: Validation of BITE and Cobra BITE Scoring Systems and their Bacteriological Differences in Wound Cultures

Patients bitten by Protobothrops mucrosquamatus, Viridovipera stejnegeri, and Naja atra develop different degrees of wound infection. This study validated BITE and Cobra BITE scoring systems that we established previously. Bacteriological studies of patients with wound infection were conducted. The operating characteristic curves and area under the curve (AUC) and wound infection rates were compared between the derivation set (our previous study patient population) and the validation set (new patient cohorts enrolled between June 2017 and May 2021). No significant differences in the AUC for both the BITE (0.84 vs. 0.78, p = 0.27) and Cobra BITE (0.88 vs. 0.75, p = 0.21) scoring systems were observed between the derivation and validation sets. Morganella morganii and Enterococcus faecalis were the two most commonly detected bacteria in the microbiological study. More bacterial species were cultured from N. atra-infected wounds. Antibiotics such as amoxicillin with clavulanic acid, oxacillin, and ampicillin may not be suitable for treating patients with P. mucrosquamatus, V. stejnegeri, and N. atra bites in Taiwan. Carbapenem, third-generation cephalosporins, and fluoroquinolone may be superior alternatives.

In-Hospital and Long-Term Outcomes in Patients with Head and Neck Cancer Bleeding

Background and Objectives: The purpose of the present study was to elucidate the in-hospital and long-term outcomes of patients with head and neck cancer (HNC) bleeding and to analyze the risk factors for mortality. Materials and Methods: We included patients who presented to the emergency department (ED) with HNC bleeding. Variables of patients who survived and died were compared and associated factors were investigated by logistic regression and Cox’s proportional hazard model. Results: A total of 125 patients were enrolled in the present study. Fifty-nine (52.8%) patients experienced a recurrent bleeding event. The in-hospital mortality rate was 16%. The overall survival at 1, 3 and 5 years was 48%, 41% and 34%, respectively. The median survival time was 9.2 months. Multivariate logistic regression analyses revealed that risk factors for in-hospital mortality were inotropic support (OR = 10.41; Cl 1.81–59.84; p = 0.009), hypopharyngeal cancer (OR = 4.32; Cl 1.29–14.46; p = 0.018), and M stage (OR = 5.90; Cl 1.07–32.70; p = 0.042). Multivariate Cox regression analyses indicate that heart rate >110 (beats/min) (HR = 2.02; Cl 1.16–3.51; p = 0.013), inotropic support (HR = 3.25; Cl 1.20–8.82; p = 0.021), and hypopharygneal cancer (HR = 2.22; Cl 1.21–4.06; p = 0.010) were all significant independent predictors of poorer overall survival. Conclusions: HNC bleeding commonly represents the advanced disease stage. Recognition of associated factors aids in the risk stratification of patients with HNC bleeding.

Systemic lupus erythematosus complicated by Crohn's disease with rectovaginal fistula

Background

Systemic lupus erythematosus (SLE) is a multisystemic autoimmune disease, and few cases combine with Crohn’s disease. We present the first SLE patient concurrent with Crohn’s disease and rectovaginal fistula. She was successfully treated with vedolizumab and surgical intervention. Besides, she also had a rare opportunistic infection, cryptococcal pneumonia, in previous adalimumab treatment course.

Case

A 57 year-old female had SLE in disease remission for 27 years. She suffered from progressive rectal ulcers with anal pain and bloody stool, and Crohn’s disease was diagnosed. She received adalimumab, but the lesion still progressed to a rectovaginal fistula. Besides, she suffered from an episode of cryptococcal pneumonia under adalimumab treatment course. Therefore, we changed the biologics to vedolizumab, and arrange a transverse colostomy for stool diversion. She had clinical remission without active inflammation, but the fistula still persisted. Then, she received a restorative proctectomy with colo-anal anastomosis and vaginal repair. Follow-up endoscopy showed no more rectal ulcers or fistula tracts, and contrast enema also noted no residual rectovaginal fistula.

Conclusion

When a SLE patient had unusual rectal ulcers, Crohn’s disease should be considered. Biologics combined with surgical intervention is an optimal solution for Crohn’s disease with rectovaginal fistula. Although cryptococcal pneumonia is a rare opportunistic infection in the biological treatment, we should always keep it in mind.

