The impact of goal-directed prehabilitation therapy on functional capacity in patients undergoing hepatobiliary and pancreatic surgery: A randomized clinical trial

BACKGROUND

Emerging evidence has supported the idea that goal-directed prehabilitation is a promising approach to boost functional capacity in preoperative patients. However, its usefulness has not been tested in the hepatobiliary and pancreatic fields. The objective of this trial was to investigate the efficacy of goal-directed prehabilitation for improving functional capacity in patients who were planned to undergo major hepatobiliary and pancreatic operations.

METHODS

This assessor-blinded, parallel-arm, randomized clinical trial recruited patients who were scheduled for major hepatobiliary and pancreatic surgeries for malignancy. Patients were randomly allocated into the step goal-directed prehabilitation group as the test group and into the conventional prehabilitation group as the control group. Patients in the goal-directed prehabilitation group participated in a walking prehabilitation program with an intergrading goal of the step count. Patients in the conventional prehabilitation group received standard physical and nutritional prehabilitation. The primary outcome was change in the 6-minute walking distance, which ranged from the time before starting prehabilitation (baseline) to the time after completing prehabilitation (immediately before surgery).

RESULTS

Among 180 randomized patients, 144 patients were included in the primary analysis (73 patients in the conventional prehabilitation group and 71 patients in the goal-directed prehabilitation group). The mean change in the 6-minute walking distance was 27 meters in the conventional prehabilitation group and 31 meters in the goal-directed prehabilitation group (P = .633).

CONCLUSION

In patients undergoing major hepatobiliary and pancreatic surgeries for malignancies, a goal-directed prehabilitation program did not result in a significantly greater increase in functional capacity than did conventional prehabilitation.

REGISTRATION NUMBER

UMIN000038791 (https://www.umin.ac.jp/).

Effects of acute phase intensive electrical muscle stimulation in COVID-19 patients requiring invasive mechanical ventilation: an observational case-control study

We investigated the effects of acute-phase intensive electrical muscle stimulation (EMS) on physical function in COVID-19 patients with respiratory failure requiring invasive mechanical ventilation (IMV) in the intensive care unit (ICU). Consecutive COVID-19 patients requiring IMV admitted to a university hospital ICU between January and April 2022 (EMS therapy group) or between March and September 2021 (age-matched historical control group) were included in this retrospective observational case-control study. EMS was applied to both upper and lower limb muscles for up to 2 weeks in the EMS therapy group. The study population consisted of 16 patients undergoing EMS therapy and 16 age-matched historical controls (median age, 71 years; 81.2% male). The mean period until initiation of EMS therapy after ICU admission was 3.2 ± 1.4 days. The EMS therapy group completed a mean of 6.2 ± 3.7 EMS sessions, and no adverse events occurred. There were no significant differences between the two groups in Medical Research Council sum score (51 vs. 53 points, respectively; P = 0.439) or ICU mobility scale at ICU discharge. Addition of upper and lower limb muscle EMS therapy to an early rehabilitation program did not result in improved physical function at ICU discharge in severe COVID-19 patients.

In-Hospital Fall Risk Prediction by Objective Measurement of Lower Extremity Function in a High-Risk Population

OBJECTIVES

Limited data exist regarding association between physical performance and in-hospital falls. This study was performed to investigate the association between physical performance and in-hospital falls in a high-risk population.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

The study population consisted of 1200 consecutive patients with a median age of 74 years (50.8% men) admitted to a ward with high incidence rates of falls, primarily in the departments of geriatrics and neurology, in a university hospital between January 2019 and December 2021.

METHODS

Short Physical Performance Battery (SPPB) was measured after treatment in the acute phase. As the primary end point of the study, the incidence of in-hospital falls was examined prospectively based on data from mandatory standardized incident report forms and electronic patient records.

RESULTS

SPPB assessment was performed at a median of 3 days after admission, and the study population had a median SPPB score of 3 points. Falls occurred in 101 patients (8.4%) over a median hospital stay of 15 days. SPPB score showed a significant inverse association with the incidence of in-hospital falls after adjusting for possible confounders (adjusted odds ratio for each 1-point decrease in SPPB: 1.19, 95% CI 1.10-1.28; P < .001), and an SPPB score ≤6 was significantly associated with increased risk of in-hospital falls. Inclusion of SPPB with previously identified risk factors significantly increased the area under the curve for in-hospital falls (0.683 vs. 0.740, P = .003).

CONCLUSION AND IMPLICATIONS

This study demonstrated an inverse association of SPPB score with risk of in-hospital falls in a high-risk population and showed that SPPB assessment is useful for accurate risk stratification in a hospital setting.

Efficacy of rehabilitation initiated in the early phase after simultaneous deceased donor liver and kidney transplantation: A case report

RATIONALE

The purpose of this case report is to describe a case of successful early rehabilitation intervention for simultaneous liver and kidney transplantation (SLKT).

PATIENT CONCERNS

A 51-year-old Japanese man was diagnosed with Caroli disease 27 years ago. Hemodialysis was introduced due to end-stage renal disease 17 years ago.

DIAGNOSES

After successful SLKT, the patient was extubated on postoperative day (POD) 1, liberated from dialysis on POD 4, and discharged from the intensive care unit on POD 9.

INTERVENTIONS

Supervised rehabilitation was started on POD 2, and the patient was able to walk 100 m on POD 9. Electrical muscle stimulation therapy was started to improve muscle weakness in both legs on POD 16, and aerobic exercise using a cycle-ergometer was started on POD 24.

OUTCOMES

The 6-minute walking distance improved from 324 m on POD 14 to 501 m on POD 28. The patient could walk 4000 to 5000 steps per day at hospital discharge, and was discharged home on POD 32. There were no adverse events, including worsening hepatic or renal function, during the rehabilitation period. One month after discharge, the patient was able to perform 30 to 40 minutes of aerobic exercise every day, and returned to work 5 months after discharge.

LESSONS

This case shows that early rehabilitation intervention immediately after SLKT safely and rapidly improved physical performance without adverse events. The results in the present case suggest that regular physical assessment and appropriate interventions with a variety of exercise modalities can contribute to improved physical performance in SLKT patients.

