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Background & Aims: Metastasis indicates a grave prognosis in patients with hepatocellular carcinoma (HCC). Our previous studies showed that RNA binding motif protein Y-linked (RBMY) is potentially a biomarker for poor survival in HCC patients, but its role in metastasis is largely unclear. Methods: A total of 308 male patients with primary HCC were enrolled. RBMY expression was traced longitudinally by immunostaining from the manifestation of a primary HCC tumor to the formation of a distant metastasis, and its upstream regulators were screened with a protein microarray. A series of metastasis assays in mouse models and HCC cell lines were performed to explore new functional insights into RBMY. Results: Cytoplasmic expression of RBMY was associated with rapid distant metastasis (approximately 1 year after resection) and had a predictive power of 82.4% for HCC metastasis. RBMY conferred high migratory and invasive potential upon phosphorylation by the provirus integration in Moloney 1 (PIM1) kinase. Binding of PIM1 to RBMY caused mutual stabilization and massive translocation of RBMY from nuclei to mitochondria, thereby preventing mitochondrial apoptosis and augmenting mitochondrial generation of adenosine triphosphate/reactive oxygen species to enhance cell motility. Depletion of RBMY suppressed Snail1/zinc finger E-box binding homeobox transcription factor 1–mediated epithelial–mesenchymal transition and dynamin-related protein 1–dependent mitochondrial fission. Inactivation and knockout of PIM1 down-regulated the expression of RBMY. In nude mice, cytoplasmic RBMY promoted liver-to-lung metastasis by increasing epithelial–mesenchymal transition, mitochondrial proliferation, and mitochondrial fission, whereas nuclear-restricted RBMY impeded the mitochondrial switch and failed to induce lung metastasis. Conclusions: This study showed the regulation of HCC metastasis by PIM1-driven cytoplasmic expression of RBMY and suggested a novel therapeutic target for attenuating metastasis.

Background: Practical barriers exist in applying threshold-concept–based clinical teaching. We applied the practice model to the subject of acute liver failure and reported the experiences in teaching and learners’ reactions. Methods: The course comprised a 10-min online preclass video and a 1-h class with in-depth discussion. The video explained six extracted threshold concepts, which were labelled TC1–TC6. Three sets of feedback questionnaires were given to students. Questionnaires were provided after they watched the online video (Q1), after class (Q2), and before the end of the curriculum section (Q3). All the feedback questionnaires were analysed. Results: Of the 136 attendees in the academic year 2018, 127 (93.4%), 69 (50.7%), and 112 (82.4%) completed the Q1, Q2, and Q3 questionnaires, respectively, and 48 (42.6%) provided comments. The degree of comprehension varied among threshold concepts and individual students. TC1 and TC2 were viewed as transformative for all three surveys. The threshold-concept-based learning process was satisfactory, and students could auto-reflect on the defining features of a threshold concept. Students became aware of their deficiencies in knowledge and acknowledged room for development with regard to their mindset for future patient management. Conclusion: Threshold-concept–based clinical teaching is a feasible strategy. Students' reflections indicate that thresholds were crossed, which does not guarantee that students’ mindsets are ready for future clinical practice.

Background/purpose: To investigate the role of microRNA (miRNA) dysregulation in liver cancer by assessing the miRNA profiles of human hepatic stem cells (HpSCs), marker-carrying human hepatoblastoma (HB) cells, and hepatocellular carcinoma (HCC) cells vs. those of fetal hepatocytes. Methods: We subjected human HCC and HB tumor specimens to immunohistochemical (IHC) staining for markers of HpSCs. We analyzed the miRNA patterns of HpSCs, HCC cells, HB cells, and fetal hepatocytes using microarray analysis, with confirmation via quantitative real-time polymerase chain reaction. The roles of the miRNAs in liver cancer stem cells (CSCs) were also elucidated. Results: The epithelial cell adhesion molecule (EpCAM) was the most prevalent HpSCs marker in human HB and HCC tumor cells and hepatoma cells. EpCAM-positive HB and HCC cells exhibited greater self-renewal and tumorigenicity than their EpCAM-negative counterparts or EpCAM-positive fetal hepatocytes. In EpCAM-positive fetal hepatocytes, miR-126 expression level increased with gestational age. The EpCAM-positive HB cells exhibited downregulation of miR-126 in comparison to EpCAM-positive fetal hepatocytes. An miR-126 mimic reduced sphere and colony formation in, and induced apoptosis of, HB cells. In comparison to EpCAM-positive fetal hepatocytes, EpCAM-positive HCC cells exhibited downregulation of miR-126, miR-144, and miR-451. Transfection of miR-126, miR-144, and miR-451 induced apoptosis of, and reduced sphere and colony formation in, HCC cells. Conclusion: Dysregulation of liver developmental miRNAs, which exert a tumor suppressant effect, in EpCAM-positive HpSCs may contribute to liver carcinogenesis by promoting the transformation of HpSCs to CSCs of HB and HCC.