Wound Infections from Taiwan Cobra (Naja atra) Bites: Determining Bacteriology, Antibiotic Susceptibility, and the Use of Antibiotics-A Cobra BITE Study

Wound necrosis and secondary infection are common complications after Naja atra bites. Clinical tools to evaluate the infection risk after Taiwan cobra bites are lacking. In this Cobra BITE study, we investigated the prevalence of wound infection, bacteriology, and corresponding antibiotic usage in patients presenting with Taiwan cobra snakebites. Patients with wound infection lacking tissue necrosis were included in developing Cobra BITE score utilizing univariate and multiple logistic regression, as patients with wound necrosis require antibiotics for infection treatment. 8,295,497 emergency department visits occurred in the span of this study, with 195 of those patients being diagnosed as having cobra bites. Of these patients, 23 had wound necrosis, and 30 had wound infection, resulting in a wound infection rate of 27.2% (53/195). Enterococcus faecalis and Morganella morganii were the main bacteria identified in the culture report regardless of whether patients’ wounds had necrosis. As per our Cobra BITE score, the three factors predicting secondary wound infection after cobra bites are hospital admission, a white blood cell count (in 103/µL) × by neu-trophil-lymphocyte ratio value of ≥114.23, and the use of antivenin medication. The area under the receiver operating characteristic curve for the Cobra BITE score system was 0.88; ideal sensitivity and specificity were 0.89 and 0.76. This scoring system enables the assessment of wound infections after N. atra bites, and it could be modified and improved in the future for other Naja spp. bites.

Vedolizumab in Crohn’s disease with rectal fistulas and presacral abscess: A case report

BACKGROUND

Fistula and intraabdominal abscess are common complications of Crohn’s disease (CD), but complex rectal fistula with abscess formation is rare. Tumor necrosis factor antagonists combined with percutaneous drainage or surgical intervention is optimal treatment for fistulizing CD with intraabdominal abscess. There is no study showing the efficacy of vedolizumab in such complicated condition.

CASE SUMMARY

A 47-year-old man has decompensated liver cirrhosis, Child B. He suffered from abdominal pain, bloody diarrhea, fever, and body weight loss. CD with rectoprostatic fistula, rectopresacral fistula, presacral abscess and cyto-megalovirus (CMV) infection were noted. He received antibiotics, anti-viral therapy, transverse colostomy and vedolizumab treatment. Six months later, he had deep remission and complete fistula tracts closure.

CONCLUSION

Early vedolizumab and stool diversion are effective and safe in treating CD with complex rectal fistula with abscess formation.

Evaluation of the BAX® System for Detection of Salmonella in Selected Foods: Collaborative Study

A multilaboratory study was conducted to compare the automated BAX® System to the standard cultural methods for detection of Salmonella in selected foods. Five food types—frankfurters, raw ground beef, mozzarella cheese, raw frozen tilapia fish, and orange juice—at 3 inoculation levels, were analyzed by each method. A sixth food type, raw ground chicken, was tested using 3 naturally contaminated lots. A total of 16 laboratories representing government and industry participated. In this study, 1386 samples were analyzed, of which 1188 were paired samples and 198 were unpaired samples. Of the 1188 paired samples, 461 were positive by both methods and 404 were negative by both methods. Thirty-seven samples were positive by the BAX System but negative by the standard reference method, and 11 samples were positive by standard cultural method and negative by the BAX System. Of the 198 unpaired samples, 106 were positive by the BAX System and 60 were positive by the standard cultural method. A Chi square analysis of each of the 6 food types, at the 3 inoculation levels tested, was performed. For all foods, the BAX System demonstrated results comparable to those of the standard reference methods based on the Chi square results.

