Prognostic impact of concomitant pH-regulating drugs in patients with non-small cell lung cancer receiving epidermal growth factor receptor tyrosine kinase inhibitors: the Tokushukai REAl-world Data project 01-S1

PURPOSE

This study aimed to examine the prognostic impact of concomitant pH-regulating drug use in patients with epidermal growth factor receptor (EGFR)-mutation-positive non-small-cell lung cancer (NSCLC) receiving EGFR-tyrosine kinase inhibitors (TKIs).

METHODS

We conducted a nationwide retrospective cohort study and reviewed clinical data of consecutive patients with NSCLC treated with the first-line EGFR-TKIs in 46 hospitals between April 2010 and March 2020. Cox regression analyses were conducted to examine the differences in overall survival (OS) between patients treated with and without concomitant pH-regulating drugs, including potassium-competitive acid blockers (P-CABs), proton pump inhibitors (PPIs), and H2-receptor antagonists (H2RAs).

RESULTS

A total of 758 patients were included in the final dataset, of which 307 (40%) were administered concomitant pH-regulating drugs while receiving frontline EGFR-TKIs. After adjusting for basic patient characteristics, patients administered gefitinib, erlotinib, afatinib, and osimertinib with concomitant pH-regulating drugs had lower OS than those without concomitant pH-regulating drugs, with hazard ratios of 1.74 (with a 95% confidence interval of 1.34-2.27), 1.33 (0.80-2.22), 1.73 (0.89-3.36), and 5.04 (1.38-18.44), respectively. The 2-year OS rates of patients receiving gefitinib with or without concomitant pH-regulating drugs were 65.4 and 77.5%, those for erlotinib were 55.8 and 66.6%, and those for afatinib were 63.2 and 76.9%, respectively. The 1-year OS rates of patients receiving osimertinib with or without concomitant pH-regulating drugs were 88.1% and 96.9%, respectively.

CONCLUSION

In addition to the first-generation EGFR-TKIs, the second- and third-generation EGFR-TKIs also resulted in OS deterioration in patients with EGFR mutation-positive NSCLC when used concurrently with pH-regulating drugs.

Stepwise prolongation of overall survival from first to third generation EGFR-TKIs for EGFR mutation-positive non-small-cell lung cancer: the Tokushukai REAl-world Data project (TREAD 01)

OBJECTIVE

The introduction of new-generation epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) has afforded promising overall survival outcomes in clinical trials for non-small-cell lung cancer. We aim to investigate the current adoption rate of these agents and the real-world impact on overall survival among institutions.

METHODS

In a nationwide retrospective cohort study of 46 Tokushukai Medical Group hospitals in Japan, we analyzed clinical data of consecutive patients with non-small-cell lung cancer receiving EGFR-TKIs between April 2010 and March 2020. Univariate and multivariate Cox regression analyses examined the associations between overall survival and patient/tumor-related factors and first-line EGFR-TKIs.

RESULTS

A total of 758 patients (58.5% females; median age, 73 years) were included. Of 40 patients diagnosed in 2010, 72.5% received gefitinib, whereas 81.3% of 107 patients diagnosed in 2019 received osimertinib as the first-line EGFR-TKI. With a median follow-up of 15.8 months, the median overall survival was 28.4 months (95% confidence interval, 15.3-31.0). In a multivariate Cox regression analysis, age, body mass index, disease status, EGFR mutational status and first-line epidermal growth factor receptor tyrosine kinase inhibitor were identified as significant prognostic factors after adjusting for background factors including study period, hospital volume and hospital type. The estimated 2-year overall survival rates for gefitinib, erlotinib, afatinib and osimertinib were 70.1% (95% confidence interval 59.7-82.4), 67.8% (95% confidence interval 55.3-83.2), 75.5% (95% confidence interval 64.7-88.0) and 90.8% (95% confidence interval 84.8-97.3), respectively. The median time to treatment failure of gefitinib, erlotinib, afatinib and osimertinib were 12.8, 8.8, 12.0 and 16.9 months or more, respectively.

CONCLUSIONS

Our real-world data revealed that the swift and widespread utilization of newer-generation EGFR-TKIs in patients with EGFR mutation-positive non-small-cell lung cancer, and that these newer-generation EGFR-TKIs can prolong overall survival regardless of hospital volume or type. Therefore, osimertinib could be a reasonable first choice treatment for these patients across various clinical practice settings.

Inflammation‑based prognostic markers of metastatic pancreatic cancer using real‑world data in Japan: The Tokushukai REAl‑world Data (TREAD) project

Inflammation-based prognostic markers based on a combination of blood-based parameters, including the modified Glasgow prognostic score (mGPS), have been associated with clinical outcomes in patients with various types of cancer. The present study aimed to evaluate and compare the accuracy of these previously reported markers in patients with metastatic pancreatic cancer receiving first-line chemotherapy. A total of 846 patients were identified between April 2010 and March 2020 as part of a nationwide real-world study from 46 Tokushukai medical group hospitals in Japan. Blood laboratory data collected within 14 days of starting first-line chemotherapy assessed 17 inflammation-based prognostic markers. Information from patients with no missing data was used to compare the accuracy and performance of the inflammation-based prognostic markers. A total of 487 patients were eligible for this supplemental analysis. The 17 inflammation-based markers demonstrated significant prognostic value. Among them, the concordance rate with overall survival (OS) was highest for mGPS. The median OS time of patients with mGPS 0, 1 and 2 was 8.2, 6.0 and 2.9 months, respectively. Compared with mGPS 0, mGPS 1 and 2 showed hazard ratios of 1.39 (95% confidence interval, 1.07-1.81) and 2.63 (2.00-3.45), respectively. The present real-world data analysis showed that various previously reported inflammation-based markers had significant prognostic value in patients with metastatic pancreatic cancer. Among these markers, the mGPS demonstrated the highest level of accuracy. This trial has been registered in the University Hospital Medical Information Network Clinical Trials Registry as UMIN000050590 on April 1, 2023.

Real-world treatment outcomes of metastatic biliary tract cancer patients in Japan: the Tokushukai REAl-world data project 04 (TREAD 04)

OBJECTIVES

To investigate temporal trends in treatment patterns and prognostic factors for overall survival in patients with metastatic biliary tract cancer.

METHODS

From the Tokushukai REAl-world Data project, we identified 945 patients with metastatic biliary tract cancer treated with gemcitabine, tegafur/gimeracil/oteracil, gemcitabine plus cisplatin, gemcitabine plus tegafur/gimeracil/oteracil or gemcitabine plus cisplatin and tegafur/gimeracil/oteracil between April 2010 and March 2022. Stratified/conventional Cox regression analyses were conducted to examine the association between overall survival and patient- and tumour-related factors, study period, hospital volume, hospital type and first-line chemotherapy regimen. Using inverse probability of treatment weighting with propensity scores, overall survival was also compared between monotherapy and combination therapy groups.

RESULTS

We enrolled 366 patients (199 men; median age, 72 years). Over a median follow-up of 5.2 months, the median overall survival was 7.0 months (95% confidence interval 6.2-9.0), and the median time to treatment failure was 3.5 months (95% confidence interval 3.1-4.5). Median overall survival and time to treatment failure for gemcitabine/tegafur-gimeracil-oteracil/gemcitabine plus cisplatin/gemcitabine plus tegafur-gimeracil-oteracil/gemcitabine plus cisplatin and tegafur-gimeracil-oteracil regimen were 6.2/6.6/7.9/16.2/15.1 and 2.8/3.4/4.1/15.3/7.4 months, respectively. Primary disease site, previous surgery, previous endoscopic procedures and hospital type were identified as significant prognostic factors. Inverse probability of treatment weighting analysis demonstrated that combination therapy had a significantly better prognosis than monotherapy (hazard ratio 0.61, 95% confidence interval 0.43-0.88, P = 0.006).