Summary: Objective: Morbidity rates after living donor hepatectomy vary greatly among centers. Donor morbidity in a tertiary center over the past two decades was revisited. Methods: Clinical data and grading of complications were reviewed by a nontransplant surgeon based on Clavien 5 tier grading. Risk factors were analyzed. Results: In total, 473 consecutive living liver donors from 1997 to 2016 were included for analysis; 305 were right liver donors and 168 left liver donors, and the corresponding morbidity rates were 27.2% and 9.5%. The majority (81/99, 81.2%) of complications were grade I and II. Donors with morbidity compared with those without were significantly younger, nonoverweight body figure (BMI

Background: Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-related mortality in Taiwan. To help clinical physicians to manage patients with HCC, the Taiwan Liver Cancer Association and the Gastroenterological Society of Taiwan produced the management consensus guideline for HCC. Methods: The recommendations focus on nine important issues on management of HCC, including surveillance, diagnosis, staging, surgery, local ablation, transarterial chemoembolization/transarterial radioembolization/hepatic arterial infusion chemotherapy, systemic therapy, radiotherapy, and prevention. Results: The consensus statements were discussed, debated and got consensus in each expert team. And then the statements were sent to all of the experts for further discussion and refinement. Finally, all of the experts were invited to vote for the statements, including the level of evidence and recommendation. Conclusion: With the development of the management consensus guideline, HCC patients could benefit from the optimal therapeutic modality. Keywords: Diagnosis, Hepatocellular carcinoma, Staging, Surveillance, Treatment

Postoperative acute lung injury (ALI) after liver transplantation is clinically relevant and common. The perioperative thoracic fluid indices changes as well as the association with ALI in liver transplantation have not been thoroughly investigated. Methods: A total of 52 consecutive adult recipients for elective living donor liver transplantation were enrolled. Each recipient received the same perioperative care plan. Thoracic fluid indices, including the cardiac index, intrathoracic blood volume index (ITBVI), extravascular lung water index (EVLWI), and pulmonary vascular permeability index (PVPI), were obtained at seven time points (pretransplantation, anhepatic phase, 30 minutes after reperfusion, 2 hours after reperfusion, and postoperative days 1–3) using the pulse contour cardiac output system. The indices of those who developed ALI (PaO2/FiO2

The effect of rituximab on B cell and immunoglobulin production after therapeutic apheresis has not been studied in ABO-incompatible renal transplant patients. Methods: Twenty consecutive ABO-incompatible renal transplant patients receiving rituximab induction and double filtration plasmapheresis were enrolled; one case was excluded because of repeated plasmapheresis and immunoglobulin therapy (Incompatible group). The B cell count of the Incompatible group was compared to another group of 18 ABO-compatible renal transplant patients who were operated on during the same period (Compatible group). In the Incompatible group, the total IgM, IgG, and IgG1-4 subclasses after transplantation were compared to those before desensitization. Tacrolimus, mycophenolate mofetil, and steroids were used for both groups. Results: The B cell count of the Incompatible group was significantly lower than the Compatible group post-transplant from Month 1 to Month 11 only. The B cell count of the Compatible group also decreased for the first 6 months, suggesting that maintenance immunosuppressive agents suppress B cells. Total IgG and IgM levels after transplantation were significantly lower than before desensitization during the 24-month follow-up period. The post-transplant IgG3 level was significantly lower than before desensitization for only 3 months. Conclusion: With the aid of tacrolimus and mycophenolate mofetil, rituximab resulted in sustained suppression of B cell count and total IgG and IgM. Among the IgG subclasses, IgG3 was less sensitive to rituximab.

