Background::Heterotaxy (HTX) is a thoracoabdominal organ anomaly syndrome and commonly accompanied by congenital heart disease (CHD). The aim of this study was to analyze rare copy number variations (CNVs) in a HTX/CHD cohort and to examine the potential mechanisms contributing to HTX/CHD.Methods::Chromosome microarray analysis was used to identify rare CNVs in a cohort of 120 unrelated HTX/CHD patients, and available samples from parents were used to confirm the inheritance pattern. Potential candidate genes in CNVs region were prioritized via the DECIPHER database, and PNPLA4 was identified as the leading candidate gene. To validate, we generated PNPLA4-overexpressing human induced pluripotent stem cell lines as well as pnpla4-overexpressing zebrafish model, followed by a series of transcriptomic, biochemical and cellular analyses. Results::Seventeen rare CNVs were identified in 15 of the 120 HTX/CHD patients (12.5%). Xp22.31 duplication was one of the inherited CNVs identified in this HTX/CHD cohort, and PNPLA4 in the Xp22.31 was a candidate gene associated with HTX/CHD. PNPLA4 is expressed in the lateral plate mesoderm, which is known to be critical for left/right embryonic patterning as well as cardiomyocyte differentiation, and in the neural crest cell lineage. Through a series of in vivo and in vitro analyses at the molecular and cellular levels, we revealed that the biological function of PNPLA4 is importantly involved in the primary cilia formation and function via its regulation of energy metabolism and mitochondria-mediated ATP production. Conclusions::Our findings demonstrated a significant association between CNVs and HTX/CHD. Our data strongly suggested that an increased genetic dose of PNPLA4 due to Xp22.31 duplication is a disease-causing risk factor for HTX/CHD.

Objective:To summarize the experience of surgical treatment of primary liver cancer.Methods:The clinical data of 10 966 surgically managed cases with primary liver cancer, from January 1986 to December 2019 at Hepatobiliary Center, the First Affiliated Hospital of Nanjing Medical University, were retrospectively analyzed. The life table method was used to calculate the survival rate and postoperative recurrence rate. Log‐rank test was used to compare the survival process of different groups, and the Cox regression model was used for multivariate analysis. In addition, 2 884 cases of hepatocellular carcinoma(HCC) with more detailed follow‐up data from 2009 to 2019 were selected for survival analysis. Among 2 549 patients treated with hepatectomy, there were 2 107 males and 442 females, with an age of (56.6±11.1) years (range: 20 to 86 years). Among 335 patients treated with liver transplantation, there were 292 males and 43 females, with an age of (51.0±9.7) years (range: 21 to 73 years). The outcomes of hepatectomy versus liver transplantation, anatomic versus non-anatomic hepatectomy were compared, respectively.Results:Of the 10 966 patients with primary liver cancer, 10 331 patients underwent hepatectomy and 635 patients underwent liver transplantation. Patients with liver resection were categorized into three groups: 1986－1995(712 cases), 1996－2008(3 988 cases), 2009?2019(5 631 cases). The 5‐year overall survival rate was 32.9% in the first group(1986－1995). The 5‐year overall survival rate of resected primary liver cancer was 51.7% in the third group(2009‐2019), among which the 5‐year overal survival rates of hepatocellular carcinoma, intrahepatic cholangiocarcinoma and mixed liver cancer were 57.4%, 26.6% and 50.6%, respectively. Further analysis was performed on 2 549 HCC patients with primary hepatectomy. The 1‐, 3‐, 5‐, and 10‐year overall survival rates were 88.1%, 71.9%, 60.0%, and 41.0%, respectively, and the perioperative mortality rate was 1.0%. Two hundred and forty‐seven HCC patients underwent primary liver transplantation, with 1‐, 3‐, 5‐, and 10‐year overall survival rates of 84.0%, 64.8%, 61.9%, and 57.6%, respectively. Eighty‐eight HCC patients underwent salvage liver transplantation, with the 1‐, 3‐, 5‐, and 10‐year overall survival rates of 86.8%, 65.2%, 52.5%, and 52.5%, respectively. There was no significant difference in survival rates between the two groups with liver transplantation ( P>0.05). Comparing the overall survival rates and recurrence rates of primary hepatectomy (2 549 cases) with primary liver transplantation (247 cases), the 1‐, 3‐, 5‐, and 10‐year overall survival rates in patients within Milan criteria treated with hepatectomy and transplantation were 96.3%, 87.1%, 76.9%, 54.7%, and 95.4%, 79.4%, 77.4%, 71.7%, respectively ( P=0.754). The 1‐, 3‐, 5‐year recurrence rates were 16.3%, 35.9%, 47.6% and 8.1%, 11.7%, 13.9%, respectively( P<0.01). The 1‐, 3‐, 5‐, 10‐year overall survival rates in patients with no large vessels invasion beyond the Milan criteria treated with liver resection and transplantation were 87.2%, 65.9%, 53.0%, 33.0% and 87.6%, 71.8%, 71.8%, 69.3%, respectively( P=0.003); the 1‐, 3‐, 5‐year recurrence rate were 39.2%, 57.8%, 69.7% and 29.7%, 36.7%, 36.7%, respectively ( P<0.01). The 1‐, 3‐, 5‐, and 10‐year overall survival rates in patients with large vessels invasion treated with liver resection and transplantation were 62.1%, 36.1%, 22.2%, 15.0% and 62.9%, 31.8%,19.9%, 0, respectively ( P=0.387); the 1‐, 3‐, 5‐year recurrence rates were 61.5%, 74.7%, 80.8% and 59.7%, 82.9%, 87.2%, respectively( P=0.909). Independent prognostic factors for both overall survival and recurrence‐free survival rates of HCC patients treated with liver resection included gender, neoadjuvant therapy, symptoms, AST, intraoperative or postoperative blood transfusion, tumor number, tumor size, cirrhosis, macrovascular invasion, microvascular invasion, and pathological differentiation. Propensity score matching analysis of 443 pairs further showed that there was no significant difference in overall survival rate between anatomical liver resection and non‐anatomical liver resection( P=0.895), but the recurrence rate of non‐anatomical liver resection was higher than that of anatomical liver resection( P=0.035). Conclusions:In the past decade, the overall survival rate of HCC undergoing surgical treatment is significantly higher than before. For HCC patients with good liver function reservation, surgical resection can be performed first, and salvage liver transplantation can be performed after recurrence. The effect of salvage liver transplantation is comparable to that of primary liver transplantation. As for the choice of liver resection approaches, non‐anatomical resection can reserve more liver tissue and can be selected as long as the negative margin is guaranteed.

