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Surgical site infections (SSIs) after liver transplantation (LT) are associated with an increased risk of graft loss and death. The incidence of SSIs after LT and their risk factors have been determined for first LT but not for second LT. The importance of reporting the incidence of SSIs risk-stratified by first LT versus second LT is not known. All patients undergoing second LT at a single institution between 2003 and 2011 (n = 152) were reviewed. The Kaplan-Meier method was used to estimate the cumulative SSI incidence. Relative risks (RRs) and 95% confidence intervals (CIs) from Cox proportional hazards regression models were used to evaluate associations of potential risk factors with SSIs after second LT. Thirty-one patients developed SSIs (6 superficial SSIs, 1 deep SSI, and 24 organ/space SSIs). The cumulative incidence of SSIs 30 days after LT was 20.8% (95% CI = 14%-27%), which was slightly but not significantly higher than the previously reported incidence of SSIs after first LT at our institution between 2003 and 2008 (16%, RR = 1.32, 95% CI = 0.90-1.93, P = .16). Units of transfused red blood cells [RR (doubling) = 1.38, 95% CI = 1.02-1.86, P = .04] and hepaticojejunostomy (RR = 2.22, 95% CI = 1.05-4.72, P = .04) were the only factors associated with SSIs after second LT in single-variable analysis. The associations weakened in a multivariate analysis (P = .07 and P = .07, respectively), potentially because of the correlation of red blood cell transfusions and hepaticojejunostomy (P = .08). In conclusion, the incidence of SSIs after second LT was slightly higher but not significantly different than the published incidence of SSIs (16%) after first LT at the same institution. Significant independent risk factors for SSIs after second LT were not identified. Risk stratification for retransplantation may not be necessary when the incidence of SSIs after LT is being reported.

Patients with an acute exacerbation of idiopathic pulmonary fibrosis (AE-IPF) have extremely poor prognosis. Lung transplantation (LT) is not routinely performed in this group. Our study compares outcomes after LT in patients with IPF with and without an acute exacerbation at the time of LT. Of forty-one patients with IPF who underwent LT, fourteen were identified as having AE-IPF at the time of hospitalization. Descriptive statistics for the groups were compared using the Mann-Whitney test and the Fisher9s exact test. Survival data were evaluated using the log-rank test and Kaplan-Meier plots. Patients with AE-IPF had higher mean pulmonary artery pressures prior to LT (44.3 mmHg for AE-IPF, 27.0 mmHg for IPF, p = 0.002), and spent more days in hospital prior to LT (7.6 days for AE-IPF, 0.6 days for IPF, p = 0.004). Histological exam of explanted tissue showed diffuse alveolar damage on a interstitial pneumonia background, fibroblastic foci, and honeycombing. Secondary causes for exacerbation such as cytopathologic changes or evidence of chronic thromboemboli were not seen. The median hospital stay was 14.5 days for AE-IPF patients and 13.0 days for IPF patients (p = 0.762). The median ICU stay was 7 days for AE-IPF patients and 9 days for the IPF patients (p = 0.516). Median follow-up was 18 months (0 – 64 months). 90-day survival was 85.7% for the AE-IPF patients and 81.5% for the IPF patients (p = 0.678). One-year survival was 78.6% for the AE-IPF and 77.8% for the IPF groups, respectively (p = 0.865). In this cohort, similar clinical outcomes were observed in patients undergoing LT for AE-IPF and IPF. LT may be a viable option in patients with AE-IPF.

Following introduction of effective antiviral prophylaxis, recurrent hepatitis B after liver transplantation (LT) has become a rare event.From 1998 to 2001, 402 patients underwent 467 LTs at our center including 24 individuals (28 LTs) with chronic hepatitis B. All patients received HBIg prophylaxis; 23 in combination with lamivudine and one (YMDD mutant) received adefovir.Eleven patients (46%) had HCC (five outside the Milan criteria); only one died from tumor recurrence four years post LT. The one-year graft and patient survival were 87% and 92%, respectively. Currently 19 patients (79%) are alive with well functioning grafts (minimum follow up of7 years). No patient developed recurrent hepatitis B; 12 currently receive lamivudine/HBIg, 3 lamivudine monotherapy, 3 discontinued antivirals. Follow up liver biopsies showed minimally active or no active hepatitis and negative HBV immunostains in all patients. Long term comorbid conditions included hypertension (77%), chronic renal failure (50%), diabetes mellitus (77%), hyperlipidemia (36%), obesity (55%), malignancies (37%) and neuropsychiatric disorders (55%). During the study period, 24 individuals (6%) were transplanted for chronic hepatitis B as opposed to only 38 individuals (3.3%) from 2002 to 6/2008 (1298 LTs in 1162 patients).LT for chronic HBV produced excellent long term results despite inclusion of patients with HCC outside the Milan criteria. Long term medical complications must be considered. Indication for LT for chronic HBV is declining but long term development of resistance remains a matter of concern.