Background: Minimally invasive liver resection is feasible for select patients. The flexibility of robotic surgical instruments improves the possibility of minimally invasive liver resection, even in challenging major liver resection. Materials and methods: We accumulated 69 patients who underwent pure laparoscopic liver resection from 2007 to 2011, and 52 patients who underwent robotic-assisted minimally invasive liver resection in 2012. The patients' characteristics, surgical procedures, and perioperative parameters were described and compared between these two groups. Results: In 2012, we performed 56 robotic hepatobiliary procedures, which included 52 (92%) robotic-assisted minimally invasive liver resection procedures. Under the assistance of a robotic system, we increased the number of patients undergoing minimally invasive liver resection by more than twofold, and we increased the percentage of minimally invasive surgery for patients with fresh hepatocellular carcinoma, compared to our laparoscopic group (44% vs. 15%, respectively). We also increased the percentage of major hepatectomy for minimally invasive liver resection by a robotic approach (39% vs. 15%) with a comparable conversion rate (5%) and morbidity (8%), compared to the laparoscopic group. We can even perform a challenging living donor liver harvest procedure with a robotic-assisted minimally invasive approach. Conclusion: Robotic assistance increased the percentage of minimally invasive liver resections and the percentage of major minimally invasive liver resections with comparable perioperative results. Robotic-assisted minimally invasive liver resection is feasible, but its role needs more accumulated experience to clarify.

A long-term retrospective study was conducted to assess the risk factors of renal transplant graft failure focusing on the effects of gender of both the donor and the recipient. Methods: Medical records of primary renal transplantation performed in a single transplant hospital were reviewed. Cases of ABO incompatibility, positive cross-matches, or multiple organ transplants were excluded. A total of 766 patient records were reviewed, and variables were analyzed with Kaplan–Meier survival curves and Cox regression to determine the independent factors associated with graft survival. Results: The overall 5-year graft and patient survival rates were 84.7% and 92.2%, respectively. Univariate analysis showed significantly poorer prognosis in male patients and in those with acute rejection, delayed function, or more mismatches in human lymphocyte antigens. Multivariate analysis with step-wise regression identified three independent prognostic factors for poor graft survival (male gender, acute rejection, and delayed function). The 5-year graft survival rates for female and male patients were 87.9% and 81.3%, respectively. The risk ratio of graft failure for male renal transplant recipients was 1.3732, when compared with that for female patients. The risk ratios for those with acute rejection and delayed function were 1.8330 and 1.5422, respectively. Conclusion: Male gender, in addition to acute rejection and delayed function, was found to be an independent prognostic factor for poor renal transplant survival in this long-term retrospective study.

Background/Objective: As renal transplantation may increase survival rates and improve quality of life for children with end-stage renal disease, we investigated the long-term outcomes and prognostic factors of pediatric renal transplantation. Methods: A retrospective study was conducted to review 25 pediatric renal transplantations, either from live or deceased donors, in our hospital from 1995 to 2008. The cumulative graft survival rate was calculated using the Kaplan-Meier method. Log rank tests were employed to identify categorical prognostic factors for graft survival of the pediatric renal transplantations, and Cox regression analysis for numeric factors. Results: The mean age of our study subjects was 11.63 ± 3.76 years, and the mean follow-up period was 49.24 ± 33.72 months. The 12-month and 36-month graft survival rates were 92% and 82.14%, respectively. The rejection-free survival rates were 88% and 72.88% in the first and third years, respectively. All of the patients were alive during the follow-up period. Acute rejection (p = 0.0175) and male sex (p = 0.0384) were found to be significant factors for graft survival. Conclusion: For pediatric patients, we found that renal transplantation is now a safe and effective surgical procedure for children with end-stage renal disease. Acute rejection and male gender were identified as prognostic factors for poor graft survival.