Objective:To summarize the experience of surgical treatment of primary liver cancer.Methods:The clinical data of 10 966 surgically managed cases with primary liver cancer, from January 1986 to December 2019 at Hepatobiliary Center, the First Affiliated Hospital of Nanjing Medical University, were retrospectively analyzed. The life table method was used to calculate the survival rate and postoperative recurrence rate. Log‐rank test was used to compare the survival process of different groups, and the Cox regression model was used for multivariate analysis. In addition, 2 884 cases of hepatocellular carcinoma(HCC) with more detailed follow‐up data from 2009 to 2019 were selected for survival analysis. Among 2 549 patients treated with hepatectomy, there were 2 107 males and 442 females, with an age of (56.6±11.1) years (range: 20 to 86 years). Among 335 patients treated with liver transplantation, there were 292 males and 43 females, with an age of (51.0±9.7) years (range: 21 to 73 years). The outcomes of hepatectomy versus liver transplantation, anatomic versus non-anatomic hepatectomy were compared, respectively.Results:Of the 10 966 patients with primary liver cancer, 10 331 patients underwent hepatectomy and 635 patients underwent liver transplantation. Patients with liver resection were categorized into three groups: 1986－1995(712 cases), 1996－2008(3 988 cases), 2009?2019(5 631 cases). The 5‐year overall survival rate was 32.9% in the first group(1986－1995). The 5‐year overall survival rate of resected primary liver cancer was 51.7% in the third group(2009‐2019), among which the 5‐year overal survival rates of hepatocellular carcinoma, intrahepatic cholangiocarcinoma and mixed liver cancer were 57.4%, 26.6% and 50.6%, respectively. Further analysis was performed on 2 549 HCC patients with primary hepatectomy. The 1‐, 3‐, 5‐, and 10‐year overall survival rates were 88.1%, 71.9%, 60.0%, and 41.0%, respectively, and the perioperative mortality rate was 1.0%. Two hundred and forty‐seven HCC patients underwent primary liver transplantation, with 1‐, 3‐, 5‐, and 10‐year overall survival rates of 84.0%, 64.8%, 61.9%, and 57.6%, respectively. Eighty‐eight HCC patients underwent salvage liver transplantation, with the 1‐, 3‐, 5‐, and 10‐year overall survival rates of 86.8%, 65.2%, 52.5%, and 52.5%, respectively. There was no significant difference in survival rates between the two groups with liver transplantation ( P>0.05). Comparing the overall survival rates and recurrence rates of primary hepatectomy (2 549 cases) with primary liver transplantation (247 cases), the 1‐, 3‐, 5‐, and 10‐year overall survival rates in patients within Milan criteria treated with hepatectomy and transplantation were 96.3%, 87.1%, 76.9%, 54.7%, and 95.4%, 79.4%, 77.4%, 71.7%, respectively ( P=0.754). The 1‐, 3‐, 5‐year recurrence rates were 16.3%, 35.9%, 47.6% and 8.1%, 11.7%, 13.9%, respectively( P<0.01). The 1‐, 3‐, 5‐, 10‐year overall survival rates in patients with no large vessels invasion beyond the Milan criteria treated with liver resection and transplantation were 87.2%, 65.9%, 53.0%, 33.0% and 87.6%, 71.8%, 71.8%, 69.3%, respectively( P=0.003); the 1‐, 3‐, 5‐year recurrence rate were 39.2%, 57.8%, 69.7% and 29.7%, 36.7%, 36.7%, respectively ( P<0.01). The 1‐, 3‐, 5‐, and 10‐year overall survival rates in patients with large vessels invasion treated with liver resection and transplantation were 62.1%, 36.1%, 22.2%, 15.0% and 62.9%, 31.8%,19.9%, 0, respectively ( P=0.387); the 1‐, 3‐, 5‐year recurrence rates were 61.5%, 74.7%, 80.8% and 59.7%, 82.9%, 87.2%, respectively( P=0.909). Independent prognostic factors for both overall survival and recurrence‐free survival rates of HCC patients treated with liver resection included gender, neoadjuvant therapy, symptoms, AST, intraoperative or postoperative blood transfusion, tumor number, tumor size, cirrhosis, macrovascular invasion, microvascular invasion, and pathological differentiation. Propensity score matching analysis of 443 pairs further showed that there was no significant difference in overall survival rate between anatomical liver resection and non‐anatomical liver resection( P=0.895), but the recurrence rate of non‐anatomical liver resection was higher than that of anatomical liver resection( P=0.035). Conclusions:In the past decade, the overall survival rate of HCC undergoing surgical treatment is significantly higher than before. For HCC patients with good liver function reservation, surgical resection can be performed first, and salvage liver transplantation can be performed after recurrence. The effect of salvage liver transplantation is comparable to that of primary liver transplantation. As for the choice of liver resection approaches, non‐anatomical resection can reserve more liver tissue and can be selected as long as the negative margin is guaranteed.