Simulating Tsunami Inundation and Soil Response in a Large Centrifuge

Tsunamis are rare, extreme events and cause significant damage to coastal infrastructure, which is often exacerbated by soil instability surrounding the structures. Simulating tsunamis in a laboratory setting is important to further understand soil instability induced by tsunami inundation processes. Laboratory simulations are difficult because the scale of such processes is very large, hence dynamic similitude cannot be achieved for small-scale models in traditional water-wave-tank facilities. The ability to control the body force in a centrifuge environment considerably reduces the mismatch in dynamic similitude. We review dynamic similitudes under a centrifuge condition for a fluid domain and a soil domain. A novel centrifuge apparatus specifically designed for exploring the physics of a tsunami-like flow on a soil bed is used to perform experiments. The present 1:40 model represents the equivalent geometric scale of a prototype soil field of 9.6 m deep, 21 m long, and 14.6 m wide. A laboratory facility capable of creating such conditions under the normal gravitational condition does not exist. With the use of a centrifuge, we are now able to simulate and measure tsunami-like loading with sufficiently high water pressure and flow velocities. The pressures and flow velocities in the model are identical to those of the prototype yielding realistic conditions of flow-soil interaction.

Regulatory B Cell-Dependent Islet Transplant Tolerance Is Also Natural Killer Cell Dependent

Immunologic tolerance to solid organ and islet cell grafts has been achieved in various rodent models by using antibodies directed at CD45RB and Tim-1. We have shown that this form of tolerance depends on regulatory B cells (Bregs). To elucidate further the mechanism by which Bregs induce tolerance, we investigated the requirement of natural killer (NK) and NKT cells in this model. To do so, hyperglycemic B6, μMT, Beige, or CD1d^-/- mice received BALB/c islet grafts and treatment with the tolerance-inducing regimen consisting of anti-CD45RB and anti-TIM1. B6 mice depleted of both NK and NKT cells by anti-NK1.1 antibody and mice deficient in NK activity (Beige) did not develop tolerance after dual-antibody treatment. In contrast, transplant tolerance induction was successful in CD1d^-/- recipients (deficient in NKT cells), indicating that NK, but not NKT, cells are essential in B cell-dependent tolerance. In addition, reconstitution of Beige host with NK cells restored the ability to induce transplant tolerance with dual-antibody treatment. Transfer of tolerance by B cells from tolerant mice was also dependent on host Nk1.1⁺ cells. In conclusion, these results show that regulatory function of B cells is dependent on NK cells in this model of transplantation tolerance.

The Effects of Exogenous Administration of Human Coagulation Factors Following Pig-to-Baboon Liver Xenotransplantation

We sought to determine the effects of exogenous administration of human coagulation factors following pig-to-baboon liver xenotransplantation (LXT) using GalT-KO swine donors. After LXT, baboons received no coagulation factors (historical control, n = 1), bolus administration of a human prothrombin concentrate complex (hPCC; 2.5 mL/kg, n = 2), continuous infusion of hPCC (1.0 mL/h, n = 1) or continuous infusion of human recombinant factor VIIa (1 µg/kg per hour, n = 3). The historical control recipient demonstrated persistent thrombocytopenia despite platelet administration after transplant, along with widespread thrombotic microangiopathy (TMA). In contrast, platelet levels were maintained in bolus hPCC recipients; however, these animals quickly developed large-vessel thrombosis and TMA, leading to graft failure with shortened survival. Recipients of continuous coagulation factor administration experienced either stabilization or an increase in their circulating platelets with escalating doses. Furthermore, transfusion requirements were decreased, and hepatic TMA was noticeably absent in recipients of continuous coagulation factor infusions compared with the historical control and bolus hPCC recipients. This effect was most profound with a continuous, escalating dose of factor VIIa. Further studies are warranted because this regimen may allow for prolonged survival following LXT.

Abstract OT3-01-12: Phase II trial of lapatinib and everolimus for HER2 positive metastatic breast cancer

Background:

Although the treatment of HER2 positive metastatic breast cancer (MBC) has improved with anti-HER2 agents and chemotherapy, most patients will eventually develop resistance to these agents. Preclinical studies have shown that mTOR inhibition may reverse trastuzumab resistance. We hypothesize that combining mTOR inhibitor everolimus with lapatinib will be an effective strategy for patients who have progressed on prior anti-HER2 therapies.