Background/Objective: Hepatocyte transplantation is a promising alternative to liver transplantation in children with liver metabolic disorders and acute liver failure. Currently, it is difficult to assess rapidly hepatocyte function before transplantation. The aim of this study was to investigate whether the uptake and release of indocyanine green (ICG) by hepatocytes could be used. Methods: Human hepatocytes (106 cells) isolated from unused donor livers were incubated at 37°C for 30 minutes with ICG (0–2 mg/mL) in both cell suspension and on collagen-coated culture plates. Cells were then incubated in medium without ICG for 3 hours with supernatants collected at 1, 2 and 3 hours for measurement of ICG release. Cell viability was determined by trypan blue exclusion, (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay (mitochondrial dehydrogenase activity) and sulforhodamine B (SRB) assay (cell attachment). HepG2 cells were also used. Results: ICG was taken up and secreted by hepatocytes with the release reaching a plateau level soon after 1 hour. Concentrations of ICG > 1.0 mg/mL had toxic effects on hepatocytes. Hepatocytes incubated with 1.0 mg/mL ICG had higher mitochondrial dehydrogenase activity compared to 0.5 mg/mL ICG or control cells (0.025±0.0004 OD unit vs. 0.019±0.0008 OD unit or 0.020±0.002 OD unit, p

Biliary complications remain a major weakness of liver transplantation. The purpose of this retrospective study was to determine risk factors associated with biliary complications after liver transplantation, and how they were managed. Methods: From October 1989 to December 2007, we collected all variables of interest in 253 consecutive liver transplant recipients at the National Taiwan University Hospital. Risk factors and the outcome of different treatments of the biliary complications were analyzed. Results: Forty-three (17.0%) of the 253 liver transplant patients developed biliary complications. Bile leakage and biliary stricture rate was 7.9% and 6.7%, respectively. By univariate analysis, risk factors associated with bile leakage were older age, cadaveric liver donation, and use of a T-tube. The only protecting factor against bile leakage was the use of a straight intrahepatic stent. Risk factors associated with biliary stricture were rejection and male sex. Multivariate analysis demonstrated that T-tube [odds ratio (OR) =3.45] and older age group (OR =7.98) were the only independent risk factors for bile leakage, whereas graft rejection (OR =4.89) and male sex (OR =5.56) were the only independent risk factors for biliary stricture. Percutaneous transhepatic cholangiography drainage (37.2%) or computed-tomography-guided drainage (27.9%) was the most frequent initial treatment. Biliary event-free rate after initial treatment was 67.6% and 66.7% in the non-surgical and surgical group, respectively. Conclusion: The risk factors for bile leakage and biliary stricture were different due to different pathogenesis. Straight biliary stent in our series showed a protective effect against bile leakage. Non-surgical management can be a highly successful initial treatment, and surgery should be reserved for patients who have failed conservative treatment.

Background/Purpose: Combined therapy of sirolimus and cyclosporine has been found to exacerbate cyclosporine-related nephrotoxicity and to imperil graft renal function. We hypothesized that tacrolimus could bring about better renal function than cyclosporine when used in combination with sirolimus and corticosteroids for de novo renal transplantation. Methods: A two-arm randomized study was conducted to test the hypothesis. Patients who gave written informed consent and received renal transplantation were randomized to take sirolimus in combination with either tacrolimus or cyclosporine. The primary endpoint of this study was renal function, and the secondary endpoints were acute rejection, graft and patient survival, metabolic side effects and infectious complications. Results: A total of 41 Taiwanese renal transplant patients were randomized to receive cyclosporine (CsA group, n = 20) or tacrolimus (TAC group, n = 21) in combination with sirolimus and corticosteroids. The average estimated glomerular filtration rate (eGFR) was 52.77 ± 3.86 mL per minute for the TAC group at 6 months, and 46.42 ± 3.95 mL per minute for the CsA group (p > 0.05). At 12 months, the average eGFR was 52.04 ± 4.38 mL per minute for the TAC group, and 46.79 ± 4.38 mL per minute for the CsA group (p > 0.05). The biopsy-proven acute rejection rate of the TAC group was 4.76% (1/21), and that of the CsA group was 5.00% (1/20) at 12 months. The 12-month graft survival rates for the TAC and CsA groups were 100% and 90% (p = 0.142), respectively. Conclusion: Our study demonstrated that concomitant tacrolimus and sirolimus therapy resulted in a favorable outcome in Taiwanese renal transplant patients at 12 months. Large-scale clinical trials will be needed to further address the issue of which calcineurin inhibitor, cyclosporine or tacrolimus, provides better renal function and graft survival for renal transplant patients.

