Through exomic sequencing of 32 intrahepatic cholangiocarcinomas, we discovered frequent inactivating mutations in multiple chromatin-remodeling genes (including BAP1, ARID1A and PBRM1), and mutation in one of these genes occurred in almost half of the carcinomas sequenced. We also identified frequent mutations at previously reported hotspots in the IDH1 and IDH2 genes encoding metabolic enzymes in intrahepatic cholangiocarcinomas. In contrast, TP53 was the most frequently altered gene in a series of nine gallbladder carcinomas. These discoveries highlight the key role of dysregulated chromatin remodeling in intrahepatic cholangiocarcinomas.

Bone morphogenetic proteins (BMPs) are known as ectopic bone inducers. The FDA approved BMPs (BMP2 and BMP7) for clinical use. However, direct effects of BMPs on endogenous bone metabolism are not yet well known. We conditionally disrupted BMP receptor type IA (BMPRIA) in osteoblasts during weanling and adult stages to show the impact of BMP signaling on endogenous bone modeling and remodeling. Cre recombination was detected in immature osteoblasts in the periosteum, osteoblasts, and osteocytes but not in chondrocytes and osteoclasts after tamoxifen administration. Bmpr1a conditional knockout mice (cKO) showed increased bone mass primarily in trabecular bone at P21 and 22 wk as determined by H&E staining. Vertebrae, tails, and ribs showed increased radiodensity at 22 wk, consistent with a significant increase in BMD. Both CT and histomorphometry showed an increase in trabecular BV/TV and thickness of cKO adult bones, whereas osteoclast number, bone formation rate, and mineral apposition rate were decreased. Expression levels of bone formation markers (Runx2 and Bsp), resorption markers (Mmp9, Ctsk, and Tracp), and Rankl were decreased, and Opg was increased in adult bones, resulting in a reduction in the ratio of Rankl to osteoprotegerin (Opg). The reduction in osteoclastogenesis through the RANKL-OPG pathway was also observed in weanling stages and reproduced in newborn calvaria culture. These results suggest that Bmpr1a cKO increased endogenous bone mass primarily in trabecular bone with decreased osteoclastogenesis through the RANKL-OPG pathway. We conclude that BMPRIA signaling in osteoblasts affects both bone formation and resorption to reduce endogenous bone mass in vivo.

Objective In 2012, Medicare began cutting reimbursement for hospitals with high readmission rates. We sought to define the incidence and risk factors associated with readmission after surgery. Methods A total of 230,864 patients discharged after general, upper gastrointestinal (GI), small and large intestine, hepatopancreatobiliary (HPB), vascular, and thoracic surgery were identified using the 2011 American College of Surgeons National Surgical Quality Improvement Program. Readmission rates and patient characteristics were analyzed. A predictive model for readmission was developed among patients with length of stay (LOS) 10 days or fewer and then validated using separate samples. Results Median patient age was 56 years; 43% were male, and median American Society of Anesthesiologists (ASA) class was 2 (general surgery: 2; upper GI: 3; small and large intestine: 2; HPB: 3; vascular: 3; thoracic: 3; P < 0.001). The median LOS was 1 day (general surgery: 0; upper GI: 2; small and large intestine: 5; HPB: 6; vascular: 2; thoracic: 4; P < 0.001). Overall 30-day readmission was 7.8% (general surgery: 5.0%; upper GI: 6.9%; small and large intestine: 12.6%; HPB: 15.8%; vascular: 11.9%; thoracic: 11.1%; P < 0.001). Factors strongly associated with readmission included ASA class, albumin less than 3.5, diabetes, inpatient complications, nonelective surgery, discharge to a facility, and the LOS (all P < 0.001). On multivariate analysis, ASA class and the LOS remained most strongly associated with readmission. A simple integer-based score using ASA class and the LOS predicted risk of readmission (area under the receiver operator curve 0.702). Conclusions Readmission among patients with the LOS 10 days or fewer occurs at an incidence of at least 5% to 16% across surgical subspecialties. A scoring system on the basis of ASA class and the LOS may help stratify readmission risk to target interventions.

No abstract