Physical function and mental health trajectories in COVID-19 patients following invasive mechanical ventilation: a prospective observational study

This prospective observational cohort study was performed to investigate the physical function and mental health trajectories of novel coronavirus disease 2019 (COVID-19) patients requiring invasive mechanical ventilation (IMV) after discharge from the intensive care unit (ICU). The study population consisted of 64 patients (median age, 60 years; 85.9% male; median IMV duration, 9 days). At ICU discharge, 28.1% of the patients had Medical Research Council (MRC) sum score < 48 points, and prolonged IMV was significantly associated with lower MRC sum score and handgrip strength. Symptoms were similar between groups at ICU discharge, and the symptoms most commonly reported as moderate-to-severe were impaired well-being (52%), anxiety (43%), tiredness (41%), and depression (35%). Although muscle strength and mobility status were significantly improved after ICU discharge, Edmonton Symptom Assessment System score did not improve significantly in the prolonged IMV group. EuroQol five-dimension five-level summary index was significantly lower in the prolonged than short IMV group at 6 months after ICU discharge. We found substantial negative physical function and mental health consequences in the majority of surviving COVID-19 patients requiring IMV, with prolonged period of IMV showing greater negative effects not only immediately but also at 6 months after discharge from the ICU.

Chest three-dimensional-computed tomography imaging data analysis for the variation of exercise capacity after lung lobectomy

BACKGROUND

Postoperative loss of exercise capacity and pulmonary function is a major concern among lung cancer patients. In this study, the time for a stair-climbing to 12-m height was used to investigate whether preoperative chest 3D-computed tomography (CT) could be a useful tool for predicting postoperative variations in exercise capacity and pulmonary function.

METHODS

Seventy-eight patients undergoing lobectomy for suspected stage I lung cancer were prospectively enrolled. Preoperatively, lobe volume and low attenuation volume (LAV) were evaluated using the SYNAPSE VINCENT system. Preoperative data on stair-climbing time, spirometry, and diffusing capacity of the lung for carbon monoxide (DL_CO ) at baseline and 6-month postoperative data were used to evaluate variations in exercise capacity and pulmonary function. Maximal oxygen uptake (VO₂ t) was evaluated based on the stair-climbing time.

RESULTS

Significant differences in the variation of exercise capacity at 6 months postoperatively were found between the groups categorized by target lobe volume and LAV status: The large volume/LAV (+) group had a greater decline in VO₂ t. Mean loss of VO₂ t was -6.2%, -1.4%, -1.6%, and -0.1% in the large volume/LAV (+), large volume/LAV (-), small volume/LAV (+), and small volume/LAV (-) groups, respectively. The large volume/LAV (-) group had a greater decline in forced expiratory volume in 1 s. The small volume/LAV (+) group showed a reduced decline in the DL_CO .

CONCLUSIONS

Analysis of chest 3D-CT scans is a potential tool for predicting the loss of exercise capacity and pulmonary function after lung lobectomy. This article is protected by copyright. All rights reserved.

Preoperative paraspinous muscle sarcopenia and physical performance as prognostic indicators in non-small-cell lung cancer

BACKGROUND

Despite the associations of both preoperative sarcopenia and physical performance with post-operative mortality in non-small-cell lung cancer (NSCLC), there have been no comprehensive studies of the impact of physical status on prognosis. This study was performed to investigate the prognostic significance of preoperative sarcopenia and physical performance in NSCLC.

METHODS

This retrospective cohort study was performed in NSCLS patients undergoing curative lung resection at a university hospital between January 2014 and December 2017. The patients were divided into four groups according to the skeletal muscle index [sarcopenia (lowest sex-specific tertile) and non-sarcopenia] and 6 min walking distance (6MWD) [short distance (<400 m) and long distance (≥400 m)]. Sarcopenia was assessed by preoperative cross-sectional areas of right and left paraspinous muscles at the level of the 12th thoracic vertebra from computed tomography images, and physical performance was determined by preoperative 6MWD. The primary and secondary endpoints were post-operative overall survival (OS) and disease-free survival (DFS).

RESULTS

The 587 patients [mean age: 68.5 ± 8.8 years, 399 men (68%)] included in the study were divided into the non-sarcopenia/long-distance group (58%), sarcopenia/long-distance group (26%), non-sarcopenia/short-distance group (9%), and sarcopenia/short-distance group (7%). A total of 109 (18.6%) deaths and 209 (35.6%) combined endpoints were observed over a mean follow-up of 3.1 ± 1.3 years. After adjusting for other covariates, the sarcopenia/short-distance group showed significant associations with shorter OS (hazard ratio, 3.38; 95% confidence interval, 1.79-6.37; P < 0.001) and DFS (hazard ratio, 2.11; 95% confidence, 1.27-3.51; P = 0.004) compared with the non-sarcopenia/long-distance group on multivariate analyses. Although not significant, adding skeletal muscle index and 6MWD to the pre-existing risk model increased the area under the curve on time-dependent receiver operating characteristic curve analysis for OS and DFS, except within 2 years of surgery.

CONCLUSIONS

The presence of both preoperative paraspinous muscle sarcopenia and short distance in 6MWD had an adverse effect on post-operative prognosis in patients with NSCLC, suggesting that preoperative assessment of thoracic sarcopenia and physical performance may be useful for risk stratification of surgical candidates with potential for targeted interventions.

Preoperative six-minute walk distance as a predictor of postoperative complication in patients with esophageal cancer

Surgery for esophageal cancer is associated with high morbidity and mortality. Reduced pulmonary functions and exercise capacity are known as risk factors for complications after esophagectomy. The 6-minute walk distance (6MWD) measured by the 6-minute walk test (6MWT) is a simple field test that can be used to evaluate the functional exercise capacity of patients who undergo thoracic surgery. The aim of this study was to evaluate the association of the preoperative 6MWD with postoperative complications in patients with esophageal cancer. Records of a total of 111 patients who underwent thoracic surgery followed by postoperative rehabilitation from January 2013 to December 2015 were retrospectively reviewed. Data of patients who experienced Clavien-Dindo grade II or severer (grade ≥ II) complications were compared with those who experienced grade ≤I complications. The 6MWD was significantly correlated with age, serum albumin concentration, hemoglobin concentration, and hand grip strength. A total of 42 patients experienced grade ≥II. The 6MWD of patients with grade ≥ II complications was significantly shorter than that of those with grade ≤I complications. In receiver operating characteristic analysis, 6MWD ≤ 454 m was a threshold for predicting grade ≥II complications with 71.0% sensitivity and 54.8% specificity. The incidence of grade ≥II complications led to delayed ambulation and longer stays in hospital. In the multiple regression analysis, the preoperative risk factors for incidence of grade ≥II complications included lower levels of preoperative 6MWD and % of the predicted value of forced expiratory volume in 1 second. Our results indicate that the 6MWT is useful to assess preoperative physical status in patients with esophageal cancer.