Trial Design:

We are conducting an open-label phase II pilot study of the combination of everolimus and lapatinib for pts with HER-2 positive MBC. Eligible pts must have histologically documented locally advanced (inoperable) or metastatic HER-2 positive breast cancer that have progressed on at least one HER-2 based regimen in the metastatic or locally advanced setting. Pts with disease progression during or within 12 mos of the completion of adjuvant trastuzumab are eligible. Pts with untreated asymptomatic brain metastases are allowed. Pts with symptomatic brain metastases are allowed to enroll after they have completed radiation and are off steroids. Eligible pts are started on everolimus 5 mg PO daily and lapatinib 1250 mg PO daily without interruption. Among subjects progressing on lapatinib, lapatinib is continued and everolimus initiated. Pts will continue to receive treatment until there is evidence of progressive disease (PD), unacceptable toxicity, or withdrawal of consent. Pts will have radiological evaluation every 8 weeks with CT, bone scan, and MRI brain (for pts with known brain metastasis at baseline).

Specific Aims:

Primary objective is to assess the effectiveness of the combination of RAD-001 and lapatinib as measured by the six-month Overall Response Rate in women with MBC who have progressed on trastuzumab and/or lapatinib based therapies. Secondary objectives are six-month PFS, safety and tolerability of the combination, six-month objective CNS response rate, six-month clinical benefit rate of systemic disease, and six-month clinical benefit rate in CNS.

Statistical methods:

The response rate of lapatinib monotherapy in heavily pre-treated patients is estimated to be 7% (Blackwell 2009). For an expected ORR of 17%, a sample size of 45 subjects will provide 79% power to detect the difference at 0.10 Type I error rate according to 1-sided exact binomial test.

Present accrual and target accrual:

The trial has accrued 20 patients with a target accrual of 45 patients.

Citation Format: Barr JA, Sharma P, Fabian CJ, Yeh H, Baccaray S, Springer M, Khan QJ. Phase II trial of lapatinib and everolimus for HER2 positive metastatic breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr OT3-01-12.

Pilot Study Evaluating Regulatory T Cell-Promoting Immunosuppression and Nonimmunogenic Donor Antigen Delivery in a Nonhuman Primate Islet Allotransplantation Model

The full potential of islet transplantation will only be realized through the development of tolerogenic regimens that obviate the need for maintenance immunosuppression. Here, we report an immunotherapy regimen that combines 1-ethyl-3-(3'-dimethylaminopropyl)-carbodiimide (ECDI)-treated donor lymphoid cell infusion (ECDI-DLI) with thymoglobulin, anti-interleukin-6 receptor antibody and rapamycin to achieve prolonged allogeneic islet graft survival in a nonhuman primate (NHP) model. Prolonged graft survival is associated with Treg expansion, donor-specific T cell hyporesponsiveness and a transient absence of donor-specific alloantibody production during the period of graft survival. This regimen shows promise for clinical translation.

Role of Patient Factors and Practice Patterns in Determining Access to Liver Waitlist

Geographic variability in access to care is a persistent challenge in transplantation. Little is known about how patients with end-stage liver disease are chosen for referral, evaluation and listing. Utilizing death certificate data from the Centers for Disease Control and Prevention from 2002 to 2009, estimated liver demand (ELD) was measured by aggregating annual deaths from liver disease and liver transplants performed in each donor service area (DSA). In DSAs with higher ELD, more patients per capita were listed for transplantation (p < 0.001). In addition, listing rates per ELD varied fivefold across DSAs, with more patients per ELD being transplanted in DSAs with higher listing rates (p < 0.001). After adjusting for liver donor risk index and MELD at transplant, there was no association between listing rate and posttransplant survival (HR 1.002, p = 0.77). In addition, DSAs with lower listing rates were more likely to export organs (p < 0.001) of lower liver donor risk index (p < 0.001). Listing sicker patients was associated with increased access to the waitlist and transplantation and more efficient organ utilization, but had minimal effect on posttransplant outcomes after adjusting for the resulting organ shortage.