One of the hallmark findings in patients suffering from SARS (severe acute respiratory syndrome) is lymphopenia, which is the result of massive lymphocyte death. SARS-CoV (SARS coronavirus), a novel coronavirus that has been etiologically associated with SARS cases, is homologous with MHV (murine hepatitis coronavirus), and MHV small envelope E protein is capable of inducing apoptosis. We hypothesized that SARS-CoV encodes a small envelope E protein that is homologous with MHV E protein, thus inducing T-cell apoptosis. To test this hypothesis, a cDNA encoding SARS-CoV E protein was created using whole gene synthesis. Our results showed that SARS-CoV E protein induced apoptosis in the transfected Jurkat T-cells, which was amplified to higher apoptosis rates in the absence of growth factors. However, apoptosis was inhibited by overexpressed antiapoptotic protein Bcl-xL. Moreover, we found that SARS-CoV E protein interacted with Bcl-xL in vitro and endogenous Bcl-xL in vivo and that Bcl-xL interaction with SARS-CoV E protein was mediated by BH3 (Bcl-2 homology domain 3) of Bcl-xL. Finally, we identified a novel BH3-like region located in the C-terminal cytosolic domain of SARS-CoV E protein, which mediates its binding to Bcl-xL. These results demonstrate, for the first time, a novel molecular mechanism of T-cell apoptosis that contributes to the SARS-CoV-induced lymphopenia observed in most SARS patients.

Bcl-xL plays a critical role in maintaining cell survival. However, the relationship between the potential interaction of Bcl-xL with other cytosolic proteins and the regulation of cell survival remains incompletely defined. We have identified translationally controlled tumor protein (TCTP), a multifunctional protein, as a novel antiapoptotic Bcl-xL-interacting protein. TCTP interacted in vivo and in vitro with Bcl-xL, and their sites have been mapped to an N-terminal region of TCTP and the Bcl-2 homology domain 3 of Bcl-xL. Consistent with a role in maintaining T-cell survival during activation, TCTP was significantly upregulated in murine T cells activated by T-cell antigen receptor (TCR) ligation and CD28 costimulation, which was correlated with the upregulation of Bcl-xL in activated T cells. Moreover, downregulation of TCTP expression by antisense technology in T cells results in the increase of T-cell apoptosis. Furthermore, the N-terminal region of TCTP was required for its ability to inhibit apoptosis. In conclusion, this study has demonstrated that an N-terminal region of a cytosolic protein, TCTP, is required for its binding to Bcl-xL and for its antiapoptotic activity.

Acinar cell carcinoma is an uncommon malignancy of the pancreas. It has characteristic histomorphology, immunohistochemistry profile, and clinicopathological behavior.We report a rare case of recurrent pancreatitis secondary to acinar cell carcinoma of the pancreas. We describe the endoscopic ultrasound characteristic, treatment and the surgical outcome.Acinar cell carcinoma should be considered in the differential diagnosis of cystic pancreatic tumors presenting with recurrent pancreatitis.

Combined Thoracic Organ and Liver Transplantation in Multi-Organ End-Stage Patients As a Successful Therapeutic Strategy B. Ramlawi, L.J. Garcia-Morales, J.D. Estep, H. Seethamraju, R.B. Kesavan, B.A. Bruckner, A.D. Parulekar, P.J. Kolodziejski, J. Nguyen, K.N. Chmielowiec, G.P. Noon, O. Gaber, M. Loebe. Cardiovascular Surgery, Methodist DeBakey Heart & Vascular Center, Houston, TX; Baylor College of Medicine, Houston, TX.