How Many Steps Per Day are Necessary to Prevent Postoperative Complications Following Hepato-Pancreato-Biliary Surgeries for Malignancy?

PURPOSE

The current study was designed to investigate the association between the average preoperative physical activity and postoperative outcomes in patients undergoing surgeries for hepato-pancreato-biliary (HPB) malignancy.

METHODS

Patients who were scheduled to undergo open abdominal surgeries for HPB malignancies (major hepatectomy, pancreatoduodenectomy, or hepato-pancreatoduodenectomy) between 2016 and 2017 were included. The average steps per day were recorded by a pedometer and calculated for each patient during the preoperative waiting period. Physical activity levels were classified according to the average number of daily steps as poor (< 5000 steps/day) and good (≥ 5000 steps/day).

RESULTS

Of the 105 eligible patients, 78 met the inclusion criteria. The median number of steps per day was 6174. There were 48 patients (62%) with good physical activity and 30 patients (38%) with poor physical activity. Patients with poor physical activity revealed a significantly higher rate of major complications with Clavien grade ≥ 3 (63% vs. 35%, p = 0.016), a higher rate of infectious complications (53% vs. 23%, p = 0.006), and a longer postoperative hospital stay (median, 30 vs. 21 days, p < 0.001) compared with those with good physical activity. After a multivariate analysis, poor physical activity was identified as an independent risk factor for the development of major complications (odds ratio, 2.842, p = 0.042) and infectious complications (odds ratio, 3.844, p = 0.007).

CONCLUSIONS

The current study demonstrated that preoperative physical activity levels are associated with the incidence of major postoperative complications following HPB surgery for malignancy.

P4384Noninvasive and novel method to evaluate left ventricular contractility using pressure-volume loop area obtained by 3-dimensional speckle tracking echocardiography

Introduction

Left ventricular (LV) pressure-volume (P-V) loop area reflects stroke work (SW), but clinical use of this index is limited by the need of invasive pressure measurement. A noninvasive method to obtain LV pressure-strain loop was recently introduced to assess myocardial work (MW). The minimum LV diastolic pressure (mLVP) was reported to have a strong correlation with Tau and we reported that Tau was noninvasively evaluated by speckle tracking echocardiography (STE).

Purpose

We sought to evaluate the impact of preload change by leg lifts on LV SW noninvasively obtained by the novel method and to examine the utility to assess LV contractility by SW and end-diastolic (ED) volume relation (SW-VED).

Methods

Thirty six controls (age 71±10) and 30 patients with heart failure with reduced ejection fraction (EF) <50% (HF) (age 73±6) were enrolled. LV pressure in a cardiac cycle was estimated using systolic blood pressure (SBP), minimum diastolic pressure (mDP) and ED pressure (EDP) by utilizing the profile of an empiric, normalized reference curve. The mDP and EDP were estimated as (Tau − 33.7)/2.06 and as 12.3 − 10.1 x Log (left atrial active emptying function/minimum volume) as we reported. LVSW was obtained by P-V loop by the combination of these pressures and LV volume using 3-D STE.

Results

LVEF and longitudinal strain in HF before leg up by 3D-STE were lower compared to normal (LVEF; normal: 58±5 vs HF: 39±10*% and strain; −12±3 vs −8±3%*, *p<0.05 vs normal). LVEF was increased after leg up by 7±6% in normal and by 8±8% in HF associated with increased LVED volume (normal: 84±24 to 90±24 and HF: 124±36* to 136±42*ml). LV MW and SW in HF before leg up were lower compared to normal (MW: 1790±412 vs 1002±432*mmHg% and SW: 3946±1682 vs 3352±1026mmHgml). LV SW increased after leg up by 26±19% in normal and by 25±20% in HF. LV SW-VED in normal was greater than HF (241±151 vs 90±54*).

Conclusion

LV SW noninvasively obtained by P-V loop area was increased after leg up in both normal and HF but SW-VED in HF was smaller than normal, indicating reduced contractility in HF. This noninvasive method may be a new echocardiographic approach for quantification of LV SW and contractility.

P3548Noninvasive estimation of left ventricular diastolic function in patients with hypertension and normal ejection fraction using 3-dimensional speckle tracking echocardiography

Background

Left ventricular (LV) relaxation (eTau) and pulmonary capillary wedge pressure (ePCWP) were reported to be estimated by speckle tracking echocardiography (STE). LV camber stiffness (e-c stiffness) may be estimated with the use of 2 diastolic pressure-volume coordinates. The minimum diastolic pressure (mP) is reported to have a strong correlation with Tau.

Purpose

We sought to examine the impact of hypertension on LV diastolic function and LA properties and to elucidate the feature of hypertensive heart failure with preserved EF (HFpEF).

Methods

The e', E/e', Tau, PCWP, LVEDP, LV stiffness, LAV, LA emptying function (LAEF) and LA strain were examined in 53 controls (age 66±11), 136 hypertensive patients (HTN) with normal EF (69±11) and 39 HFpEF (77±14). ePCWP and estimated EDP (eEDP) was calculated as previously reported. Tau was calculated as isovolumic relaxation time/(ln 0.9 x systolic blood pressure − ln PCWP). Myocardial stiffness (e-m stiffness) was estimated as LVED stress/LV strain. LV c-stiffness was calculated as LV pressure change (from mP to EDP) obtained by catheterization divided by LV volume change. Estimated LV c-stiffness (e-c-stiffness) was noninvasively obtained using e-mP and e-EDP. The eTau, eEDP and e-mP by STE were validated by catheterization (n=126).

Results

The mP had a good correlation with Tau (r=0.70, p<0.01). The eTau, eEDP and e-mP by STE had a good correlation with those by catheterization (r=0.75, 0.63 and 0.70, p<0.01). Multivariate analysis revealed that ePCWP and LA strain were independent predictors of HFpEF.