Recent three-dimensional multidetector row computed tomography (3D MDCT) can provide detailed images of a gastric tumor, including its general contour, location and depth. We therefore evaluated the efficacy of MDCT in the differential diagnosis and staging of gastric tumors in patients prepared for surgery. Methods: Seventy-nine patients with gastric tumors identified by gastric optical endoscopy were admitted for preoperative evaluation. All patients received double-contrast barium meal (DCBM) study and abdominal MDCT with 3D reconstruction before surgery. We compared the accuracy of MDCT with DCBM study in detecting and differentiating gastric tumors. In addition, the MDCT findings were correlated with surgical and pathologic results in gastric cancers for Borrmann type, T and N stages. Results: Among the 79 patients with gastric tumors, there were 24 cases of early gastric cancer, 40 cases of advanced gastric cancer, 12 cases of gastrointestinal stromal tumor, and three cases of gastric lymphoma. Both MDCT and DCBM were very accurate in picking up the lesions (100%). The diagnostic accuracies of MDCT and DCBM were similar (94% vs. 96%) in differentiating mucosal and submucosal lesions as well as classification of Borrmann type in advanced gastric cancer (70% vs. 63%). In 64 patients with gastric cancers, there was good correlation between MDCT images and pathology in 73% of T staging and 69% of N staging. Conclusion: MDCT has a similar high accuracy in the preoperative diagnosis of different gastric tumors compared with DCBM and provides additional information including tumor depth, lymph node and hepatic metastasis. Therefore, MDCT may be used as a primary tool for preoperative tumor diagnosis and staging.

A 47-year-old man with chronic hepatitis B had progressive elevated oc-fetoprotein of 2 years' duration. A pancreatic tail tumor, instead of liver tumor, was detected. He underwent elective distal pancreatectomy and splenectomy and the pathology turned out to be acinar cell carcinoma of the pancreas. Serum level of oc-fetoprotein returned to normal soon after surgery. No cancer recurrence was noted after 3 years of follow-up. Alpha-fetoprotein is commonly used as a tumor marker to screen for hepatocellular carcinoma in high-risk patients. However, elevated oc-fetoprotein could occur in a much rarer disease, acinar cell carcinoma of the pancreas.

Intrahepatic portal vein aneurysm is rare and its natural history is unknown. A 22-year-old healthy man, who wished to donate part of his liver to his diseased father, was incidentally diagnosed to have an intrahepatic portal vein aneurysm. The surgical decision of performing live donor hepatectomy for such a patient is normally difficult. We combined modern imaging reconstruction technologies with scientific computing as a new modality to foresee the risks of surgical complications. Methods: Cross-sectional computed tomography images were used to reconstruct the three-dimensional image of portal vein distribution using the 3D-Doctor v3.5 software. The reconstructed images were further employed to generate surface and interior meshes with CFX software. Simulated hemodynamic changes in velocity, pressure, and wall stress were determined for the right lobectomy case pre- and postoperatively Results: The simulation results indicated that aneurismal pressure would be elevated significantly to 12.03 mmHg after operation. The left segmental portal venous blood flow would increase from 2.95- to 4.25-fold. The area near the branch point of one left segmental portal vein, which supplies blood to liver segment 4, and the portal vein aneurysm would endure high shear stress gradient. The resulting elevated aneurismal pressure may cause the thin wall to enlarge and rupture, while the high shear stress gradient would lead to vascular endothelial cell injury. Living donor surgery was not recommended hemodynamically based on the simulated results. Conclusion: Scientific computing and modern imaging technologies can be applied together to aid surgeons to make the best decision in difficult clinical situations.

