Nutrition‐related factors associated with waiting list mortality in patients with interstitial lung disease: A retrospective cohort study

Japanese patients with interstitial lung disease (ILD) sometimes die waiting for lung transplantation (LTx) because it takes about 2 years to receive it in Japan. We evaluated nutrition‐related factors associated with waiting list mortality. Seventy‐six ILD patients were hospitalized in Kyoto University Hospital at registration for LTx from 2013 to 2015. Among them, 40 patients were included and analyzed. Patient background was as follows: female, 30%; age, 50.3 ± 6.9 years; body mass index, 21.1 ± 4.0 kg/m²; 6‐minute walk distance (6MWD), 356 ± 172 m; serum albumin, 3.8 ± 0.4 g/dL; serum transthyretin (TTR), 25.3 ± 7.5 mg/dL; and C‐reactive protein, 0.5 ± 0.5 mg/dL. Median observational period was 497 (range 97‐1015) days, and median survival time was 550 (95% CI 414‐686) days. Survival rate was 47.5%, and mortality rate was 38.7/100 person‐years. Cox analyses showed that TTR (HR 0.791, 95% CI 0.633‐0.988) and 6MWD (HR 0.795, 95% CI 0.674‐0.938) were independently correlated with mortality and were influenced by body fat mass and leg skeletal muscle mass, respectively. It is suggested that nutritional markers and exercise capacity are important prognostic markers in waitlisted patients, but further study is needed to determine whether nutritional intervention or exercise can change outcomes.     

Efficacy of an artificial pancreas device for achieving tight perioperative glycemic control in living donor liver transplantation

Intraoperative hyperglycemia during liver transplantation can induce infectious bacterial complications after surgery. The aim of this study was to evaluate the efficacy of the artificial endocrine pancreas in achieving perioperative blood glucose control and preventing infection in patients undergoing living donor liver transplantation (LDLT). We compared 14 patients with an artificial endocrine pancreas device to 14 patients who underwent glycemic control using the sliding scale method with respect to perioperative blood glucose level and postoperative infection. In this study, we aimed to control the perioperative glucose levels consecutively for 24 hours from the induction of anesthesia. The average blood glucose level in the artificial pancreas group was significantly lower than that in the sliding scale group (118 vs. 141 mg/dL, P < 0.05). The postoperative bacterial infection rate of the artificial pancreas group was significantly lower than that of the sliding scale group within one month after LDLT (35.7% vs. 78.6%, P < 0.05). Multiple regression analysis showed non‐application of artificial endocrine pancreas as a significant risk factor of posttransplant infection. The artificial endocrine pancreas enabled the perioperative glucose level to be stably controlled without hypoglycemia. Artificial pancreas may reduce the incidence of postoperative infection after LDLT.     

Antegrade selective cerebral perfusion with mild hypothermic systemic circulatory arrest during thoracic aortic surgery

Objective Antegrade selective cerebral perfusion (ASCP) and retrograde cerebral perfusion (RCP) have proven to be reliable methods of brain protection during aortic surgery. These techniques are usually accompanied by systemic circulatory arrest with moderate hypothermia (24–28°C) or deep hypothermia (18–24°C). However, hypothermia can lead to various problems. The present study therefore reports results for thoracic aorta replacement using ASCP with mild hypothermic systemic arrest (28–32°C).

Design Between 1995 and 2003, 68 consecutive patients underwent repair of the ascending aorta and/or aortic arch. Mild hypothermic ASCP was utilized in 31 cases, moderate hypothermic ASCP in 20, and deep hypothermic RCP in 17. Various parameters were compared between the mild hypothermic ASCP, moderate hypothermic ASCP, and RCP.

Results Hospital mortality was 10.3%, with no significant differences observed between any groups. Permanent neurological dysfunction was 8.8%, and no significant differences were observed between any groups. Mild hypothermic ASCP displayed significantly decreased transfusion volume, intubation time, and ICU stay.