LV diastoric function Variables Control HTN HFpEF LVEF, % 68±6 68±8 63±9*+ LV longitudinal strain x (s–1) 19.1±3.0 16.8±4.3* 14.5±5.1*+ E/e' 9.2±2.6 11.6±4.5* 15.9±7.9*+ eTau, ms 35±12 48±17* 59±17*+ ePCWP, mmHg 7.3±2.7 8.3±4.3 15.0±4.4*+ eLVEDP, mmHg 9.4±2.2 10.4±3.5 15.9±3.7*+ LV e-myocardial stiffness, kdynes/cm 0.56±0.25 0.69±0.56 1.27±0.71*+ LV e-chamber stiffness, mmHg/ml 0.19±0.06 0.20±0.08 0.36±0.19*+ Maximum LAVI, ml/m2 42±15 50±21* 68±17*+ Total LAEF, % 55±7 51±11 36±12*+ LA peak strain 41±15 40±17 19±8*+ *p<0.05 vs Control, +p<0.05 vs HTN.

Conclusion

We demonstrated that LV diastolic function in HTN may be accurately and noninvasively evaluated by STE.

P2474Noninvasive estimation of pulmonary capillary wedge pressure by novel 3D speckle tracking echocardiography and validation study by cardiac catheterization

Background

We previously reported that pulmonary capillary wedge pressure (PCWP) was noninvasively evaluated by 2D speckle tracking echocardiography (STE). Recently, novel software was introduced to examine volume and function of left ventricular and left atrium (LA) by 3D-STE automatically.

Purpose

We sought to compare the PCWP estimated by conventional 2D-STE (2D-ePCWP) and by novel 3D-STE (3D-ePCWP), and validate those values by cardiac catheterization.

Methods

Echocardiography and catheterization were performed in 29 patients (age 72±2) (7 ischemic heart disease, 2 hypertensive heart disease, 5 dilated cardiomyopathy, 12 valvular heart disease and 3 primary pulmonary hypertension).The ePCWP (mmHg) is noninvasively obtained as 10.8 − 12.4 x Log (left atrial active emptying function/minimum volume) as we previously reported. Echocardiography was performed just before the catheterization and we analyzed the 2D and 3D data by novel off-line software. 3D data was automatically analyzed and the border settings were fixed at default (ES60, ED30) (Figure).

Results

2D-ePCWP and 3D-ePCWP had a good correlation with PCWP invasively obtained by catheterization (r=0.87 and 0.83, respectively, both p<0.001). There was an excellent correlation between 2D-ePCWP and 3D-ePCWP (r=0.94, p<0.001) and there was a good correlation between 2D-LA volume index and 3D- LA volume index (r=0.80, p<0.001). Bland-Altman analysis revealed a good agreement between 2D-ePCWP and 3D-ePCWP, and between 2D-ePCWP and 3D-ePCWP without fixed and proportional bias.

Conclusion

This study demonstrated that PCWP might be noninvasively assessed by not only 2D-STE but also 3D-STE with reasonable accuracy and 3D-STE might have utility and value in the routine clinical practice.

P4351Validation by cardiac catheterization of noninvasive evaluation of left ventricular chamber and myocardial stiffness as a diastolic function using speckle tracking echocardiography

Background

Left ventricular (LV) diastolic function is mainly composed of LV relaxation and LV stiffness. We reported that pulmonary capillary wedge pressure (ePCWP) and LV relaxation assessed by Tau (eTau) are noninvasively evaluated by speckle tracking echocardiography (STE). The minimum LV diastolic pressure (mLVP) was reported to have a strong correlation with Tau. Therefore, LV chamber stiffness (c-stiffness) may be assessed with the use of two LV diastolic pressure-volume coordinates: the mLVP and volume and the end-diastolic pressure (EDP) and volume.

Purpose

We sought to noninvasively assess LV stiffness using STE and validate the value by cardiac catheterization.

Methods

Echocardiography and catheterization were performed in 124 patients (age 72±8) (70 angina pectoris, 20 prior myocardial infarction, 19 hypertensive heart disease, 11 congestive heart failure and 4 paroxysmal atrial fibrillation). The ePCWP (mmHg) is noninvasively obtained as 10.8 − 12.4 × Log (left atrial active emptying function/minimum volume) and the eTau (ms) is obtained as isovolumic relaxation time/(ln 0.9 × systolic blood pressure − ln ePCWP) as previously reported. The mLVP (e-mLVP) was estimate using Tau. The estimated EDP (e-EDP) was calculated as 12.3 − 10.1 × Log (left atrial active emptying function / minimum volume). LV c-stiffness (mmHg/ml) was calculated as LV pressure change (from mLVP to EDP) obtained by catheterization divided by LV volume change during diastole which equals to stroke volume by echocardiography. Estimated c-stiffness (e-c-stiffness) was noninvasively obtained using e-mLVP and e-EDP. Furthermore, LV myocardial stiffness (m-stiffness) was calculated by LVED stress / LV longitudinal strain by STE, where LV stress (kdynes/cm2) was calculated as 0.334 × pressure × dimension / [thickness (1 + thickness/dimension)]. The estimated m-stiffness (e-m-stiffness) was calculated using e-EDP.

Results

The eTau and e-EDP estimated by STE had a good correlation with Tau and EDP invasively obtained by catheterization (r=0.75 and 0.63, respectively, both p<0.001). There was a good correlation between Tau and mLVP (Tau = 2.06 mLVP + 33.7, r=0.70). The estimated LVED stress had good correlation with ED stress obtained by catheterization (r=0.77, p<0.001). The e-c-stiffness and e-m-stiffness had a good correlation with those obtained by catheterization (e-c-stiffness; 0.116±0.07 and c-stiffness; 0.115±0.06, r=0.603, e-m-stiffness; 0.81±0.41 and m-stiffness; 0.85±0.45, r=0.89, respectively). Bland-Altman analysis revealed a good agreement between e-c-stiffness and c-stiffness, and between e-m-stiffness and m-stiffness without fixed and proportional bias.

Conclusion

This study demonstrated that LV stiffness may be noninvasively assessed by STE with reasonable accuracy and may have utility and value in the routine clinical practice for the diagnosis and treatment in patients with diastolic dysfunction.

Refractory Hypotension during Combined General and Epidural Anaesthesia in a Patient on Tricyclic Antidepressants

We report a case of refractory hypotension that occurred after epidural injection of local anaesthetic, in a patient who was receiving tricyclic antidepressant therapy and was under general anaesthesia. The patient failed to respond to repeated injections of appropriate doses of sympathomimetics, but did respond to high-dose catecholamine infusions. We suggest that epidural anaesthesia should be used with care when combined with general anaesthesia for patients on long-standing tricyclic antidepressant therapy. If refractory hypotension should occur in such patients, the use of direct-acting vasoconstrictors such as noradrenaline should be considered.