Objective: G-protein-coupled receptor 30 (GPR30) has been reported to be a novel estrogen receptor a (ERa) in vitro. Therefore, the interactions among GPR30, ERa, progesterone receptor (PR) and human epidermal growth factor receptor-2 (HER-2/neu), and their prognostic utilities in the infiltrating ductal carcinoma (IDC) of the breast were evaluated. Materials and Methods: Messenger RNA (mRNA) levels of GPR30, ERa, PR and HER-2/neu in the tumor samples of 118 Taiwanese IDC patients and 27 non-tumor mammary tissues were measured via quantitative polymerase chain reaction analyses. The correlations of GPR30 mRNA levels with clinical parameters, i.e. tumor/non-tumor, ERa, PR, HER-2/neu, age, lymph node metastasis, lymph–vascular invasion, grade, stage and patient survival, were assessed by using appropriate statistical analyses. Results: GPR30 expression was observed to be lower in IDC (p < 0.001) than in non-tumor mammary tissues. Importantly, GPR30 mRNA level was positively correlated with that of ERa (p = 0.001) and PR (p = 0.001) but not correlated with that of HER-2/neu when they were analyzed as continuous variables. However, lower GPR30 was noticed in tumors with HER-2/neu protein overexpression. GPR30 expression was not correlated with age, lymph node metastasis, lymph–vascular invasion, grade and stage in IDC. GPR30 expression was not an independent prognostic factor for patient survival. Conclusion: GPR30 expression is downregulated in IDC. GPR30 is preferentially co-expressed with ER and/or PR but is lowly expressed in HER-2/neu(+) tumors. The correlation of GPR30 expression with clinical parameters, including patient survival, was not evident in this cohort.

Information is needed on renal function improvement after late elimination of calcineurin inhibitors (CNIs) and conversion to combined therapy of sirolimus (SRL) and mycophenolate mofetil (MMF) in Asian renal transplant recipients. Methods: A single-arm prospective study was undertaken to assess the outcome of stable Taiwanese renal transplant recipients who had CNI withdrawn and received combined SRL and MMF therapy. The primary endpoints were acute rejection and renal function. The secondary endpoints were graft and patient survival, side effects and infectious complications. Therapeutic drug monitoring of SRL and MMF was conducted during the study period. Results: Thirty patients were recruited at 9-72 (31.7 ± 18.6) months post-transplantation. The graft and patient survival rates were both 100% at 12 months, though one of the 30 patients (3.33%, 1/30) had biopsy- proven acute rejection. On paired t test, the estimated glomerular filtration rates (GFR) from 4 to 12 months were significantly higher than the baseline GFR. The average trough level of SRL was 7.38 ± 3.74 ng/mL at 12 months and the average abbreviated area under the concentration curve of mycophenolic acid was 64.86 ± 36.62 mg/L·hour at an average MMF dose of 1.56 ± 0.45 g/day. However, two patients (6.67%, 2/30) had tuberculosis (TB) reactivation at 3 and 4 months, respectively, after the combined SRL and MMF therapy. Conclusion: Conversion to combined SRL and MMF therapy improved renal function in stable renal transplant recipients, though the risk of TB reactivation should be kept in mind when the combined therapy is employed in the Asian countries with a high prevalence of TB.

Gene expression profiles of liver regeneration are well explored in rat models. However, there are limited relative data in humans. This study aimed to show that mRNA expression profiles change immediately after right hepatectomy in living-related donors and correlate with mechanisms of liver regeneration reported in the literature. Methods: Prospective study was conducted from March 2003 to August 2004. Living-related donors who donated right lobe of liver were included. Liver biopsies were performed at the beginning and, 5 hours later, at the end of liver resection. RNAs were isolated to synthesize cRNA. Oligo DNA microarray experiments were conducted and paired signal intensity ratios (Cy3/Cy5) were normalized with rank-invariant global Lowess regression analysis by taking base two logarithms. Genes whose average residuals more than 2.5-fold increased or less than −2.5-fold decreased were selected to get the most pronounced expression changes during this period. Results: Five of 34 donors were included with qualified samples. The expression patterns of paired DNA microarray experiments were similar in five donors. A total of 28 upregulated and 14 downregulated genes were collected. Acute-phase proteins (serum amyloid A, complement-reactive protein, heme oxygenase-1) were up-regulated. Genes related to growth signal transduction (G-protein coupled receptor-30) were downregulated. Conclusion: Gene expression profiles immediately after partial hepatectomy were reported first in humans with the techniques of oligo DNA microarray, which were compatible with the initial gene expression patterns of liver regeneration in rats. [J Formos Med Assoc 2007;106(4):288-294]