Socioeconomic status and ethnicity of deceased donor kidney recipients compared to their donors

Public perception and misperceptions of socioeconomic disparities affect the willingness to donate organs. To improve our understanding of the flow of deceased donor kidneys, we analyzed socioeconomic status (SES) and racial/ethnic gradients between donors and recipients. In a retrospective cohort study, traditional demographic and socioeconomic factors, as well as an SES index, were compared in 56,697 deceased kidney donor and recipient pairs transplanted between 2007 and 2012. Kidneys were more likely to be transplanted in recipients of the same racial/ethnic group as the donor (p < 0.001). Kidneys tended to go to recipients of lower SES index (50.5% of the time, p < 0.001), a relationship that remained after adjusting for other available markers of donor organ quality and SES (p < 0.001). Deceased donor kidneys do not appear to be transplanted from donors of lower SES to recipients of higher SES; this information may be useful in counseling potential donors and their families regarding the distribution of their organ gifts.

Subnormothermic machine perfusion for ex vivo preservation and recovery of the human liver for transplantation

To reduce widespread shortages, attempts are made to use more marginal livers for transplantation. Many of these grafts are discarded for fear of inferior survival rates or biliary complications. Recent advances in organ preservation have shown that ex vivo subnormothermic machine perfusion has the potential to improve preservation and recover marginal livers pretransplantation. To determine the feasibility in human livers, we assessed the effect of 3 h of oxygenated subnormothermic machine perfusion (21°C) on seven livers discarded for transplantation. Biochemical and microscopic assessment revealed minimal injury sustained during perfusion. Improved oxygen uptake (1.30 [1.11-1.94] to 6.74 [4.15-8.16] mL O2 /min kg liver), lactate levels (4.04 [3.70-5.99] to 2.29 [1.20-3.43] mmol/L) and adenosine triphosphate content (45.0 [70.6-87.5] pmol/mg preperfusion to 167.5 [151.5-237.2] pmol/mg after perfusion) were observed. Liver function, reflected by urea, albumin and bile production, was seen during perfusion. Bile production increased and the composition of bile (bile salts/phospholipid ratio, pH and bicarbonate concentration) became more favorable. In conclusion, ex vivo subnormothermic machine perfusion effectively maintains liver function with minimal injury and sustains or improves various hepatobiliary parameters postischemia.

HCC patients suffer less from geographic differences in organ availability

It has been suggested that the number of exception model for end-stage liver disease (MELD) points for hepatocellular carcinoma (HCC) overestimates mortality risk. Average MELD at transplant, a measure of organ availability, correlates with mortality on an intent-to-treat basis and varies by donation service area (DSA). We analyzed Scientific Registry of Transplant Recipients data from 2005 to 2010, comparing transplant and death parameters for patients transplanted with HCC exception points to patients without HCC diagnosis (non-HCC), to determine whether the two groups were impacted differentially by DSA organ availability. HCC candidates are transplanted at higher rates than non-HCC candidates and are less likely to die on the waitlist. Overall risk of death trends downward by 1% per MELD point (p = 0.65) for HCC, but increases by 7% for non-HCC patients (p < 0.0001). The difference in the change of mortality with MELD is statistically significant between HCC and non-HCC candidates p < 0.0001. Posttransplant risk of death trends downward by 2% per MELD point (p = 0.28) for HCC patients, but increases by 3% per MELD point in non-HCC patients (p = 0.027), with the difference being statistically significant with p < 0.005. In summary, increasing wait time impacts HCC candidates less than non-HCC candidates and under increased competition for donor organs, HCC candidates' advantage increases.

Clinical benefit in patients with metastatic bone disease: results of a phase 3 study of denosumab versus zoledronic acid

BACKGROUND

Patients with metastatic bone disease are living longer in the metastatic stage due to improvements in cancer therapy, making strategies to prevent the aggravation of bone disease and its complications, such as skeletal-related events (SREs) and pain, increasingly important.

PATIENTS AND RESULTS

In this phase 3 trial in patients with advanced cancer (excluding breast and prostate cancer) or multiple myeloma, denosumab reduced the risk of radiation to bone by 22% relative to zoledronic acid (P = 0.026), prevented worsening of pain and pain interference (2-point increase in Brief Pain Inventory score; P < 0.05 versus zoledronic acid), and reduced the frequency of a shift from no/weak opioid analgesic use to strong opioids (P < 0.05 versus zoledronic acid at months 3-5). Denosumab delayed the time to moderate-to-severe pain compared with zoledronic acid in patients with mild or no pain at the baseline (P = 0.04), supporting early treatment. Health-related quality-of-life scores were similar in both groups. The number needed to treat to avoid one SRE for denosumab was 3 patient-years versus placebo and 10 patient-years versus zoledronic acid.