Post-operative delayed ambulation after thymectomy is associated withpre-operative six-minute walk distance

OBJECTIVE

Delayed post-operative ambulation is a risk of post-operative complications and increases overall healthcare costs. We investigated pre-operative and intraoperative variables associated with delayed ambulation in patients who underwent thymectomy.

METHODS

A total of 57 consecutive patients undergoing thymectomy were included in this study. Pre-operative functional exercise capacity was evaluated by six-minute walk distance. Ambulation was considered to be delayed if the patient could not walk the ward on post-operative day 1. Binary logistic regression analysis was performed to clarify the factors associated with delayed ambulation.

RESULTS

Pre-operative six-minute walk distance was the only significant variable that was associated with delayed ambulation. The area under the receiver operating characteristic curve for predicting delayed ambulation was 0.684 (95% confidential interval: 0.546-0.823, p = 0.017), and the optimal discriminatory pre-operative six-minute walk distance value was 498 m. Post-operative hospital stay was significantly longer in patients with low six-minute walk distance (<498 m) than those with high six-minute walk distance (≥498 m). In contrast, the presence of myasthenia gravis or adjuvant chemoradiotherapy was not associated with delayed ambulation.

CONCLUSIONS

Our results suggest that low pre-operative six-minute walk distance is associated with delayed post-operative ambulation and longer post-operative hospital stay in patients who underwent thymectomy. Implications for rehabilitation The predictors for delayed ambulation after thymectomy are not fully investigated. The presence of myasthenia gravis was not associated with delayed ambulation. Low pre-operative six-minute walk distance was associated with delayed ambulation.

Changes in Muscle Strength and Six-Minute Walk Distance Before and After Living Donor Liver Transplantation

BACKGROUND

Impaired exercise capacity and muscle weakness are important characteristics of liver transplantation recipients. Perioperative rehabilitation has been introduced to promote early mobilization of patients and to prevent postoperative pulmonary complications. However, it is unknown how physical status recovers during the hospital stay after a liver transplant. The purpose of this study was to evaluate the changes in clinical indicators that represent the functional exercise capacity and muscle strength before and after living donor liver transplantation (LDLT).

METHODS

We retrospectively reviewed 21 consecutive patients who underwent LDLT with perioperative rehabilitation from April 2014 to December 2015. Twelve patients who were tested for 6-minute walk distance, hand-grip strength, and isometric knee extensor muscle strength before and 4 weeks after LDLT were enrolled.

RESULTS

At the preoperative baseline, the 6-minute walk distance significantly correlated with the Model for End-stage Liver Disease score and pulmonary functions (vital capacity, forced vital capacity, and forced expiratory volume in 1 second of predictive values). Comparisons between the preoperative and postoperative values revealed significant decreases in weight, Barthel Index, hand-grip strength, and isometric knee extensor muscle strength. Changes in hand-grip strength and isometric knee extensor muscle strength after LDLT correlated with the preoperative Model for End-stage Liver Disease score.

CONCLUSIONS

Physical functional status had not been fully recovered 4 weeks after LDLT. Further investigation regarding developing a strategy for prevention of muscle atrophy before LDLT and recovery of physical fitness after LDLT would be helpful.

Changes in exercise capacity, muscle strength, and health-related quality of life in esophageal cancer patients undergoing esophagectomy

Background

Surgery for cancer of the thoracic esophagus is a challenging procedure associated with high morbidity and mortality. Perioperative rehabilitation has been introduced to promote early mobilization of the patients and to prevent postoperative pulmonary complications. The purpose of the present study was to characterize the preoperative functional exercise capacity, muscle strength, anxiety, depression, and health-related quality of life (QOL) in patients with esophageal cancer, and to evaluate the impact of radical esophagectomy on these parameters.

Methods

We performed a retrospective review of 34 consecutive patients with newly diagnosed resectable esophageal cancer who underwent esophagectomy followed by postoperative rehabilitation from January to December 2014. Patients were tested for 6-min walk distance (6MWD), knee-extensor muscle strength, hand grip strength, the Hospital Anxiety and Depression Scale (HADS), and the chronic obstructive pulmonary disease (COPD) assessment test (CAT) before and two weeks after the surgery. Before surgery, the pulmonary function test, and components of the MOS 36-item Short-Form Health Survey (SF-36) Questionnaire for general health were assessed.

Results

The mean age was 67.3 ± 8.1 years. The patients were predominantly male (76.4 %), had high rates of smoking history (91.2 %), and squamous cell carcinoma (97.1 %). The predicted value for forced expiratory volume in 1 s was 94.0 ± 15.9 %, and 12 patients (35.3 %) had COPD. The clinical stage was 0-I in 12 patients, II in 4 patients, III in 16 patients, and IV in 2 patients. Thirty-one patients (91.2 %) underwent open surgery. At the baseline, components of the SF-36 scores significantly correlated with CAT and HADS scores, and the physical status was significantly poorer in patients with COPD than those without. Comparisons between the preoperative and postoperative values revealed significant decreases in 6MWD, hand grip strength, isometric knee extensor muscle strength, and a significant increase in CAT scores but not in HADS scores after surgery. In multiple regression analysis, decreases in 6MWD after the surgery significantly correlated with the preoperative physical component summary of SF-36.

Conclusions

Our results indicate that surgery remained detrimental to health outcomes at two weeks. Further research should investigate whether prehabilitation would improve the postoperative outcomes, QOL, and physical fitness.

Electronic supplementary material

The online version of this article (doi:10.1186/s13102-016-0060-y) contains supplementary material, which is available to authorized users.

Preoperative 6-minute walk distance accurately predicts postoperative complications after operations for hepato-pancreato-biliary cancer

BACKGROUND

Operation for hepato-pancreato-biliary cancer is among the most invasive open abdominal operations, with a high postoperative morbidity and mortality rate. The purpose of the present study is to investigate whether a preoperative 6-minute walk distance can predict major postoperative complications after operation for hepato-pancreato-biliary diseases.