The serious shortage of cadaveric organs has prompted the development of ABO-incompatible live donor renal transplantation. We report our experience of the initial two live donor ABO incompatible renal transplants at our hospital. The first patient was a 55-year-old type A female who received a kidney from her AB type husband. The second patient was a 27-year-old type O male who received renal transplantation from his type A father. Preconditioning immunosuppressive therapy in the two patients with tacrolimus, mycophenolate mofetil and methylprednisolone was started 7 days before transplantation. During the period of preconditioning, double filtration plasmapheresis (DFPP) was employed to remove anti-A and -B antibodies. Laparoscopic splenectomy and renal transplantation were performed after the anti-donor ABO antibodies were reduced to a titer of 1:4. Rituximab, a humanized monoclonal anti-CD20 antibody, was administered to the second patient due to a rebound in the anti-A antibody titer during the preconditioning period. Under a tacrolimus-based immunosuppressive regimen, both patients recovered very well without any evidence of rejection. Serum creatinine levels were 1.0 and 1.4 mg/dL at 6 and 3 months after transplantation, respectively. These cases illustrate that with new immunosuppressive agents, DFPP and splenectomy, ABO-incompatible renal transplantation can be successfully conducted in end-stage renal disease patients whose only available live donors are blood group incompatible.

Conventional training in bronchoscopy may increase patient's discomfort and procedure-related morbidity. Computer-based bronchoscopy simulator (CBBS) permits the acquisition and evaluation of the necessary skills through a realistic bronchoscopic experience. This study was conducted to validate the use of a CBBS system developed in Taiwan as a learning and assessment tool. Methods: Twenty novice bronchoscopists and 10 expert bronchoscopists were enrolled as subjects in this prospective study. The 20 novice bronchoscopists were randomized into two groups, which received conventional bronchoscopic training or CBBS training and then completed a satisfaction survey. Subsequently, the novices who received CBBS training underwent an observational performance trial and the results were compared with those of expert bronchoscopists. All 10 expert bronchoscopists completed a realism survey and observational trial after CBBS performance. Results: The satisfaction survey showed that the CBBS training program significantly increased participants' satisfaction (p = 0.002) and interest in learning (p < 0.001). The realism survey by the 10 expert broncho-scopists indicated that CBBS provides a favorable degree of realism with regard to the mechanical and visual parameters examined. Analysis of the performance results showed that the following parameters were capable of differentiating the participants by level of expertise: total procedure time (p = 0.002), percentage of bronchial segments entered (p = 0.012), percentage of bronchial segments identified (p

Nodular goiter is a common disease in Taiwan, and substernal or intrathoracic goiters are not infrequent. However, intrathoracic goiters are mainly of the secondary type and primary intrathoracic goiters are rarely seen. We report a 55-year-old woman who was incidentally found to have an ectopic goiter located in the anterior upper mediastinum with the initial presenting symptom of productive cough. Imaging studies including chest X-ray and computed tomography identified the lesion, and 131I-uptake scan showed weak uptake in the thorax. Surgical removal via thoracotomy was performed and the diagnosis was confirmed by pathology. A primary intrathoracic goiter, although rare, should also be considered in the differential diagnosis of mediastinal tumor.

Immune thrombocytopenic purpura (ITP) is a rare complication after liver transplantation. Infection with cytomegalovirus (CMV) is a frequent complication of organ transplantation and may induce autoimmune diseases, such as ITP. We report a case of ITP after primary CMV infection in a 3-year-old boy recipient of living-related orthotopic liver transplantation (OLT). The ITP developed 2 years after OLT in this patient who had received tacrolimus as an immunosuppressive agent, with nadir platelet counts of 5000/mm3 in 2 weeks. The patient was treated with two courses of intravenous gamma globulin (1 g/kg/day for 2 days) and subsequent oral prednisolone (1.3 mg/kg/day for 2 weeks). He recovered from thrombocytopenia 4 weeks later. An inadequate immunosuppression, as evident by the low serum tacrolimus level (5.8 ng/mL before the episode of ITP) in this patient, may allow the development of ITP after CMV infection. [J Formos Med Assoc 2007;106(4):327-329]