CONCLUSIONS

Our real-world data analysis showed that standard care for metastatic biliary tract cancer is widely used in hospitals throughout Japan and verified the survival benefits of combination therapy over monotherapy observed in prior clinical trials.

CLINICAL TRIAL NUMBER

UMIN000050590 (http://www.umin.ac.jp/ctr/index.htm).

Preoperative prognostic predictors and treatment strategies for surgical procedure focused on the sequential organ failure assessment score in nonocclusive mesenteric ischemia: a multicenter retrospective cohort study

BACKGROUND

Several large-scale studies have assessed endovascular and surgical treatment methods for nonocclusive mesenteric ischemia (NOMI); however, the prognostic factors for NOMI remain unclear. Therefore, this study aimed to evaluate risk factors for in-hospital mortality among patients with NOMI who underwent laparotomy and to examine therapeutic strategies that may improve the prognosis.

MATERIALS AND METHODS

In this multicenter retrospective study, the authors reviewed the electronic medical records retrieved from the inpatient database of patients with NOMI at eight district general hospitals between January 2011 and January 2021. A total of 88 patients who underwent laparotomies were divided into survivor and nonsurvivor groups, and statistical analysis was performed to determine clinical and physiological factors.

RESULTS

Exploratory laparotomy based on second-look surgery was the first treatment choice. The overall mortality rate was 48.8%, with a male-to-female ratio of 1.1:1. The median Sequential Organ Failure Assessment (SOFA) score was 8 [interquartile range: 3.75-14.2], and the median SOFA scores were 5 [3-7] in the survivor group and 13 [9-17.5] in the nonsurvivor group. Univariate analysis revealed a significant difference in BMI ( P <0.001), hypoglycemia ( P =0.0012), previous cardiovascular surgery ( P =0.0019), catecholamine use ( P <0.001), SOFA score ( P <0.001), platelet count ( P =0.0023), and lactate level ( P <0.001). Logistic regression analysis using the factors with significant differences revealed that SOFA score ≥10 (odds ratio 23.3; 95% CI: 1.94-280.00; P =0.013) was an independent prognostic factor. In addition, catecholamine use was suggested as a factor with a SOFA score greater than or equal to 10.

CONCLUSION

This study confirmed that a SOFA score of greater than or equal to 10 may be associated with increased mortality. While closely monitoring low blood pressure and renal dysfunction, survival rates may be improved if surgical intervention is performed before the SOFA score reaches greater than or equal to 10.

Real‑world treatment outcomes among patients with metastatic pancreatic cancer in Japan: The Tokushukai real‑world data project

The present study aimed to investigate temporal trends in treatment patterns and prognostic factors for overall survival (OS) among patients with metastatic pancreatic cancer. From the Tokushukai REAl-world Data project, 1,093 patients with metastatic pancreatic cancer treated with gemcitabine, tegafur/gimeracil/oteracil (S-1), gemcitabine plus S-1, gemcitabine plus nab-paclitaxel, or fluorouracil, folic acid, oxaliplatin and irinotecan (FOLFIRINOX) between April 2010 and March 2020 were identified. Stratified/conventional Cox regression analyses were conducted to examine associations between patient- and tumor-related factors, study period, hospital volume, hospital type and first-line chemotherapy regimens. Overall, 846 patients were selected (503 male patients; median age, 70 years) after excluding ineligible patients. Over a median follow-up of 5.4 months, the median OS was 6.8 months (95% confidence interval, 6.3-7.4). The median OS for gemcitabine, S-1, gemcitabine plus S-1, gemcitabine plus nab-paclitaxel and FOLFIRINOX regimens was 5.9, 5.3, 7.7, 9.0 and 9.5 months, respectively. The median OS for 2010-2013, 2014-2017 and 2017-2020 was 6.2, 7.1 and 7.8 months, respectively. Performance status, body mass index and first-line chemotherapy regimens were identified to be significant prognostic factors. In summary, the real-world data indicated that standard care, including chemotherapy, for metastatic pancreatic cancer was widely used in hospitals throughout Japan and verified the survival benefits of gemcitabine plus nab-paclitaxel and FOLFIRINOX observed in prior clinical trials. This trial has been registered in the University Hospital Medical Information Network Clinical Trials Registry as UMIN000050590 on April 1, 2023.

Real-World Outcomes of Systemic Therapy in Japanese Patients with Cancer (Tokushukai REAl-World Data Project: TREAD): Study Protocol for a Nationwide Cohort Study

Cohort studies using large-scale databases have become increasingly important in recent years. The Tokushukai Medical Group is a leading medical group in Japan that includes 71 general hospitals nationwide from Hokkaido to Okinawa, with a total of 18,000 beds, and a unified electronic medical record system. This retrospective cohort study aims to evaluate the real-world outcomes of systemic therapy for Japanese patients with cancer using this merit of scale. All adult patients with cancer who received systemic therapy using a centrally registered chemotherapy protocol system at 46 hospitals from April 2010 to March 2020 will be identified (~48,850 patients). Key exclusion criteria include active double cancer and inadequate data extraction. Data will be obtained through electronic medical records, diagnosis procedure combination data, medical prescription data, and the national cancer registration system that includes sociodemographic variables, diagnostic and laboratory tests, concomitant drug prescriptions, cost, and overall survival. Kaplan–Meier estimates will be calculated for time-to-event analyses. Stratified/conventional Cox proportional hazards regression analyses will be conducted to examine the relationships between overall survival and related factors. Our findings provide important insights for future research directions, policy initiatives, medical guidelines, and clinical decision-making.

Clinical impact of laparoscopic surgery and adhesion prevention material for prevention of small bowel obstruction

Aim

Adhesive small bowel obstructions (SBO) are one of the most common complications following abdominal surgery, and they decrease patient quality of life. Since 2000, laparoscopic surgery has been employed with increasing frequency, as has adhesion prevention material (APM). In this study we tried to evaluate whether laparoscopic surgery and APM reduce the incidence of SBO.

Methods

In Cohort 1, we included patients who developed SBO and received inpatient treatment between 2015 and 2018. We evaluated the elapsed time between precedent surgery and the onset of SBO, and what kind of surgery most often causes SBO. In Cohort 2, we included patients who underwent digestive surgery between 2012 and 2014 and evaluated SBO incidence within 5 y after the precedent surgery.

Results

In all, 2058 patients were included in Cohort 1. Of these, 164 had experienced no precedent surgery. Among patients with a history of abdominal surgery, 29.7% experienced SBO within 1 y after the precedent surgery and 48.1% within 3 y. Altogether, 18798 patients were analyzed in Cohort 2. The incidence of SBO after laparoscopic colorectal surgery was lower than that of open colorectal surgery (P < .001), and laparoscopic gastroduodenal surgery was also lower (P = .02). However, there were no differences between laparoscopic and open surgery for other types of surgery. The use of APM had no effect on SBO incidence in any type of abdominal surgery.

Conclusions

Laparoscopic surgery helps to reduce SBO incidence only in colorectal surgery, and possibly in gastroduodenal surgery. APM does not reduce SBO after abdominal surgery.