Conclusions Use of ASCP with mild hypothermic systemic circulatory arrest during aortic surgery resulted in acceptable hospital mortality and neurological outcomes. ASCP with mild hypothermic arrest allows decreased transfusion volume and reduced duration of intubation and ICU stay.     

Rehospitalization after pediatric living-donor liver transplantation

BACKGROUND: Although rehospitalization is one of the factors affecting quality of life after successful liver transplantation, the effects of rehospitalization have not been assessed to date. PATIENTS AND METHODS: Of 40 consecutive cases of pediatric living-donor liver transplantation (LDLT) performed between April 1994 and October 2000, 28 patients with a graft survival of more than 1 year were enrolled in this study to examine rehospitalization after successful LDLT. The rate and cause of rehospitalization were analyzed retrospectively on the basis of medical records. RESULTS: A total of 23 of the 28 patients were rehospitalized. There were 84 episodes of rehospitalization. The mean number of rehospitalization days per episode per patient was 21.06 +/- 21.02 days. The rate of total rehospitalization days to the days after the hospitalization for LDLT was 6.56% +/- 8.73%. Rehospitalization episodes were attributable to the following: cholangitis (21.4%), viral infection (16.7%), and portal stenosis (PS) (13.1%). Rehospitalization as the result of rejection accounted for 9.5% of the episodes. The period of rehospitalization was long in the case of cholangitis (49.7 +/- 62.4 days), PS (13.8 +/- 13.4 days), and rejection (52.9 +/- 45.4 days). Although there were a lot of rehospitalization episodes as the result of viral infection subsequent to cholangitis, each rehospitalization period lasted 4.4 +/- 6.6 days. CONCLUSION: It is suggested that prevention of cholangitis and PS, which were the causes of frequent and long rehospitalization periods, would result in a reduction of rehospitalization and therefore a better quality of life after pediatric LDLT.     

Oxygen pressure measurement during grip exercise reveals exercise intolerance after radial harvest

BACKGROUND: Exercise intolerance of the hand after harvest of the radial artery is not well understood, although mild reductions of blood flow to the hand are reported. To ascertain its prevalence, patient symptoms implying potential exercise intolerance were evaluated by measuring transcutaneous oxygen pressure of the hand during grip exercise. For ascertaining predictive values, we verified ulnar flow reserve measured by Doppler ultrasonography before the harvest of radial artery. METHODS: Forty patients whose radial artery was harvested for coronary bypass graft, were interviewed and tested 1 year after operation, and their preoperative ultrasonographic data compared. RESULTS: Five patients (12.5%) had mild symptoms implying exercise intolerance. Exercise tests revealed severe decreases in tissue oxygenation in 7 patients (17.5%), but in accordance with symptoms (p = 0.0018). Tissue oxygenation in the operated hand was lower than in the nonoperated even in asymptomatic patients (p = 0.0011). Preoperative Doppler echography revealed that ulnar arteries of symptomatic patients were smaller (p = 0.0019) and carried lower blood flows during manual compression of the radial artery (p = 0.0004) compared with those of asymptomatic patients. Smaller ulnar arteries (less than 1.4 mm/m(2)) with poor flow reserves (less than 60 mL x min(-1) x m(-2) during radial compression) appear to indicate risks for exercise intolerance (p = 0.0004). CONCLUSIONS: More than 10% of patients after harvest of radial arteries had mild symptoms implying exercise-intolerance, which accorded with abnormal tissue oxygenation during grip exercise. Work habits of patients should be considered in radial harvest decisions, especially if preoperative Doppler echography indicates lower flow reserves for the ulnar artery.     

Transcatheter embolization of an aortobronchial fistula with N-butyl cyanoacrylate

Aortobronchial fistula is a fatal complication after thoracic aortic surgery. So far, treatment options for aortobronchial fistula have included surgical and endovascular stent-graft methods. Herein, a case of an aortobronchial fistula with life-threatening hemoptysis managed with transcatheter embolization of the fistula with N-butyl cyanoacrylate is reported. For the patient with an aortobronchial fistula who cannot be treated by surgical or endovascular stent-graft methods, transcatheter embolization of the fistula may be the only available life-saving method.     