METHODS

A total of 81 participants who underwent pancreaticoduodenectomy, major hepatectomy with extrahepatic bile duct resection, or hepatopancreatoduodenectomy were included. The 6-minute walk distance was performed within 1 week before operation. Patients were categorized into 2 groups based on surgical complications: Clavien-Dindo grade <3 and Clavien-Dindo grade ≥3. Clinical differences between the 2 groups were analyzed. Multivariate logistic regression analysis was performed to identify risk factors for postoperative complications that were categorized as Clavien-Dindo grade ≥3.

RESULTS

The multiple logistic regression model revealed a significant correlation between major postoperative complications and preoperative low 6-minute walk distance, low body mass index, and major blood loss. In patients with 6-minute walk distance <400 m (1,312 feet), the Clavien-Dindo grade was considerably greater than patients with ≥400 m.

CONCLUSION

The 6-minute walk distance is useful in identifying patients with a greater chance of developing major postoperative complications after surgery for hepato-pancreato-biliary cancer.

An Effective New Cryopreservation Procedure for Pancreatic Islets Using Hollow Fiber Vitrification

The present study aimed at establishing a new cryopreservation method for mouse pancreatic islets by vitrification using hollow fibers as a container. A unique feature of the hollow fiber vitrification (HFV) method is that this method achieves stable vitrification using a minimum volume of cryoprotectant (CPA) solution, thereby ensuring high viability of the islets. The cytotoxicity, optimum composition, and concentration of the CPAs for vitrifying islets were examined. The viability, functional-integrity of vitrified islets were evaluated in comparison with those vitrified by conventional methods. Insulin secretion was measured in vitro by a static incubation assay and the metabolic functions was tested after transplantation into Streptozotocin-induced diabetic mice. The combination of 15% dimethyl sulfoxide+15% ethylene glycol resulted in the best CPA solution for the HFV of islets. HFV showed the highest viability in comparison to 2 vitrification methods, open pulled straws and vitrification with EDT324 solution. The vitrified islets stably expressed β-cells markers NeuroD, Pancreatic and duodenal homeobox-1, and MafA. Transplantation of the vitrified islets achieved euglycemia of the host diabetic mice and response to an intraperitoneal glucose tolerance test to a similar extent as non-vitrified transplanted islets. The HFV method allows for efficient long-term cryopreservation of islets.

31 PRODUCTION EFFICIENCY OF GENE KNOCKOUT PIGS USING GENOME EDITING AND SOMATIC CELL CLONING

Genome editing technologies have been used as a powerful strategy for the generation of genetically modified pigs. We previously developed genetically modified clone pigs with organogenesis-disabled phenotypes, as well as pigs exhibiting diseases with similar features to those of humans. Here, we report the production efficiency of various gene knockout cloned pigs from somatic cells that were genetically modified using zinc finger nucleases (ZFN) or transcription activator-like effector nucleases (TALEN). The ZFN- or TALEN-encoding mRNAs, which targeted 7 autosomal or X-linked genes, were introduced into porcine fetal fibroblast cells using electroporation. Clonal cell populations carrying induced mutations were selected after limiting dilution. The targeted portion of the genes was amplified using PCR, followed by sequencing and mutation analysis. Among the collected knockout cell colonies, cells showing good proliferation and morphology were selected and used for somatic cell nuclear transfer (SCNT). In vitro-matured oocytes were obtained from porcine cumulus-oocyte complexes cultured in NCSU23-based medium and were used to obtain recipient oocytes for SCNT after enucleation. SCNT was performed as reported previously (Matsunari et al. 2008). The cloned embryos were cultured for 7 days in porcine zygote medium (PZM)-5 to assess their developmental ability. Cloned embryos were transplanted into the oviduct or uterus of oestrus-synchronized recipient gilts to evaluate their competence to develop to fetuses or piglets. Cloned embryos reconstructed with 7 types of knockout cells showed equal development to blastocysts compared with those derived from the wild-type cells (54.5–83.3% v. 60.7%). Our data (Table 1) demonstrated that the reconstructed embryos derived from knockout cells could efficiently give rise to cloned offspring regardless of the type of genome editing methodology (i.e. ZFN or TALEN). Table 1.Production efficiency of gene knockout cloned pigs using genome editing This study was supported by JST, ERATO, the Nakauchi Stem Cell and Organ Regeneration Project, JST, CREST, Meiji University International Institute for Bio-Resource Research (MUIIBR), and JSPS KAKENHI Grant Number 26870630.

26 IN VIVO EXOGENIC ORGAN GENERATION WITH ORGANOGENESIS-DISABLED CLONED PIGS AS A PLATFORM

The generation of organs from pluripotent stem cells (PSC) is one of the ultimate goals of regenerative medicine. We have demonstrated that functional organs can be generated in vivo from xenogenic PSC in the body of organogenesis-disabled mice using blastocyst complementation. To apply this principle in generating human organs, a technical platform using large non-rodent mammals is essential. The aim of the present study was to establish a blastocyst complementation system using cloned pig embryos. We generated transgenic-cloned pigs with an apancreatic phenotype via the overexpression of Hes1 (hairy and enhancer of split-1) under the Pdx1 promoter (pancreatic and duodenal homeobox-1). Cloned embryos of apancreatic pigs (host embryos, male) were complemented (i.e. chimerized) by blastomeres of cloned embryos (donor cells, female) with normal developmental competence. Chimeric embryos were cultured for 1 or 2 days before being transferred into the uteri of oestrus-synchronized gilts. The complementation of 292 Pdx1-Hes1 cloned embryos gave rise to 260 (89.0%) blastocysts. The transfer of these blastocysts resulted in 5 male chimeric pigs. Chimerism was confirmed by the detection of host embryo-derived Pdx1-Hes1 and marker transgenes of the donor cells, such as humanized Kusabira-Orange (huKO) or Pdx1-Venus. Chimeric pigs possessed normally formed pancreata entirely derived from the exogenous donor cells. We thus established a blastocyst complementation system in the pig using cloned embryos that would otherwise give rise to apancreatic animals. Chimeric pigs obtained developed normally, maintaining normal serum glucose concentrations up to maturity, and became fertile boars. Mating the chimeric boars with 7 wild-type sows gave rise to 72 fetuses/piglets of which 37 (51.4%) exhibited the apancreatic phenotype. These results indicate that a missing organ can be generated from exogenous cells when functionally normal pluripotent cells chimerize with a cloned dysorganogenetic embryo. Blastocyst complementation using cloned porcine embryos may permit the use of a large animal for the generation of functional organs from xenogenic PSC, including human iPSC. The chimeric boar produced by blastocyst complementation sired fetuses/offspring with the apancreatic phenotype in a Mendelian fashion. Porcine fetuses with an organogenesis-disabled phenotype may provide a useful platform for organ regeneration research. Table 1.Production of chimeric pigs by complementation and of Pdx1-Hes1 cloned embryos