Monitoring the Sequential Organ Failure Assessment score in nonocclusive mesenteric ischemia increases the survival rate: A single-center observational study

Several large-scale studies have assessed the endovascular and surgical treatments for nonocclusive mesenteric ischemia (NOMI); nonetheless, the prognostic factors for NOMI remain unclear.In this single-center study, we retrospectively reviewed the electronic medical records of 197, 149 patients were retrieved from the inpatient database of our hospital from January 2011 to January 2020; 79 patients with NOMI were observed. A total of 44 patients who underwent laparotomy were statistically analyzed and divided into the survivor and non-survivor groups. Prognostic factors were compared between the 2 groups. Exploratory laparotomy based on a second-look surgery was the first treatment choice.The overall mortality rate was 61.3%, with a male-to-female ratio of 1.6:1. The median Sequential Organ Failure Assessment (SOFA) score was 11.06 [5.75-17.25]. The median SOFA score was 5 [interquartile range: 3-8] in the survivor group and 14.8 [interquartile range: 10.5-19] in the non-survivor group. The log-rank test showed a significant difference in the presence of diabetes mellitus (P = .025), hypoglycemia (P = .001), SOFA score ≥10 (P < .001), hemoglobin levels ≥11 g/dL (P = .003), platelet count ≥12.9 × 104/μL (P = .01), lactate levels ≥2.6 mmol/L (P = .005), and base excess <-3.0 (P < .023). Multivariate analysis using the factors with significant differences revealed that SOFA score ≥10 (hazard ratio for death, 1.199; 95% confidence interval, 1.101-1.305; P < .001) was an independent prognostic factor.The SOFA score can be used to assess disease severity. A SOFA score of ≥10 may be associated with increased mortality.

Resolution of fibrosis by siRNA HSP47 in vitamin A-coupled liposomes induces regeneration of chronically injured livers

BACKGROUND AND AIM

In chronic hepatic diseases where treatment strategies are not available, deposited fibrotic tissues deteriorate the intrinsic regeneration capacity of the liver by creating special restrictions. Thus, if the anti-fibrosis modality is efficiently applied, the regeneration capacity of the liver should be reactivated even in such refractory hepatic diseases.

METHODS

Rat liver fibrosis was induced by dimethyl-nitrosamine (DMN). Another liver fibrosis model was established in CCl4 treated Sox9CreERT2ROSA26: YFP mice. To resolve hepatic fibrosis, vitamin A-coupled liposomes containing siRNA HSP47 (VA-liposome siHSP47) were employed. EpCAM + hepatic progenitor cells from GFP rats were transplanted to DMN rat liver to examine their trans-differentiation into hepatic cells after resolution of liver fibrosis.

RESULTS

Even under continuous exposure to such strong hepatotoxin as DMN, rats undergoing VA-liposome siHSP47 treatment showed an increment of DNA synthesis of hepatocytes with the concomitant restoration of impaired liver weight and normalization of albumin levels. These results were consistent with the observation that GFP + EpCAM hepatic progenitor cells transplanted to DMN rat liver, trans-differentiated into GFP + mature hepatic cells after VA-liposome siHSP47 treatment. Another rodent model also proved regeneration potential of the fibrotic liver in CCl4 administered Sox9CreERT2ROSA26: YFP mice, VA-liposome siHSP47 treatment-induced restoration of liver weight and trans-differentiation of YEP + Sox9 + cells into YFP + hepatic cells, although because of relatively mild hepatotoxicity of CCl4, undamaged hepatocytes also proliferated.

CONCLUSIONS

These results demonstrated that regeneration of chronically damaged liver indeed occurs after anti-fibrosis treatment even under continuous exposure to hepatotoxin, which promises a significant benefit of the anti-fibrosis therapy for refractory liver diseases.

Multimodal treatment for acute empyema based on the patient's condition, including patients who are bedridden: A single center retrospective study

Background

The incidence of acute empyema has increased in various countries; some elderly patients with acute empyema have contraindications for surgery under general anesthesia. Therefore, suitable management based on a patient's clinical condition is required.

Methods

We evaluated the different surgical and nonsurgical therapeutic approaches available for patients with acute empyema. This was a retrospective study of 57 patients with acute empyema who received treatment in our department between May 2015 and February 2019. For patients who did not initially improve with drainage or drainage combined with fibrinolytic therapy, surgery, or additional percutaneous drainage was performed based on their general condition. We compared several clinical factors pertaining to the patients who underwent surgical versus nonsurgical treatment.

Results

Our study showed that the patients with a performance status of 0-2 and an American Society of Anesthesiologists physical status classification of class II or lower underwent surgery safely without major operative complications. The combination of repeated drainage of the pleural cavity and fibrinolytic therapy appeared to be a reasonable nonsurgical management option for patients in poor overall condition.

Conclusion

For an aging population, we think that the combination of repeated pleural cavity drainage procedures and fibrinolytic therapy is a reasonable nonsurgical strategy for the management of patients with acute empyema.

Sigmoid colon strangulation caused by bilateral fallopian tubes: A case report

INTRODUCTION

There are no reports regarding sigmoid colon strangulation caused by bilateral fallopian tubes, which is a rare type of large bowel obstruction. Herein, we report a case of successful laparoscopic treatment of sigmoid colon strangulation.

PRESENTATION OF CASE

A 54-year-old woman presented to our hospital with intermittent abdominal pain. Her medical history was significant for endometriosis; however, there was no surgical history. The physical examination revealed tenderness over the lower abdomen. CT scan shows closed loop obstruction of sigmoid colon. Exploratory laparoscopy was performed, and a sigmoid colon strangulated by bilateral fallopian tubes was detected. The adhesions consisting of bilateral fallopian tubes were dissected laparoscopically. The patient's postoperative course was uneventful, with no complications.

DISCUSSION

The most common cause of large bowel obstruction (LBO) is colorectal cancer, including volvulus and diverticulitis. In this case, the adhesion of both the right and left fallopian tubes caused LBO, and it is conceivable that the etiology involved is endometriosis. Few cases have reported bowel obstruction associated with a fallopian tube, and the laparoscopic approach is very rare. In our case, we immediately performed laparoscopic exploration before colon strangulation led to necrosis or perforation. Therefore, we succeeded in releasing the strangulation laparoscopically.

CONCLUSION

We report a case of sigmoid colon strangulation that was treated laparoscopically. This approach can be the treatment of choice for sigmoid colon strangulation.

Laparoscopic treatment for renal paratransplant hernia: A case report

INTRODUCTION

There are limited reports regarding renal paratransplant hernia (RPH), which is a rare type of internal hernia. Herein, we report a case of successful laparoscopic treatment of RPH.

PRESENTATION OF CASE

A kidney transplant recipient presented to our emergency department with a 6-h history of abdominal pain and vomiting. The patient had received a living-related donor kidney transplantation and native nephrectomy in our hospital last year. Computed tomography (CT) confirmed a diagnosis of RPH. We performed laparoscopic exploration, and the findings showed an incarcerated small bowel in the retroperitoneal space through a peritoneal defect. Short laparotomy was performed to resect the non-viable bowel. The peritoneal defect was opened adequately. The patient's postoperative course was uneventful, with no complications.

DISCUSSION

RPH is an uncommon variant of internal hernia, which is a rare surgical complication after kidney transplantation. Early diagnosis and treatment are important once RPH develops. Due to immunosuppression in kidney transplant recipients, typical signs of peritonitis were not observed. This event can be critical to the patient. Laparoscopic surgery has recently become a treatment option for small bowel obstructions. We believe that this surgical procedure is useful for patients with RPH.