Objective To investigate the clinical efficacy and prognostic factors of radical hepatectomy of hepatocellular carcinoma (HCC).Methods The retrospective case-control study was conducted.The clinicopathological data of 760 HCC patients who were admitted to the First Affiliated Hospital of Nanjing Medical University from August 2003 to June 2015 were collected.Surgical procedures were determined according to the location,number and size of tumors and anatomical relations among vessels.Observation indicators included:(1)intra-and post-operative situations:surgical procedures,operation time,volume of intraoperative blood loss,cases of intraoperative blood transfusion,postoperative complications,duration of postoperative hospital stay and pathological examination;(2) follow-up:1-,3-,5-year overall and tumor-free survival situations;(3) prognostic factors analysis of HCC patients.Follow-up using outpatient examination and telephone interview was performed to detect patients' survival up to January 2016.Measurement data with normal distribution were represented as-x±s.The survival curve and survival rate were respectively drawn and calculated by the Kaplan-Meier method.The univariate analysis and multivariate analysis were done using the COX regression model.Results (1) Intra-and post-operative situations:all the 760 patients underwent successful operations,including 419 undergoing anatomical hepatectomy and 341 undergoing non-anatomical hepatectomy.R0 and R1 resections were respectively applied to 742 and 18 patients.Two patients were combined with portal vein resection and reconstruction and 1 was combined with resection and reconstruction of inferior vena cava.Operation time,volume of intraoperative blood loss and cases of intraoperative blood transfusion were (226± 115) minutes,(714±706) mL and 88,respectively.Fifty-five patients had postoperative complications,including 20 with abdominal effusion or abscess,16 with pleural effusion,9 with recurrent fever,8 with incisional infection,7 with intra-abdominal hemorrhage,6 with liver failure,3 with pyloric or intestinal obstruction and 2 with renal failure (some patients with multiple complications).Of the 55 patients with postoperative complications,7 with hemorrhage underwent reoperation or interventional therapy and other patients underwent conventional symptomatic treatment.Of 55 patients,5 patients died and other 50 patients were improved.Duration of postoperative hospital stay was (14±6) days.There were 457 patients with minimum margin of tumors ≤ 1.0 cm and 303 with minimum margin of tumors ＞ 1.0 cm.(2) Followup:all the 760 patients were followed up for 1-139 months,with a median time of 25 months.The overall and tumor-free median survival times were 59 months and 31 months,respectively.The 1-,3-,5-year overall and tumor-free survival rates were 81.7％,63.4％,47.9％ and 68.7％,44.9％,29.6％,respectively.(3) Prognostic factors analysis of HCC patients:results of univariate analysis showed that clinical symptoms,alpha-fetoprotein (AFP),Barcelona clinic liver cancer staging,surgical procedures,intraoperative blood transfusion,minimum margin of tumors,number and diameter of tumors,tumor capsule,tumor differentiation,vascular cancer embolus,macrovascular invasion and tumor staging of American Joint Committee on Cancer (AJCC) were related factors affecting prognosis of HCC patients after radical hepatectomy [HR =1.39,1.50,1.92,0.65,1.45,1.68,1.96,1.66,2.26,1.50,2.68,3.37,2.00,95％ confidence interval (CI):1.08-1.79,1.16-1.94,1.68-2.20,0.50-0.84,1.04-2.02,1.28-2.20,1.54-2.49,1.42-1.94,1.69-3.02,1.22-1.85,1.99-3.60,2.61-4.36,1.77-2.27,P＜0.05].Results of multivariate analysis showed that AFP,number and diameter of tumors,tumor differentiation and tumor staging of AJCC were independent factors affecting prognosis of HCC patients after radical hepatectomy (HR=1.61,1.62,1.31,1.40,1.78,95％CI:1.14-2.26,1.22-2.14,1.06-1.63,1.10-1.79,1.27-2.51,P ＜ 0.05).Conclusions The anatomical and non-anatomical hepatectomies are safe and feasible for optional HCC patients,with a good long-term outcome.AFP,number and diameter of tumors,tumor differentiation and tumor staging of AJCC are independent factors affecting prognosis of HCC patients after radical hepatectomy.