20 GENERATION AND CHARACTERIZATION OF TRANSGENIC-CLONED PIGS EXPRESSING THE FAR-RED FLUORESCENT PROTEIN MONOMERIC PLUM

Transgenic (Tg) pigs expressing a fluorescent protein are extremely useful for research into transplantation and regenerative medicine. This study aimed to create Tg pigs expressing monomeric Plum (mPlum), a far-red fluorescent protein with a longer wavelength than enhanced green fluorescent protein (EGFP) and humanized Kusabira Orange (huKO), the two fluorescent proteins that have been used previously for Tg pig production. A linearized CAG-mPlum transgene construct was transferred into porcine fetal fibroblasts (PFF) by electroporation. mPlum fluorescence-positive cells were collected using a cell sorter and used as nuclear donors (mPlum-PFF) for somatic cell nuclear transfer (SCNT). In vitro-matured oocytes were obtained from porcine cumulus–oocyte complexes cultured in NCSU23-based medium and were used to obtain recipient oocytes for SCNT after enucleation. Then, SCNT was performed as reported previously (Matsunari et al., 2008). The reconstructed embryos were cultured for 7 days in porcine zygote medium-5 (PZM-5). mPlum fluorescence expression was screened during the early development of the embryos. After 5 or 6 days of culture, the SCNT embryos were surgically transferred to the uterus of a recipient gilt. We first obtained fetuses on Day 36 or 37 of gestation by Caesarean section and the PFF were retrieved from their skin. Fluorescence expression was analysed using fluorescence microscope, and the number of transgene copies in each fetus was determined by Southern blot analysis. We also analysed whether unique spectral properties of mPlum are suitable for multicolor imaging using confocal microscope and flow cytometer. The identification of mPlum-expressing PFF under the mixed culture of PFF expressing EGFP and huKO was examined. The 2 cell lines of PFF expressing EGFP and huKO were previously generated in our laboratory. Rates of normal cleavage and blastocyst formation occurred in the SCNT embryos generated with mPlum-PFF (mPlum embryos) were equivalent to those of SCNT embryos derived from nontransgenic PFF (34/42, 81.0%; 33/42, 78.6% v. 37/40, 92.5%; 30/40, 75.0%). Total cell numbers in mPlum and control blastocysts did not differ significantly (88.3 ± 6.0 v. 99.9 ± 8.8). Fluorescence expression in the mPlum embryos began at the 8-cell stage and became brighter from the morula stage. The gilt into which 103 mPlum embryos were transferred produced 3 fetuses. These fetuses expressed mPlum fluorescence systemically and had 1 to 5 copies of the transgene. Multicolor fluorescence imaging and flow cytometric analyses of a mixed culture of mPlum PFF and PFF expressing EGFP and huKO showed that clear identification and isolation of cells displaying each of the 3 fluorescence signals was possible. These observations demonstrate that the transfer of CAG-mPlum did not interfere with the development of porcine SCNT embryos and resulted in the successful generation of Tg cloned pigs that systemically expressed mPlum. This work was supported by JSPS KAKENHI Grant Number 25293279.

Advancing pig cloning technologies towards application in regenerative medicine

Regenerative medicine is expected to make a significant contribution by development of novel therapeutic treatments for intractable diseases and for improving the quality of life of patients. Many advances in regenerative medicine, including basic and translational research, have been developed and tested in experimental animals; pigs have played an important role in various aspects of this work. The value of pigs as a model species is being enhanced by the generation of specially designed animals through cloning and genetic modifications, enabling more sophisticated research to be performed and thus accelerating the clinical application of regenerative medicine. This article reviews the significant aspects of the creation and application of cloned and genetically modified pigs in regenerative medicine research and considers the possible future directions of the technology. We also discuss the importance of reproductive biology as an interface between basic science and clinical medicine.

297 PRODUCTION OF CHIMERIC PORCINE FETUSES BY AGGREGATION METHOD USING PARTHENOGENETIC EMBRYOS

Porcine induced pluripotent stem (iPS) cells are considered to be an invaluable research tool in translational research with pigs as a large animal model. Pluripotency of the iPS cells needs to be verified by their competence to contribute to chimera formation. The aim of the present study is to establish feasible system to create chimeric pig fetuses using parthenogenetic embryos. In Experiment 1, inner cell mass (ICM) was isolated by immunosurgery from Day 6 blastocysts obtained by parthenogenetic activation of in vitro matured (IVM) oocytes. Isolated ICM were used as the donor cells after staining with fluorescent carbocyanine dye (DiI). Using parthenogenetic morulae or 4- to 8-cell embryos as the host embryos, chimeric embryos were prepared by injection or aggregation method. Injection of ICM was performed by micromanipulation: a single ICM was directly injected into the centre portion of the host morulae. In the aggregation method, a single ICM was aggregated with blastomeres isolated from 2 host embryos at the morula or 4- to 8-cell stage in a micro-well (400 µm diameter, 300 µm deep). The chimeric embryos were cultured in PZM-5 (Yoshioka et al. 2008) for 2 to 3 days to examine development to blastocysts and incorporation of donor ICM cells into the resultant blastocysts ICM (ICM chimerism). In Experiment 2, donor blastomeres isolated from a parthenogenetic morula or 4- to 8-cell embryo were stained by DiI and aggregated with a parthenogenetic host embryo at the morula or 4- to 8-cell stage, and the in vitro development to the blastocyst stage and the ICM chimerism were examined. In Experiment 3, ICM isolated from IVF blastocysts harboring humanized Kusabira-Orange (huKO) gene were used as donor cells. Donor ICM were aggregated with the host embryos at the morula or 4- to 8-cell stage, and the resultant blastocysts were transferred to 4 recipient gilts to collect fetuses on Day 18. Results of Experiments 1 and 2 are summarised in Table 1. Combination of the donor ICM and host morulae yielded high rates of blastocyst formation (~95%) and ICM chimerism (~85%), regardless of the method used (injection or aggregation). Transfer of 73 blastocysts developed from host morulae to 2 recipients (Experiment 3) gave rise to 25 (34.2%) fetuses, of which 6 (24.0%) were confirmed to be chimeric by their clear orange fluorescence and immunostaining by anti-huKO antibody. Of 22 (40.7%) fetuses obtained after transfer of 54 blastocysts derived from 4- to 8-cell host embryos to 2 recipients, 3 (13.6%) were chimeric. Contribution of the donor cells in the tissues of the chimeric fetuses measured by image analysis software (ImageJ, NIH, Bethesda, MD, USA) ranged between 16.1 and 65.2%. These results demonstrate that the aggregation method using parthenogenetic host embryos is an efficient means to produce chimeric pig fetuses, and thereby feasible for verification of pluripotent cells such as iPS cells. Table 1.In vitro development of injected or aggregated porcine embryos