CONCLUSION

We report a case of RPH treated laparoscopically. This approach can be a treatment of choice for RPH.

Intraoperative angiography with indocyanine green injection for precise localization and resection of small bowel bleeding

Aim

Bleeding in the small bowel rarely occurs, and its treatment is challenging. Surgery is sometimes required in unstable patients; however, intraoperative identification of the bleeding site is extremely difficult. Many methods have been reported, but no standard strategy has been established yet. Here, we aimed to assess the safety and feasibility of intraoperative angiography with indocyanine green staining to accurately identify small bowel bleeding sites.

Methods

This retrospective study analyzed contrast‐enhanced computed tomography images of patients (n = 8) with small bowel extravasation who underwent surgery. If extravasation or other vessel abnormalities that were potential bleeding sites were detected on intraoperative angiography, a microcatheter was placed as close as possible to the extravasation site. Laparotomy was carried out, and 3–5 mL indocyanine green was injected through the microcatheter. The green‐stained segment of the small bowel was resected.

Results

Seven of the eight patients had positive angiographic findings and underwent bowel resection. The eighth patient had no abnormalities and hence did not undergo laparotomy. The rate of hemostatic success among the resected cases was 85.7% (six of seven cases). The resected specimens showed pathologic features in six of the seven patients (85.7%), all of whom achieved hemostasis. One patient had pneumonia and congestive heart failure that required longer hospital stay, but no mortality occurred.

Conclusions

Intraoperative angiography with indocyanine green injection, followed by resection for massive small bowel bleeding is effective. This can be a therapeutic option for hemodynamically unstable patients.

A Surgical Case of Bronchial Artery Aneurysm Connecting to a Pulmonary Artery and Vein Complicated by Racemose Hemangioma

We report a surgical case of bronchial artery aneurysm (BAA) that directly connected to a pulmonary artery and a pulmonary vein through an abnormal vessel. It was complicated by racemose hemangioma. This is a rare vascular malformation. An 82-year-old female had a large BAA that was found incidentally. First, we consider treating the BAA with embolization by interventional radiology (IVR). However, because of strong meandering of the bronchial artery, we could not advance a microcatheter into the BAA. Therefore, a surgical operation was performed through a standard posterior lateral thoracotomy. The BAA was located between the upper and lower lobes and directly connected to the pulmonary artery. Some bronchial artery branches that provided inflow to the aneurysm were ligated, and the abnormal vessel that connected the BAA to the upper pulmonary vein was ligated easily. A fistula between the BAA and pulmonary artery was sutured by the cardiovascular surgeon using an artificial cardiopulmonary device, with permissive stenosis of A2b (ascending A2).

Association of pre-operative chronic kidney disease and acute kidney injury with in-hospital outcomes of emergency colorectal surgery: a cohort study

BACKGROUND

Pre-operative kidney function is known to be associated with surgical outcomes. However, in emergency surgery, the pre-operative kidney function may reflect chronic kidney disease (CKD) or acute kidney injury (AKI). We examined the association of pre-operative CKD and/or AKI with in-hospital outcomes of emergency colorectal surgery.

METHODS

We conducted a retrospective cohort study including adult patients undergoing emergency colorectal surgery in 38 Japanese hospitals between 2010 and 2017. We classified patients into five groups according to the pre-operative status of CKD (defined as baseline estimated glomerular filtration rate < 60 mL/min/1.73 m2 or recorded diagnosis of CKD), AKI (defined as admission serum creatinine value/baseline serum creatinine value ≥ 1.5), and end-stage renal disease (ESRD): (i) CKD(-)AKI(-), (ii) CKD(-)AKI(+), (iii) CKD(+)AKI(-), (iv) CKD(+)AKI(+), and (v) ESRD groups. The primary outcome was in-hospital mortality, while secondary outcomes included use of vasoactive drugs, mechanical ventilation, blood transfusion, post-operative renal replacement therapy, and length of hospital stay. We compared these outcomes among the five groups, followed by a multivariable logistic regression analysis for in-hospital mortality.

RESULTS

We identified 3002 patients with emergency colorectal surgery (mean age 70.3 ± 15.4 years, male 54.5%). The in-hospital mortality was 8.6% (169/1963), 23.8% (129/541), 15.3% (52/340), 28.8% (17/59), and 32.3% (32/99) for CKD(-)AKI(-), CKD(-)AKI(+), CKD(+)AKI(-), CKD(+)AKI(+), and ESRD, respectively. Other outcomes such as blood transfusion and post-operative renal replacement therapy showed similar trends. Compared to the CKD(-)AKI(-) group, the adjusted odds ratio (95% confidence interval) for in-hospital mortality was 2.54 (1.90-3.40), 1.29 (0.90-1.85), 2.86 (1.54-5.32), and 2.76 (1.55-4.93) for CKD(-)AKI(+), CKD(+)AKI(-), CKD(+)AKI(+), and ESRD groups, respectively. Stratified by baseline eGFR (> 90, 60-89, 30-59, and < 30 mL/min/1.73 m2) and AKI status, the crude in-hospital mortality and adjusted odds ratio increased in patients with baseline eGFR < 30 mL/min/1.73 m2 among patients without AKI, while these were constantly high regardless of baseline eGFR among patients with AKI. Additional analysis restricting to 2162 patients receiving the surgery on the day of hospital admission showed similar results.

CONCLUSIONS

The differentiation of pre-operative CKD and AKI, especially the identification of AKI, is useful for risk stratification in patients undergoing emergency colorectal surgery.

Successful treatment of hepatic gas gangrene by open drainage: A case report and review of the Japanese literature

INTRODUCTION

Liver gas gangrene is rare and has a low prognosis. This case, reports a successful treatment of hepatic gas gangrene using an open drainage technique, followed by antibiotics and hyperbaric oxygen therapy (HBO).

PRESENTATION OF THE CASE

An 82-year-old male with a history of left hepatectomy and bile duct resection for hilar cholangiocarcinoma presented with chilling, lethargy and dyspnea. He had a history of diabetes mellitus, hypertension, atrial fibrillation, and angina pectoris. Physical examination revealed scleric icterus, right hypochondrium tenderness and percussion tenderness of the liver, with warm extremities. Laboratory findings revealed leukocytosis and increased levels of hepatobiliary enzymes. A computed tomography (CT) scan showed gas accumulation in an S8 lesion with portal vein gas. Percutaneous drainage was performed immediately, and broad-spectrum antibiotics were started, but the drainage was insufficient. Consequently, laparotomy drainage was carried out, followed by HBO. No abscess was detected at one-year of follow-up.

DISCUSSION

Hepatic gas gangrene progresses rapidly and has a high mortality rate. Malignant disease and diabetes mellitus may be predisposing factors. While half of non-clostridial cases survive, most cases of hepatic gas gangrene are associated with clostridial infection and have a fatal outcome.

CONCLUSION

All survival cases of hepatic gas gangrene were treated by laparotomy drainage, thus immediate laparotomy seems essential to prevent a fatal outcome.

Small intestinal metastases from esophageal carcinoma presenting as a perforation: A case report and review of the literature

INTRODUCTION

Small intestinal metastasis from oesophageal carcinoma is rare. We report a case of small intestinal metastases from oesophageal carcinoma presenting as a perforation and discuss the aetiology with other cases of small intestinal metastasis from oesophageal carcinoma reported in previous literature.