CONCLUSION

The use of denosumab was associated with better prevention of the complications of metastatic bone disease secondary to solid tumors or multiple myeloma versus zoledronic acid.

Empowerment and its effects on clinical nurses in central China

BACKGROUND

Chinese healthcare institutions have undergone constant changes in recent years. A large number of research studies conducted on work-related factors revealed that nurses in China experienced a low level of job satisfaction and a high level of turnover intention. Empowerment is one of the most important concepts in nursing and is most relevant to the study of nursing professionals' job-related outcomes.

AIM

The aim of this study was to test the Job Characteristics Model and the mediating role of structural empowerment on the relationships between the job characteristics and work-related outcomes among clinical nurses from central China.

METHODS

Three self-reported questionnaires were administered to a sample of 238 clinical nurses from two hospitals in central China. The results were analyzed using descriptive statistics, Pearson's correlation analysis and multiple linear regressions.

FINDINGS

Correlations were significant between job characteristics and job-related outcomes, and the estimated model on the effect of empowerment reduced the unique contribution of job characteristics on internal work motivation (from 17.2% to 13.0%) and general job satisfaction (from 13.4% to 10.1%), and eliminated the unique contribution of job characteristics on growth satisfaction (from 18.4% to 0%).

CONCLUSIONS

The results supported the Job Characteristics Model in a nursing sample and empowerment mediated the impact of job characteristics on internal work motivation and general job satisfaction partially and on growth satisfaction completely.

Donor kidney recovery methods and the incidence of lymphatic complications in kidney transplant recipients

BACKGROUND

Lymphatic leak and lymphocele are well-known complications after kidney transplantation.

OBJECTIVE

To determine the incidence of lymphatic complications in recipients of living donor kidneys.

METHODS

Among 642 kidney transplants performed between 1999 and 2007, the incidence of lymphatic complications was retrospectively analyzed in recipients of living donor kidneys procured by laparoscopic nephrectomy (LP, n=218) or by open nephrectomy (OP, n=127) and deceased donor kidneys (DD, n=297). A Jackson-Pratt drain was placed in the retroperitoneal space in all recipients and was maintained until the output became less than 30 mL/day.

RESULTS

Although the incidence of symptomatic lymphocele, which required therapeutic intervention, was comparable in all groups, the duration of mean±SD drain placement was significantly longer in the LP group-8.6±2.7 days compared to 5.6±1.2 days in the OP group and 5.4±0.7 days in the DD group (p<0.001). Higher output of lymphatic drainage in recipients of LP kidneys could lead to a higher incidence of lymphocele if wound drainage is not provided.

CONCLUSION

More meticulous back table preparation may be required in LP kidneys to decrease lymphatic complications after kidney transplantation. These observations also support the suggestion that the major source of persistent lymphatic drainage following renal transplantation is severed lymphatics of the allograft rather than those of the recipient's iliac space.

Feasibility of a 6-Month Diet, Exercise, and Behavior Modification Intervention for Post-Menopausal Breast Cancer Survivors