Increasing myocardial<Superscript>123</Superscript>I-BMIPP uptake in non-ischemic area in a patient with acute myocardial ischemia

The subject was a 65-year-old woman with chest pain. An electrocardiogram revealed T-wave-inversion in leads III, aVF, V1-V5. 99mTc-tetrofosmin myocardial SPECT showed mildly reduced uptake in the anteroseptal wall and the apex. These findings suggested acute myocardial ischemia. Coronary angiography did not show any stenotic lesions, but diffuse coronary ectasia was noted in three vessels. Coronary flow velocity was remarkably reduced on coronary angiography. Epicardial coronary spasm was not provoked by ergonovine loading test. Left ventriculography showed diffuse hypokinesis. 123I-BMIPP myocardial SPECT showed mildly reduced uptake in the anteroseptal wall and the apex on the early images. But 4-hour delayed images showed an increase of 8% in myocardial 123I-BMIPP uptake. We treated this patient with ticlopidine and nicorandil. After drug therapy her symptoms and left ventriculography improved. 123I-BMIPP myocardial SPECT findings on the early images improved, whereas delayed images showed a decrease of 28% in myocardial 123I-BMIPP uptake after two weeks and 36% after four weeks. These dynamic changes in 123I-BMIPP findings might be a reflection of myocardial fatty acid metabolism in patients with acute myocardial ischemia. Delayed 123I-BMIPP myocardial SPECT images are useful for the assessment of fatty acid metabolism.     

Determination of ABO genotypes with DNA extracted from formalin-fixed,paraffin-embedded tissues

Summary The gene encoding the specific glycosyltransferases which catalyze the conversion of the H antigen to A or B antigens shows a slight but distinct variation in its allelic nucleotide sequence and can be divided into 6 genotypes when digested with specific restriction enzymes. We extracted DNA from formalin-fixed, paraffin-embedded tissues using SDS/proteinase K treatment followed by phenol/chloroform extraction. The sequence of nucleotides for the A, B and O genes was amplified by the polymerase chain reaction (PCR). DNA fragments of 128 by and 200 by could be amplified in the second round of PCR, using an aliquot of the first round PCR product as template. Degraded DNA from paraffin blocks stored for up to 10.7 years could be successfully typed. The ABO genotype was deduced from the digestion patterns with an appropriate combination of restriction enzymes and was compatible with the phenotype obtained from the blood sample.     

Role of luminal Ca2+ on normal and damaged gastric mucosa in the rat

Influence of luminal Ca²⁺ on the integrity of normal mucosa and recovery of damaged mucosa in anesthetized rat stomachs was studied using a perfusion system. Changes in the mucosal integrity were monitored by measuring transmucosal potential difference (PD) and luminal pH. EDTA, a Ca²⁺ chelator, dose-dependently reduced PD and increased luminal pH. Five mM Ca²⁺ (CaCl₂) alone produced no changes in either PD and luminal pH, but the PD which was reduced by 250 mM EDTA was significantly recovered. Ethanol or NaCl concentration-dependently reduced PD, but gradually reverted to baseline levels. While 5 mM Ca²⁺ or 5 mM EDTA did not influence the reduction in PD with 50% ethanol or 1 M NaCl, these agents either enhanced or delayed the recovery processes in reduced PD, respectively. Five mM Ca²⁺ enhanced the recovery of PD which was reduced by 50% ethanol plus 5 mM EDTA. Gastric damage induced by 50% ethanol plus 5 mM EDTA was much more severe than that induced by 50% ethanol alone or 50% ethanol plus 5 mM Ca²⁺. Both 50% ethanol and 1 M NaCl significantly increased Ca²⁺ contents in the gastric lumen. Luminal Ca²⁺ appears to play an important role in maintaining mucosal integrity, under normal physiological conditions, and in accelerating the recovery process of damaged mucosa in rat stomachs.