PRESENTATION

An 86-year-old man presented with fever and coughing. He had choked while eating and had history of weight loss. He was diagnosed with aspiration pneumonia. Two days after the admission, he complained of abdominal pain. Physical examination revealed guarding and rebound tenderness in the upper abdomen. A contrast computed tomography of the abdomen showed ascites, free air, and irregular thickness of the small intestinal walls. Small intestinal perforation was noted, and surgical resection of the small intestine was performed. The pathological findings of the resected small intestine revealed ulcers with squamous cell carcinoma, and upper gastrointestinal endoscopy demonstrated oesophageal tumour, whose biopsy revealed squamous cell carcinoma. A diagnosis of small intestinal metastases from oesophageal carcinoma was made, but the patient died one month after the diagnosis.

DISCUSSION

Most cases found in the literature of oesophageal tumour involve squamous cell carcinoma with male patients, and specific symptoms are divided into obstruction and perforation. All patients with small intestinal metastasis from oesophageal carcinoma who survived were treated by a combination of resection and radiation and/or chemotherapy; thus, immediate treatments seem essential to improve the prognosis.

CONCLUSION

Physicians should keep in mind the possibility of small intestinal metastasis when patients with a history of oesophageal cancer have abdominal symptoms.

Lumbar Arterial Bleeding Treated with Endovascular Aneurysm Repair: A Report of 4 Patients

BACKGROUND

Lumbar arterial bleeding is a severe condition. Surgical exploration is not indicated because of its rich collateral flow. Transarterial embolization (TAE) is reportedly effective, but there have been cases of failure. It may be a time-consuming procedure for patients with multiple bleeding sources or those with poor vital signs. In this case series, we used endovascular aneurysm repair (EVAR) instead of TAE.

METHOD

In this case series, we described 4 male patients (2 with traumatic injury, 1 with iatrogenic injury, and 1 with drug-induced hypocoagulability) with lumbar arterial bleeding. The reasons we chose EVAR are because 2 patients had poor vital signs, one patient was a technically difficult case for selective cannulation, and one patient had accompanying aortic dissection.

RESULT

In all patients, EVAR was performed successfully, and hemostasis was obtained although one patient died of pneumonia on postoperative day 23.

CONCLUSIONS

EVAR is an effective alternative for lumbar arterial bleeding although TAE is a first choice of treatment.

Stomach resection with intraoperative fluoroscopy in laparoscopic distal gastrectomy for early gastric cancer

Background:

In Japan, laparoscopic distal gastrectomy (LDG) is common for early gastric cancer. Formerly, we used to verify the location of the marking clip to decide the proximal incisional line with our hand, through a small epigastric incision. In 2015, we introduced intracorporeal reconstruction and started to decide the incisional line using intraoperative fluoroscopy. Herein, we aimed to evaluate the efficacy and safety of intraoperative fluoroscopy in LDG.

Patients and Methods:

A total of 19 patients were included in this retrospective observational study. On the day before operation, we endoscopically clipped several points located 2 cm proximal to the tumour edge to cover about half of the tumour. After lymph node dissection, we incised the stomach with an endoscopic linear stapling device, including the previously placed clips, guided by intraoperative fluoroscopy. Reconstruction was performed in all patients who underwent Billroth I and Roux-en-Y procedures.

Results:

No complications were observed during pre-operative endoscopic clipping or intraoperatively. On pathological examination, all resected specimens had negative margins, and the mean distance from the tumour edge was 28.5 ± 16.5 (13–60) mm.

Conclusion:

Stomach resection with intraoperative fluoroscopic guidance was safe and effective.

Scarless surgery for a huge liver cyst: A case report

•

Fenestration is the definitive treatment for symptomatic/complicated liver cysts.

•

NOTES, which has been reported recently, enables surgery without scars.

•

Multiple clinical and technological barriers impede further progress with NOTES.

•

Our safe and unique method enables minimally invasive surgery with small incisions.

•

This “scarless surgery” is expected to yield some clinical benefits.

Introduction

Symptomatic or complicated liver cysts sometimes require surgical intervention and laparoscopic fenestration is the definitive treatment for these cysts. We performed minimally invasive surgery, hybrid natural orifice transluminal endoscopic surgery (NOTES) without scarring, for a huge liver cyst.

Presentation of case

An 82-year-old female presented with a month-long history of right upper abdominal pain. We diagnosed her condition as a huge liver cyst by morphological studies. She denied any history of abdominal trauma. Her serum CEA and CA19-9 were normal and a serum echinococcus serologic test was negative. Laparoscopic fenestration, using a hybrid NOTES procedure via a transvaginal approach, was performed for a huge liver cyst because we anticipated difficulty with an umbilical approach, such as single incision laparoscopic surgery (SILS). Her post-operative course was uneventful and she was discharged from our hospital three days after surgery. Pain killers were not required during and after hospitalization. No recurrence of the liver cyst or bulging was detected by clinical examination two years later.

Discussion

A recent trend of laparoscopic procedure has been towards minimizing the number of incisions to achieve less invasiveness. This hybrid NOTES, with a small incision for abdominal access, along with vaginal access, enabled painless operation for a huge liver cyst.

Conclusion

We report a huge liver cyst treated by hybrid NOTES. This approach is safe, less invasive, and may be the first choice for a huge liver cyst.

Comparison of efficacies of the self-expandable metallic stent versus transanal drainage tube and emergency surgery for malignant left-sided colon obstruction

BACKGROUND/OBJECTIVE

Patients with left-sided malignant colorectal obstruction require emergency treatment. Emergency stoma surgery has traditionally been recommended, however many stomas became permanent, decreasing patient quality of life. Recently, self-expandable metallic stents (SEMS) and transanal decompression tubes (TDT) have become widely used decompression methods to avoid stoma surgery. In this study, we evaluated: 1) the efficacy of SEMS compared with TDT and emergency surgery (ES) to avoid permanent stomas; and 2) the safety and success rate of each treatment.

METHODS

We retrospectively reviewed data from 56 patients who underwent SEMS, TDT, or emergency surgery for malignant left-sided colon obstruction. We compared the permanent stoma rate of each group, and assessed whether or not each treatment was an independent risk factor for permanent stomas. We compared morbidity and mortality for each treatment group (SEMS, TDT, ES), and the success rate of the decompression procedures (SEMS and TDT).

RESULTS

The permanent stoma rates in the SEMS, TDT, and ES groups were 5.3%, 50.0%, and 56.0%, respectively. Emergency surgery (vs. SEMS) and TDT (vs. SEMS) were independent risk factors for permanent stomas, as was age ≥ 75 years. Operative morbidity, mortality, and hospital stay were not different between groups. The success rate of SEMS was significantly higher than TDT; however, two deaths, including one perforation, occurred in the former group.

CONCLUSION

SEMS seems to be effective in avoiding permanent stomas, but caution should be taken to avoid complications.

Fatal liver gas gangrene after biliary surgery

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Liver gas gangrene is a rare condition with a highly mortality rate.

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Development of liver gas gangrene is associated with host conditions such as malignancy and immunosuppression.

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We report a case of liver gas gangrene after biliary surgery which is one of the risks of the liver parenchymal infection.

Introduction

Liver gas gangrene is a rare condition with a highly mortality rate. It is mostly associated with host factors, such as malignancy and immunosuppression.