Background: Obesity is prevalent in general population and among breast cancer (BrCa) survivors. Weight at diagnosis and weight gain after diagnosis are associated with increased risk of breast cancer recurrence and mortality. Regular exercise similarly reduces the risk of dying from breast cancer. This study was conducted to determine the feasibility of a structured diet/exercise/behavioral intervention program with a goal to achieve a weight loss of 5% or more, and to study the effect of participation in the program on serum biomarkers of breast cancer risk, measures of overall health, strength, and fitness level..Methods: Subjects in this prospective pilot study are female, overweight BrCa survivors with a BMI &gt;25, and who were at least 3 months out of adjuvant chemotherapy. The 6-month combined modality diet/exercise/behavior modification intervention included: 225 minutes per week of cardiovascular exercise in addition to resistance training, a 1200-1500 calorie/day diet including participant purchased pre-packaged meals and low calorie shakes, and a weekly in-person group behavioral meeting. Women were recruited into groups of 10 to15 participants (total n=50), with a planned goal of 4 cohorts, and anticipated complete data collection by December 2009. Participants underwent pre and post intervention assessments including: anthropometric measures, serum biomarkers, fitness test, and questionnaires to assess food frequency, fatigue, and quality of life. Changes over time were assessed using Wilcoxon signed rank test. We present here the data on first 12 women who have completed the 6 month intervention, out of a planned accrual of 50.Results: Since November 2008, 55 women were screened and 38 women agreed to participate in the 6-month intervention (13 in cohort 1; 10 in cohort 2; 15 in cohort 3). Only 1 participant dropped out of cohort 1 due to a non-study related injury. Major reasons for not participating included: already started another weight loss program, timing, and lack of availability for the evening meeting. Mean age of the participants was 50.7 (range 40-57) and mean time from diagnosis to the time of enrollment was 45 months (range 20-132). Eight five percent of the participants received adjuvant or neo-adjuvant chemotherapy and 77% were either currently or had previously taken anti-hormonal therapy.Median weight was 230 lbs (range 165-268) at baseline .and 198 lbs (range 139.6-243.8) at 6 month (median weight loss: 32 lbs or 14%; p=0.00); median BMI was 36.4kg/m2 (range 30.3-45.4) at baseline and 31.54kg/m2 (range 26.4-40.7) at 6-months (p=0.00), median percent body fat by DEXA scan was 50.9 (range 45-58.4) at baseline and 46.3 (range 35.6-55.4) at 6-months (p=0.00). Participants increased their metabolic equivalent task hours per week (MET/HRS) of exercise from 6.6 (range 0-25) at baseline to 20.4 (range11.8-40.5) at 6-months (p=0.01).Conclusion: A 6-month diet/exercise/behavior modification intervention program is feasible and results in a significant decrease in overall weight and percent body fat among overweight breast cancer survivors.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1058.

Transplant center volume and outcomes after liver retransplantation

Liver retransplantation surgery has a high rate of allograft failure due to patient comorbidities and technical demands of the procedure. Success of liver retransplantation could depend on surgeon experience and processes of care that relate to center volume. We performed a retrospective cohort study of adult liver retransplantation procedures performed from January 1, 1996 through December 31, 2005 using registry data from the Organ Procurement Transplantation Network. The primary outcome was 1-year allograft failure. Liver transplant centers were categorized as small, intermediate or high volume by dividing overall liver transplants into three tertiles of approximately equal size. Mean annual volume of overall liver transplants was <50 for low-volume centers, 50-88 for intermediate-volume centers and >88 for high-volume centers. The primary analysis consisted of 3977 liver retransplantation patients. The unadjusted risk of 1-year allograft failure was 37.8%. In multivariable logistic regression, the risk of 1-year allograft failure was not significantly different between low- (reference), intermediate- (OR 0.86, CI 0.72-1.03, p = 0.11) and high-volume centers (OR 0.88, CI 0.74-1.04, p = 0.14). Results were similar when the analysis was limited to retransplantation performed >160 days after initial transplantation. Center volume is an imprecise surrogate measure for 1-year outcomes after liver retransplantation.

Effects of denosumab treatment in breast cancer patients with bone metastases and elevated bone resorption levels after therapy with intravenous bisphosphonates: results of a phase 2 randomized trial