326 GENERATION OF A DOUBLE-TRANSGENIC PIG WITH PANCREAS-SPECIFIC GREEN AND LIVER-SPECIFIC RED FLUORESCENCE

Transgenic (Tg) pigs with organ/tissue-specific fluorescence expression provide invaluable research tools for many types of studies, such as organogenesis analysis, in vitro tissue generation from pluripotent cells, and progenitor/stem cell transplantation therapy. We aimed to develop a Tg pig characterised by pancreas- and liver-specific fluorescence expression. A 8.4 kb transgene construct expressing Venus (green fluorescence) under the control of the mouse Pdx1 (pancreatic duodenal homeobox-1) promoter and a BAC-derived construct (170 kb) consisting of the whole-length porcine albumin (Alb) promoter and humanized Kusabira-Orange (huKO, red fluorescence) was introduced into porcine in vitro-matured oocytes using the intracytoplasmic sperm injection (ICSI)-mediated gene transfer method. Injected embryos were transferred to the oviducts of oestrus-synchronized recipients after culture for 1 to 3 days. The transfer of 370 Pdx1-Venus embryos into 4 recipients produce 22 (5.9%) fetuses/piglets, and 9 (40.9%) Tg pigs exhibited pancreas-specific Venus expression. Two (1 male and 1 female) founder Pdx1-Venus-Tg pigs were mated with wild-type (WT) pigs and produced 32 offspring in 3 litters, of which 16 (50.0%) were transgenic. Pancreas-specific Venus expression was inherited in these Tg offspring. The transfer of 523 Alb-huKO embryos into 4 recipients resulted in 19 (3.6%) piglets including a Tg female, which showed liver-specific huKO fluorescent expression. Expression of huKO was detected by RT-PCR exclusively in liver, but not in 7 other organs/tissues examined, including heart, lung, stomach, small intestine, spleen, kidney and skin. This founder Tg female produced a total of 12 non-Tg and 5 Tg offspring (in 2 litters) after mating with a WT boar. Liver-specific huKO expression was inherited in these Tg offspring. Furthermore, the mating of a female Pdx1-Venus pig with an Alb-huKO boar yielded 7 non-Tg and 10 Tg pigs. Four of these Tg pigs carrying both of the transgenes exhibited both pancreas-specific Venus and liver-specific huKO expression in single individuals. Double-Tg pigs with pancreas-specific green fluorescence and liver-specific red fluorescence grew normally, and tests of their reproduction ability are currently underway. These data demonstrate that transgene introduction by ICSI-mediated gene transfer into in vitro-matured oocytes is a feasible option for generating pigs expressing fluorescent proteins in a tissue-specific manner.

Single pancreatic beta cells co-express multiple islet hormone genes in mice

AIMS/HYPOTHESIS

It is widely accepted that production of insulin, glucagon, somatostatin and pancreatic polypeptide in islet cells is specific to beta, alpha, delta and pancreatic polypeptide cells, respectively. We examined whether beta cells express other genes encoding islet hormones.

METHODS

Nested RT-PCR was performed on single beta cells of transgenic mice with green fluorescent protein (GFP) driven by mouse insulin I promoter (MIP-GFP).

RESULTS

Only 55% of adult beta cells expressed the insulin gene alone, while others expressed two or more islet hormone genes; 4% expressed all four hormone genes. In embryonic and neonatal cells, 60% to 80% of GFP(+) cells co-expressed pancreatic polypeptide and insulin genes in contrast to 29% in adult. To clarify cell fate, we conducted lineage tracing using rat insulin II promoter-cre mice crossed with reporter mice Gt(ROSA)26Sor-loxP-flanked STOP-cassette-GFP. All GFP(+) cells expressed insulin I and II genes, and showed similar heterogeneity of co-expression to that seen in MIP-GFP mice. Although we report expression of other hormone genes in a significant proportion of beta cells, our lineage tracing results demonstrate that after inducing InsII (also known as Ins2) expression, beta cell progenitors do not redifferentiate to non-beta cells.

CONCLUSIONS/INTERPRETATION

This study shows co-expression of multiple hormone genes in beta cells of adult mice as well as in embryos and neonates. This finding could: (1) represent residual expression from beta cell precursors; (2) result from alternative developmental pathways for beta cells; or (3) denote the differentiation potential of these cells. It may be linked to functional heterogeneity. This heterogeneity in gene expression may provide a means to characterise the functional, cellular and developmental heterogeneity seen in beta cells.

Colonisation on the tongue surface by respiratory pathogens in residents of a nursing home--a pilot study

OBJECTIVE

The morbidity and mortality of the dependent elderly that result from aspiration pneumonia have been recognised as a major geriatric health problem. The tongue has an extremely large surface area and due to its papillary structure can retain considerable quantities of food, and thus can support and harbour a large bacterial population. The purpose of this study was to gain more information on the microflora of the tongue surface and to assess the existence of oral infectious pathogens potentially causing respiratory disease in nursing home residents.

SUBJECTS AND METHODS

The tongue bacterial flora of 69 nursing home residents were examined to identify microorganisms by the culture method.

RESULTS

Thirteen species of microorganisms were detected from the tongue in this study. In 41 of 69 subjects (59%), potential respiratory pathogens, had colonised the tongue surface.

CONCLUSION

The results of the present study revealed that bacteria that commonly cause respiratory infection colonised the tongue of nursing home residents, suggesting that it may function as a reservoir of potential respiratory pathogens to facilitate colonisation on the oropharynx.