Presentation of case

A 57-year-old female was admitted to our hospital with abnormalities of her serum hepato-biliary enzymes. She had a history of hypertension, diabetes mellitus, cerebral infarction, and chronic renal failure. She was diagnosed with bile duct cancer of the liver hilum and a left hepatectomy was carried out, with extrahepatic bile duct resection. Initially her post-operative state was uneventful. However, she suddenly developed melena with anemia on post-operative day (POD) 18. A Computed tomography (CT) examination on POD 19 revealed a massive build up of gas and portal gas formation in the anterior segment of the liver. Although we immediately provided the drainage and a probe laparotomy, she died on POD 20 due to shock with disseminated intravascular coagulation.

Discussion

Liver gas gangrene is rare and has a high mortality rate. This case seems to have arisen from an immunosuppressive state after major surgery with biliary reconstruction for bile duct cancer and subsequent gastrointestinal bleeding, leading to gas gangrene of the liver.

Adventitial cystic disease of the popliteal artery treated by bypass graft utilizing the short saphenous vein: A case report

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CT or MRI scan is crucial in the diagnosis of adventitial cystic disease (ACD).

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Surgery is the first line in the treatment of ACD at the popliteal artery.

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The short saphenous vein was successfully employed in bypass graft surgery.

Introduction

Adventitial cystic disease is relatively rare vascular disease, frequently occurred in the popliteal artery. No definitive treatment has been established yet.

Prentation of case

A 53-year-old woman presenting intermittent claudication of the right leg was diagnosed as adventitial cystic disease of popliteal artery. Percutaneous balloon dilation yielded an immediate recurrence. The disease was successfully treated by bypass grafting utilizing the short saphenous vein to replace the part of the popliteal artery containing the adventitial cyst. No postoperative complication was found six months after surgery.

Discussion

Comparing to a great saphenous vein, a short saphenous vein as a material of bypass graft has a significant advantage, as only a single surgical field is necessary.

Conclusion

We propose that bypass graft surgery employing a short saphenous vein is worth considering as a treatment of adventitial cystic disease at the popliteal artery.

A rare case of an infected tracheal diverticulum requiring emergency intervention: A case report

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A case of an infected tracheal diverticulum presenting as a paratracheal mass is demonstrated.

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An infected tracheal diverticulum can impair the airway and require emergency intervention including surgery.

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The most commonly described procedure of surgery is resection via a transverse or lateral neck incision and drainage of the abscess.

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A CT scan plays important roles to make a diagnosis and evaluate the necessity of intervention.

Introduction

Recent advancement in radiological imaging has revealed an increasing amount of asymptomatic abnormalities. Tracheal diverticula are relatively rare entities and are incidentally found on radiological imaging such as computed tomography. Here, we present a case of an infected tracheal diverticulum presenting as a paratracheal mass, which required emergency intervention.

Case presentation

A 65-year-old Japanese nonsmoker man presented with a fever, lower neck pain, and the aggravation of dyspnea for a week. An enhanced computed tomography scan demonstrated that the trachea was displaced by a paratracheal mass with a well-defined thin wall. His respiratory status was so urgent that emergency intubation and surgical drainage of the abscess were performed. A computed tomography scan performed 4 days after admission demonstrated shrinking of the abscess, and he was extubated and discharged 7 days after admission without any complications.

Conclusion

To the best of our knowledge, this is the first report to confirm an infected tracheal diverticulum presenting as a paratracheal abscess, which required emergency intervention. Moreover, computed tomography plays an important role in the differentiation of paratracheal masses.

[Successful Treatment of Empyema with Bronchial Fistulas by Filling under Thoracoscopic Observation; Report of a Case]

Empyema with fistula usually resists conservative treatment such as thoracic cavity drainage and administration of antibacterial agents, thus it often requires surgeries such as fenestration, omental/muscle filling, and thoracoplasty. However, due to advanced age and poor condition, conducting invasive surgeries is often difficult in elderly patients. We report a case with the improvement of empyema by bronchial filling with endobronchial Watanabe spigot (EWS) under thoracoscopic observation for an 89-year-old patient who had developed chronic empyema with a bronchial fistulas. After filling EWS, air-leakage from bronchial fistula disappeared and the patient could discharged from the hospital successfully.

A phase II trial of panitumumab with irinotecan and S-1 (IRIS) as second-line treatment in patients with wild-type KRAS metastatic colorectal cancer

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Background: Panitumumab with fluorouracil, leucovorin, and irinotecan (FOLFIRI) in second-line chemotherapy increased objective response rate and prolonged progression-free survival (PFS) versus FOLFIRI alone in patients with wild-type (WT) KRAS metastatic colorectal cancer (mCRC) (Peeters et al, J Clin Oncol 2010). This trial (UMIN000004659) evaluated tolerability and efficacy of combination therapy with irinotecan and S-1, an oral fluoropyrimidine (IRIS) plus panitumumab as second-line chemotherapy in patients with WT KRASmCRC. Methods: Main inclusion criteria were: patients with WT KRAS mCRC refractory to one prior chemotherapy regimen for mCRC, ECOG PS 0-2, and age ≥20 years. Patients received panitumumab (6 mg/m2) and irinotecan (100 mg/m2) on days 1 and 15 and S-1 (40-60 mg according to body surface area) twice daily for 2 weeks, repeated every 4 weeks. The primary endpoint was completion rate of protocol therapy (CRT). The secondary endpoints were response rate (RR), progression-free survival (PFS), and overall survival (OS). Results: Thirty-seven patients were enrolled in 9 centers. The overall CRT was 62.2% (23/37). Most frequent grade 3/4 toxicities were: skin rash (24%), diarrhea (16%), and appetite loss (11%). The overall RR was 32.4% (12/37). Of these, four patients underwent conversion surgery. Median PFS and OS were 9.5 months (95% CI: 3.5-15.4 months) and 20.1 months (95% CI: 16.7-23.2 months), respectively. Conclusions: IRIS plus panitumumab has acceptable toxicity profile and promising efficacy in patients with previously treated WT KRAS mCRC. This regimen can be an additional treatment option for second-line chemotherapy in WT KRAS mCRC. Clinical trial information: UMIN000004659.

[Early diagnosis of capecitabine-induced acute leukoencephalopathy by using diffusion-weighted MRI]

A 63-year-old woman with colon cancer who was treated with capecitabine as adjuvant chemotherapy presented with vertigo on day 5, and dysarthria and dysphagia on day 7 of the treatment. Diffusion-weighted magnetic resonance imaging of the brain revealed high signal intensity in the corpus callosum and corona radiata. The patient was diagnosed with acute leukoencephalopathy, and the capecitabine treatment was discontinued. Her symptoms recovered immediately. On the basis of these findings, it can be concluded that diffusion-weighted imaging is useful for the early detection and diagnosis of acute leukoencephalopathy.

Protocol-based strategy for endovascular repair of ruptured abdominal aortic aneurysms

OBJECTIVE

Compared with conventional open surgery (COS), endovascular aneurysm repair (EVAR) has been reported to decrease the 30-day mortality rate in patients with ruptured abdominal aortic aneurysms (rAAAs). We developed an EVAR-first strategy for rAAAs that incorporates the Shonan ruptured abdominal aortic aneurysm protocol (SRAP). We describe short-term results with this protocol at our institution and compare them with outcomes in patients who underwent COS.