Abstract #1155

Background: Patients with breast cancer-induced bone disease and elevated urine-N-telopeptide (uNTx), a marker of bone resorption, are at increased risk for skeletal complications, disease progression, and death. Receptor activator of NF-kB ligand (RANKL) mediates osteoclastic bone resorption. Denosumab, a fully human monoclonal antibody, inhibits bone destruction by binding and neutralizing RANKL. Denosumab efficacy and safety were assessed in a phase 2, randomized, open-label, active-controlled trial in patients with bone metastases and elevated levels of uNTx after at least 8 weeks of intravenous (IV) bisphosphonate (BP) therapy. We report results in a subset of patients with breast cancer.&#x2028; Methods: Cancer patients with bone metastases and uNTx &gt;50 nM/mM creatinine [Cr] following at least 8 weeks of IV BP therapy were randomized to continue IV BP therapy every 4 weeks (Q4W) or switch to subcutaneous (SC) denosumab injection (180 mg) Q4W or every 12 weeks (Q12W). The primary endpoint was the proportion of patients who achieved uNTx &lt;50 nM/mM at week 13. Safety was also assessed.&#x2028; Results: The study population (N = 111) included 46 patients (41%) with breast cancer; the median time since diagnosis of bone metastases was approximately 1 year in both groups. At week 13, 76% of denosumab-treated patients and 33% of IV BP-treated patients had uNTx &lt; 50 nM/mM. Denosumab-induced suppression of uNTx was rapid (as early as 2 weeks after initial treatment), sustained through week 25, and unaffected by baseline uNTx (Table). In the total study population, adverse events of grade 3, 4, or 5 were reported in 25 (71%) IV BP-treated patients and 40 (55%) denosumab-treated patients.&#x2028; &#x2028; Discussion: Denosumab reduced bone turnover in breast cancer patients with bone metastases and elevated uNTx despite prior IV BP therapy. Phase 3 trials of denosumab in cancer patients with bone metastases are in progress.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1155.

Liver transplantation in the setting of extra-hepatic malignancy: two case reports

Candidates for liver transplantation (OLT) may be found to have an incidental extrahepatic tumor, which is amenable to resection, and may be associated with variable long-term survival. Issues to be considered include: (1) Whether it is possible to define a tumor stage and survival expectancy, which makes the patient an acceptable transplant candidate; (2) Whether cancer surgery should be preformed prior, during, or after OLT; (3) Whether the recipient be placed on immunosuppression that is tailored to address concern related to cancer recurrence. These issues are illustrated in the context of OLT and nephrectomy for renal cell carcinoma (RCC). Two patients underwent a simultaneous OLT and curative radical nephrectomy for stage 1 RCC that was incidentally discovered during OLT evaluation, one of whom received a simultaneous kidney transplant. At 51 and 14 months postoperatively, the patients are alive and healthy, with no tumor recurrence. In selected extrahepatic malignancies, simultaneous curative resection and OLT may provide the optimal outcome. This is justifiable when curative cancer-related life expectancy exceeds OLT-expected graft and patient survival. Concomitant transplantation and cancer surgery provides an acceptable cancer-free survival, avoiding the high morbidity observed when cancer resection is done in the presence of decompensated liver disease.

Structure of the elastin gene

The isolation and characterization of cDNAs encompassing the full length of chicken, cow, rat and human elastin mRNA have led to the elucidation of the primary structure of the respective tropoelastins. Large segments of the sequence are conserved but there are also considerable variations which range in extent from relatively small alterations, such as conservative amino acid substitutions, to variation in the length of hydrophobic segments and largescale deletions and insertions. In general, smaller differences are found among mammalian tropoelastins and greater ones between chicken and mammalian tropoelastins. Although only a single elastin gene is found per haploid genome, the primary transcript is subject to considerable alternative splicing, resulting in multiple tropoelastin isoforms. Functionally distinct hydrophobic and cross-link domains of the protein are encoded in separate exons which alternate in the gene. The introns of the human gene are rich in Alu repetitive sequences, which may be the site of recombinational events, and there are also several dinucleotide repeats, which may exhibit polymorphism and, therefore, be effective genetic markers. The 5' flanking region is G+C rich and contains potential binding sites for numerous modulating factors, but no TATA box or functional CAAT box. The basic promoter is contained within a 136 bp segment and transcription is initiated at multiple sites. These findings suggest that the regulation of elastin gene expression is complex and takes place at several levels.

Use of cell-based therapies for modification of host immune responses

The success of adoptive cellular therapy depends on the ability to select optimally or produce cells genetically with the desired antigenic specificity, and then induce cellular proliferation while preserving the effector function, engraftment, and homing abilities of the lymphocytes. Unfortunately, many previous clinical trials were carried out with adoptively transferred cells that were propagated in what are now understood to be sub-optimal conditions that impair the essential functions of the adoptively transferred cells. This article reviews some of the lessons and developments emerging from the past 20 years of adoptive immunotherapy trials and basic immunology regarding immunogenicity, T cell homeostasis, and the maintenance of tolerance and repertoire.