Objective To investigate the clinical significance of detecting cardiac troponin Ⅰ (cTnⅠ) and CK -MB in children with hand-foot-and-mouth disease and myocardial injury.Methods 90 children with hand-foot-and-mouth disease (observation group) were detected the level of serum cTnⅠ and CK-MB.At the same time,40 healthy children were chosen as control group.Results Compared with the control group,the levels of CK-MB and cTnl in observation group were significantly higher than those of the control group (t =8.92,5.46,all P ＜ 0.01),which indicated that children with hand,foot and mouth disease was easier to merge myocardial injury.CK-MB and cTnl levels in high-risk group were significantly higher than those in normal children group (t =9.17,6.13,all P ＜ 0.01),and the levels of CK-MB and cTnl were positively correlated with severe degree (r =0.767,0.683,all P ＜ 0.01).For children with hand,foot and mouth disease merged myocarditis,cTnl diagnostic sensitivity (53.8％) was lower than that of CK-MB diagnostic sensitivity (71.8％),but the specificity was better than that of CK-MB,and the diagnosis of cTnl detection window 2 weeks longer than CK-MB,but after 2 weeks both lose their clinical diagnostic significance.Conclusion Children with hand,foot and mouth disease easily merge myocardial damage,dynamic measuring CK-MB and cTnl levels could help early diagnosis of children with hand,foot and mouth disease whether merged myocardial damage,both applications can also complement each other,more timely and accurate reflection of disease progression and recovery,it is worth promoting.