METHODS

The records of all 57 patients in whom a rAAA was repaired during a 7-year period were reviewed retrospectively. Patients in the COS group (n = 30) were treated between January 2005 and December 2009; those in the SRAP group (n = 27) were treated between January 2010 and March 2012. The two groups were compared with respect to patient characteristics at admission, including severity of condition; operative and in-hospital variables; and 30-day mortality.

RESULTS

The baseline patient characteristics in the COS and SRAP groups were similar except that the SRAP group had a significantly higher rate of cerebrovascular disease. The 30-day mortality rate was significantly higher in the COS group (43% vs. 19%), as were the intraoperative mortality rate (27% vs. 5%) and the in-hospital mortality rate (57% vs. 26%; P < 0.05 for all comparisons). The technical success rate for EVAR was 96%; no conversions to open surgery were required.

CONCLUSIONS

Use of the SRAP is a promising strategy for improving initial outcomes in patients with rAAAs.

Web-based standard-regimen selection (SRS) and cancer-care registry (CCR) systems of a nationwide network in Japan: An attempt to improve breast cancer treatment

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Background: Tokushukai group has a nation-wide network of 67 affiliated hospitals, and has started an “oncology project” to improve the quality of cancer care using web-based SRS and CCR systems. Methods: Every institution has been introduced the same electric-medical-record (EMR) to share the unified code to order chemotherapy regimens, and patient data could be collected on a database in the central office. 141 recommended regimens for 15 types of solid tumor have been approved in the cancer committee consisting of working-group and program-evaluation members. In breast cancer, 31 recommended regimens (7 for adjuvant and 24 for metastatic settings) were selected from the NCCN guidelines and approved by the committee. Not only recommended but also non-recommended regimens have their own specific codes in EMR, and the patterns of care in the selection of chemotherapy regimen were examined. Results: In 2011, 21 of 67 hospitals utilized these systems. 71.8% of 2,676 patients with cancer including 753 with colorectal, 317 with breast, 273 with gastric, 144 with non-small cell lung, 123 with pancreatic, and 73 patients with esophageal cancer had received 97 types of recommended therapies (11,022 cycles). In terms of breast cancer, 86% of 388 patients had been treated with recommended regimens (1,994 cycles). Among 71 patients received non-recommend therapies, only 6 patients (1.5%) had been treated with three regimens which were not regarded as standard regimens. Conclusions: The introduction of web-based SRS and CCR systems in a large medical group could facilitate standard chemotherapy regimen by an accurate examination of current treatment patterns.

Range of motion exercise of temporo-mandibular joint with hot pack increases occlusal force in patients with Duchenne muscular dystrophy

The purpose of this study is to evaluate whether the range of motion exercise of the temporo-mandibular joint (jaw ROM exercise) with a hot pack and massage of the masseter muscle improve biting disorder in Duchenne muscular dystrophy (DMD). The subjects were 18 DMD patients (21.3+/- 4.1 years old). The jaw ROM exercise consisted of therapist-assisted training (2 times a week) and self-training (before each meal every day). The therapist-assisted training consisted of the application of a hot pack on the cheek of the masseter muscle region (15 minutes), the massage of the masseter (10 minutes), and jaw ROM exercise (5 minutes). The self-training involved jaw ROM exercise by opening the mouth to the maximum degree, ten times. These trainings continued for six months. Outcomes were evaluated by measuring the greatest occlusal force and the distance at the maximum degree of mouth opening between an incisor of the top and that of the bottom. Six months later, the greatest occlusal force had increased significantly compared with that at the start of jaw ROM exercise (intermediate values: from 73.8N to 97.3N) (p = 0.005) as determined by the Friedman test and Scheffi's nonparametric test. The patients' satisfaction with meals increased. However, the maximum degree of mouth opening did not change after six months of jaw ROM exercise. Jaw ROM exercise in DMD is effective for increasing the greatest occlusal force.

Single nucleotide polymorphism in ABCG2 is associated with irinotecan-induced severe myelosuppression

Irinotecan is an anti-neoplastic agent that is widely used for treating colorectal and lung cancers, but often causes toxicities such as severe myelosuppression and diarrhea. In this study, we performed a two-stage case-control association study for irinotecan-induced severe myelosuppression (grades 3 and 4). In the first stage, 23 patients who developed severe myelosuppression and 58 patients who did not develop any toxicity were examined for 170 single nucleotide polymorphisms (SNPs) in 14 genes involved in the metabolism and transport of irinotecan. A total of five SNPs were identified to show the possible association with severe myelosuppression (P(Fisher)<0.01) and were further examined in 7 cases and 20 controls in the second stage of the study. An intronic SNP, rs2622604, in ABCG2 showed P(Fisher)=0.0419 in the second stage and indicated a significant association with severe myelosuppression in the combined study (P(Fisher)=0.000237; P(Corrected)=0.036). Although only limited subjects were investigated, our results suggested that a genetic polymorphism in ABCG2 might alter the transport activity for the drug and elevate the systemic circulation level of irinotecan, leading to severe myelosuppression.

[A case of therapy for bevacizumab-induced hypertension]

The patient was a 73-year-old female with sigmoid colon cancer, who underwent resection of sigmoid colon cancer and liver metastasis. She was treated with 5-fluorouracil and levofolinate calcium(sLV5FU2)plus bevacizumab(BV) for advanced colorectal cancer. She was treated with angiotensin II receptor blocker(ARB)because hersystolic blood pressure was 200 mmHg and her diastolic blood pressure 100 mmHg after five courses of BV therapy. As a result, her blood pressure was controlled. It was possible to administer BV. Therefore, ARB may be the preferred antihypertensive agent in the management of BV-induced hypertension.

Donor selection in Japan: a trial of new criteria with predonation haemoglobin testing

BACKGROUND AND OBJECTIVES

In Japan, eligibility for blood donation depends on blood specific gravity, which does not directly measure blood haemoglobin. Additionally, the criteria are not based on normal values. Therefore, we investigated the feasibility of predonation screening by using actual haemoglobin levels, and adopted a new criterion based on the normal range for men.

MATERIALS AND METHODS

Using a portable device, we measured haemoglobin in 1032 prospective blood donors, then applied this method to all blood donations. The criterion for men was set at the 95th percentile of haemoglobin distribution, namely 13.0 g/dl and 13.5 g/dl, respectively, for 200-ml and 400-ml donations. That for women remained unchanged.

RESULTS

The percentage of men ineligible by these criteria increased from 0.6 to 1.5%, while that of women decreased from 16.5 to 14.6%. Donors with abnormal haemoglobin levels were referred to hospitals.

CONCLUSION

Predonation measurement of haemoglobin concentration, combined with the referral of those with abnormal values, provided a health benefit to that population.

Histological examination on edema formation in the rabbit brain exposed to head-down tilt

Previous studies demonstrated that exposure to simulated microgravity, head-down tilt (HDT), caused cephalad fluid shift, increased capillary pressure in the head, and produced facial edema and nasal congestion. It is also known that exposure to HDT affects hemodynamics in the brain. Cerebral blood flow (CBF) velocity increases for at least 6 hours after the onset of 6 degrees HDT in humans. Intracranial pressure (ICP) elevates during 6 degrees HDT in humans and monkeys. However, there is little information regarding edema formation in the brain due to HDT except a morphological study reported by Kaplansky and colleagues who showed that perivascular edema occurred in the monkey brain after 7 days of 6 degrees HDT. Thus, it is interesting to examine whether edema formation occurs in the other animal model for simulation of microgravity, since several factors such as the duration of HDT, angle of HDT, and species difference may affect the result. In the present study, formation of brain edema was investigated by histological examinations in rabbits exposed to 45 degrees HDT for 2 days or 8 days. We hypothesized that HDT causes brain edema which can be demonstrated as extravasation of plasma constituents and histological changes.