OBJECTIVETo explore the impact of microwave dealing with cutting surface on perioperative liver function recovery and recurrence and metastasis after hepatectomy for HCC.

METHODSClinical data of 133 patients with HCC from March 2009 to November 2010 were retrospectively analyzed. They were divided into the conventional surgery group (66 cases) and microwave treatment group (67 cases). A domestic ECO-100 microwave knife was inserted into the liver cutting surface 0.5 cm from the cutting edge, and repeated multi-point burning with an average time of 25 minutes in the microwave treatment group. Then the perioperative liver function recovery and recurrence and metastasis in the two groups were compared.

RESULTSThe operation time of conventional surgery group was (158.0 ± 31.0) minutes, and that of microwave treatment group was significantly longer (181.0 ± 28.0) minutes (P=0.027). There were no significant differences in the liver function recovery between the two groups (P>0.05). There were 6 cases of recurrence and metastasis after 6 months and 9 cases after 12 months in the microwave treatment group, while there were 15 cases of recurrence and metastasis after 6 months and 20 cases after 12 months in the conventional surgery group, showing a significant difference (P=0.034 and 0.022, respectively).

CONCLUSIONSMicrowave dealing with the cutting surface has no significant effect on perioperative liver function recovery in hepatectomy. However, microwave treatment can reduce the in situ recurrence in HCC patients within the first year after surgery, indicating a good clinical application value.

Carcinoma, Hepatocellular ; surgery ; therapy ; Hepatectomy ; Humans ; Liver ; physiology ; Liver Neoplasms ; surgery ; therapy ; Microwaves ; therapeutic use ; Neoplasm Recurrence, Local ; prevention & control ; Operative Time ; Recovery of Function ; Retrospective Studies

Objective To investigate the clinical featurcs of hepatic perivascular epithelioid cell carcinoma (PEComa) and the experiments in the surgical treatment of PEComa.Methods The clinical data of 16 patients with hepatic PEComa who received surgical treatment at the First Affiliated Hospital of Nanjing Medical University from January 2008 to January 2012 were retrospectively analyzed.The incidence,clinical manifestations,imagiong characteristics,surgical outcomes and pathological manifestations of this disease were analyzed.B sonography,hepatic function test,tumor markers test and epigastric computed tomography (CT) were applied to detect tumor recurrence and metastasis.The follow-up was ended in December 2012.Result Middle aged and female patients took large part of the patients.Of the 16 patients,8 had no subjective symptoms,and other patients had discomfort in the right upper quadrant,pain or tenderness of the liver.All the tumors were solitary,and most of them located at the right liver (11 tumors were in the right liver,4 in the left liver,1 in the caudate lobe).No specific features were detected by preoperative B sonography,while inhomogeneous low density in the tumor region was detected on by CT.All the patients received partial liver resection without morbidity and morality.The results of immunohistochemistry showed that thc expressions of HMB-45,Melan-A and vascular smooth muscle actin were positive.The mean time of follow-up was 27.9 months (range,9.0-46.0 months),no tumor recurrence and death was observed during the follow-up.Conclusions Middle aged females are susceptive to hepatic PEComa,and patients have no specific clinical presentations.Preoperative CT examination is helpful for differential diagnosis of PEComa,and partical hepatectomy can achieve satisfactory short-term clinical outcomes.

Objective To investigate the diagnostic value of plasma cardiac troponin Ⅰ (cTnI) and brain natriuretic peptide (BNP) for heart failure complicated with pneumonia in children.Methods 30 children of heart failure complicated with pneumonia (heart failure group),30 children with pneumonia in acute phase (pneumonia group) and 30 healthy children (control group) were selected.The levels of plasma cTnI and BNP in the heart failure group were detected in acute phase(6-24h) and recovery phase(5-7d),and the results were compared with pneumonia group and control group.Results The levels of plasma cTnI and BNP in the heart failure group were significantly higher than those in the pneumonia group and control group(F =5.303,4.632,all P ＜ 0.05).The levels of plasma cTnI and BNP were not significantly different between the pneumonia group and control group(P ＞ 0.05).The levels of plasma cTnI and BNP in recovery phase of the heart failure group were significantly lower than those in acute phase of the heart failure group (t =4.291,5.393,all P ＜ 0.05),but there were no siganificant differences compared with the pneumonia group and control group(P ＞ 0.05).Conclusion The plasma cTnI and BNP maybe a reliable index in the diagnosis of heart failure complicated with pneumonia in children.

Objective To explore the effect of high bilirubin on myocardial injury.Methods The levels of serum total bilirubin (TBIL),creatine kinase (CK),creatine kinase-isoenzyme MB(CK-MB),cardiac troponin Ⅰ (cTnI) were measured and compared in newborns without obvious physiological jaundice (control group) and newborns with hyperbilirubinemia (study group) before and after treatment.Results Compared with those in control group,the levels of serum TBIL,CK,CK-MB and cTnI in study group before treatment were obvious higher[(270.24 ± 36.89) μ mol/L vs.(68.95 ± 10.87) μ mol/L,(414.27 ± 135.45)U/L vs.(178.35 ± 59.62) U/L,(63.31 ± 23.25) U/L vs.(16.78 ± 8.89) U/L,(0.39 ± 0.11) μ g/L vs.(0.18 ± 0.07) μ g/L],and the differences between two groups were statistically significant (P ＜ 0.05).The levels of serum TBIL,CK,CK-MB and cTnI after treatment in study group [(69.13 ±9.98) μmol/L,(183.35 ± 61.01) U/L,(17.45 ± 9.0.8) U/L,(0.19 ± 0.01) μ g/L] were decreased obviously compared with those before treatment,and the differences between two groups were statistically significant (P ＜ 0.05).There was no significant difference between control group and study group after treatment (P ＞ 0.05).Conclusions High bilirubin can lead to a reversible myocardial injury.Cardiac enzymes and troponin testing should be routinely done for neonatal hyperbilirubinemia.It suggests doctors to attend to the treatment of myocardial protection.

ObjectiveTo investigate the therapeutic effects of the conditioning regimen with or without total body irradiation on allogeneic hematopoietic stem cell transplantation in acute leukemia.Methods We retrospectively evaluated clinical outcomes in 287 allo-HSCT recipients with acute leukemia (ALL- 105,AML-129,and AUL-53) who received myeloablative conditioning regimen with or without total body irradiation from January 2002 to August 2011.Two hundred and six patients obtained complete remission (CR) and 81 non-remission (NR) before transplantation.One hundred and ninety-nine patients received conditioning with total body irradiation (TBI+ Cy group,9 Gy given over 2 days),and 88 patients received busulfan (BuCy group,3.2 mg·kg-1 ·d-1 ),both followed by cyclophosphamide.ResultsThere were no statistically significant differences in hematopoietic reconstitution,regimen-related toxicity (RRT),graft-versus-host disease (GVHD) and relapse between two groups.For patients with AML and AUL,there was no significant difference in the 5-year survival between the two regimens (P＞ 0.05),while for ALL-CR patients,the TBI + Cy regimen had a higher over survival rate (52.0％ vs.31.3％,LogRank=4.249,P＜0.05) and DFS (50.4％ vs.27.8％,LogRank =4.445,P＜0.05) than BuCy.In TBI + Cy group and BuCy group,the proportion of CD19+ B cells at the first month after HSCT was (4.04 ± 1.86)％ and (1.47 ±0.99) ％ (P＜0.05),that of NK cells at 12th month after HSCT was (23.38 ± 12.19) ％ and (13.11± 7.99) ％ (P＜0.05),and that of CD4+ CD45RO+ cells at 9th month after HSCT was (14.63 ±6.17)％ and (9.07 ± 3.12)％ (P＜0.01),respectively.ConclusionUsing TBI-containing regimen was more effective for treating ALL-CR patients than busulphan-containing regimen,but no difference was found for long-term outcomes in patients with AML and AUL between the two regimens.The 9 Gy TBI-based regimens may not affect recipients' thymic function,T-cells reconstitution and immune tolerance,coming out a non-increase of GVHD.