Monitoring of carbamazepine and carbamazepine 10,11-epoxide in breast milk and plasma by high-performance liquid chromatography

A high-performance liquid chromatographic method was developed for the measurement of carbamazepine (CBZ) and carbamazepine 10,11-epoxide (CBZE) in human breast milk and plasma. The method involves rapid C18 solid-phase extraction of CBZ and CBZE. Chromatographic separation was achieved with a reversed-phase C8 column using a mobile phase of potassium dihydrogenphosphate (pH 2.5) and acetonitrile (67:33 v/v), with ultraviolet detection at 254 nm. 2-Methyl CBZ was used as the internal standard. Determination of both CBZ and CBZE was possible in the range of 0.01-6.0 mg/L and 0.02-6.0 mg/L in milk and plasma, respectively. The recoveries of CBZ and CBZE added to the milk and plasma were 90.6-98.0% and 88.9-104.0%, respectively, with coefficients of variation less than 8.3% and 10.5%, respectively. The method has been used for drug level monitoring in milk and plasma samples obtained from CBZ-treated patients. The mean (SD) levels for CBZ in milk and plasma samples were 3.50 (0.4) mg/L and 6.18 (2.9) mg/L, and for CBZE were 1.28 (0.3) mg/L and 1.85 (1.0) mg/L, respectively. The mean (SD) milk/plasma ratios of CBZ and CBZE were 0.64 (0.2) and 0.79 (0.3), respectively. The milk/plasma ratio of CBZE was slightly higher than that of CBZ.

Does edema formation occur in the rabbit brain exposed to head-down tilt?

Earlier studies showed that exposure to microgravity caused cephalad fluid shift, increased capillary pressure in the head, and produced facial edema and nasal congestion. In the present study, edema formation in the brain was investigated in rabbits exposed to simulated microgravity, head-down tilt (HDT), by measuring water content and histological examinations. Water content in the brain tissues of rabbits exposed to 2 and 8 days of HDT did not increase significantly compared with that of control animals. Neither vital staining using Evans blue nor immunohistochemical examination demonstrated extravasation of plasma constituents in the brain tissues of the HDT rabbits. Although marked congestion was noted in the brain, hematoxylin and eosin staining did not show edematous changes, such as distension of the perivascular and pericellular spaces and vacuolar appearance, in the tissues obtained from HDT rabbits. Transmission electron microscopy revealed that tight junctions of the capillary endothelium were intact in the HDT rabbits. These results suggest that either HDT up to 8 days does not cause brain edema in rabbits or it induces only a slight brain edema which is hard to be demonstrated by measurement of water content or histological examinations.

Monitoring of zonisamide in human breast milk and maternal plasma by solid-phase extraction HPLC method

An HPLC method was developed for the determination of zonisamide in human breast milk and plasma. Chromatographic separation was achieved using a Develosil CN analytical column with potassium dihydrogenphosphate buffer (pH 3.5 with milk, pH 2.5 with plasma)-acetonitrile as the mobile phase. Zonisamide and 1, 2-benzisoxazole-3-methansulfonamine acetate as internal standard were detected by ultraviolet absorbance at 240 nm. Zonisamide in breast milk and plasma was extracted by a rapid and simple procedure based on C(18) bonded-phase extraction. Determination of zonisamide in human breast milk and plasma was possible in the concentration range 0.05-20.0 microg/mL. The recoveries of zonisamide added to human breast milk and plasma were 79.5-85.0% and 86.3-93.1%, respectively, with coefficients of variation of less than 8.3% and 11.4% respectively. The mean concentrations of zonisamide in breast milk and plasma were 9.41 +/- 0.95 and 10.13 +/- 0.45 microg/mL, respectively. The average ratio between the breast milk concentration and plasma concentration (M/P ratio) was 0.93 +/- 0.09.

[Set-up of standard value by sex and age of biochemical tests derived from blood donors]

We set up the standard value of 7 biochemical tests from the data of approximately 237,000 blood donors who are healthy at least objectively. The abnormal data were excluded by Grubbs Smirnov method, and then converted by the log equation in order to simulate to normal distribution. Then the reference interval was set at mean +/- 2SD. If this failed, 95% percentile was adopted after non-parametric analysis. The data fluctuated much between sex and generations. Especially sex difference was dominant in ALT, AST, gamma-GTP and TP. ALT and AST was greater in males than in females, although age difference was smaller with aging. gamma-GTP peaked in 40s in males and greater in males than in females. TP was greater in males. Age difference was dominant in ALB, CHOL and BUN. ALB decreased with aging, and CHOL and BUN increased with aging. Therefore standard value in each sex and age group should be adopted in these tests. The volume of the data in each age group in this study is suitable for the set-up of the standard value.

Monitoring of phenytoin in human breast milk, maternal plasma and cord blood plasma by solid-phase extraction and liquid chromatography

A rapid liquid chromatographic method for the quantitation of phenytoin in human breast milk, maternal plasma and cord blood plasma was developed using a Develosil C85 micron reverse phase column and a potassium dihydrogen phosphate buffer/acetonitrile mobile phase. Phenytoin and mephenytoin as an internal standard were detected by ultraviolet absorbance at 240 nm. The sample preparation method involves a rapid and simple procedure based on solid-phase extraction using a C18-bonded phase. Phenytoin could be determined in the concentration range of 0.05-3 micrograms ml-1. The recovery of phenytoin added to human breast milk and plasma were 91.6-94.7 and 91.6-96.0%, respectively, with coefficient of variation less than 4.2 and 8.7%. The method has been used for drug level monitoring in the human breast milk, maternal plasma and cord blood plasma samples that were taken from patients treated with phenytoin. The average ratio between the breast milk concentrations versus the plasma concentration was 0.28 +/- 0.1, with a rather poor correlation (r = 0.3033).

Effect of carbamazepine on the single oral dose pharmacokinetics of alprazolam

The effect of carbamazepine, an inducer of cytochrome P450 (CYP) 3A4, on the single oral dose pharmacokinetics of alprazolam was examined in a double-blind, randomized crossover study with two phases. Seven healthy male subjects took carbamazepine 300 mg/day or matched placebo orally for 10 days, and on the 8th day they took a single oral 0.8 mg dose of alprazolam. Blood samples were taken and psychomotor function was assessed by the Digit Symbol Substitution Test, Visual Analog Scale, and UKU Side Effect Rating Scale up to 48 h after alprazolam dosing. Carbamazepine significantly (p < .01 to .001) decreased the plasma alprazolam concentrations during the elimination phase. Carbamazepine significantly (p < .001) increased the apparent oral clearance (0.90 +/- 0.21 vs. 2.13 +/- 0.54 ml/min/kg) and shortened the elimination half-life (17.1 +/- 4.9 vs. 7.7 +/- 1.7 h), with no significant effect on the peak plasma concentration (11.7 +/- 1.5 vs. 13.0 +/- 3.5 ng/ml). The majority of psychomotor function parameters during the carbamazepine treatment were not significantly different from those during the placebo treatment, probably because of the sedative effect of carbamazepine itself. The present study suggests that carbamazepine decreases plasma concentration of alprazolam by inducing its metabolism. It also supports the previous studies, suggesting that alprazolam is metabolized predominantly by CYP3A4.