Prediction of Postoperative Delirium after Gastrointestinal Surgery Using the Mie Constructional Apraxia Scale

Background

Postoperative delirium (POD) is a transient postoperative complication that occurs after surgical procedures. Risk factors reported for POD include dementia and cognitive decline. The purpose of this study was to identify predictors of POD by examining the use of preoperative neuropsychological tests, including the Mie Constructional Apraxia Scale (MCAS), and patient background factors.

Method

The study was performed as a retrospective cohort study. The subjects were 33 patients (mean age, 75.8 ± 10.9 years; male:female ratio, 26:7) who underwent gastrointestinal surgery at Matsusaka City Hospital between December 2019 and April 2021. Data were collected retrospectively from medical records. The study was started after receiving approval from the institution's ethics committee. The survey items included general patient information, nutritional assessment, surgical information, and neuropsychological tests. Subjects were classified into 2 groups according to the presence or absence of POD. If a significant difference was observed between the 2 groups, the sensitivity, specificity, and area under the curve were calculated using a receiver operating characteristic (ROC) curve.

Result

There were 10 patients in the POD group (male:female ratio, 6:4) and 23 patients in the non-POD group (20:3). The POD group had a shorter education history (p = 0.047) and significantly higher MCAS scores (p = 0.007) than the non-POD group. The ROC curve showed a sensitivity of 90%, a specificity of 69%, and an area under the curve of 0.798 when the MCAS cutoff value was set at 3 points.

Conclusion

Preoperative MCAS results were capable of predicting the occurrence of POD after gastrointestinal surgery. In addition, a relatively short education background was also considered a risk factor for POD.

An elevated preoperative serum carbohydrate antigen 19-9 level is a significant predictor for peritoneal dissemination and poor survival in colorectal cancer

AIM

Many studies support the role of carcinoembryonic antigen (CEA) as a strong indicator of the status of colorectal cancer patients, but evidence for carbohydrate antigen 19-9 (CA19-9) is poor. For this reason the study aimed to evaluate the prognostic value of preoperative serum CA19-9 levels in colorectal cancer patients.

METHOD

In all, 1190 colorectal cancer patients were included in this study, of whom 955 underwent a potentially curative resection. These were analysed for recurrence and survival. The 255 patients with Stage IV disease were analysed for metastatic status.

RESULTS

Patients with an elevated preoperative CEA with Stage II and III disease showed a significantly poorer survival than those with normal levels. In contrast patients with elevated preoperative CA19-9 levels were associated with a significantly poorer survival irrespective of disease stage. Of the 255 patients with Stage IV disease, 92 (39.1%) had peritoneal dissemination at laparotomy observed more frequently in patients with an elevated CA19-9 (47.9%). Of the 955 patients having a curative resection, 18 (1.9%) developed peritoneal dissemination. In multivariate analysis, an elevated preoperative CA19-9 level was a significant risk factor for postoperative peritoneal recurrence.

CONCLUSION

After curative surgery for colorectal cancer the preoperative CA19-9 level is a strong prognostic indicator of higher risk of peritoneal dissemination.

[Effectiveness of high-dose, intermittent 5'-DFUR therapy for advanced gastric cancer]

We report a case of advanced gastric cancer with multiple liver metastases and peritoneal dissemination. The patient was effectively treated with high-dose 5'-DFUR. A 52-year-old patient with advanced gastric cancer and multiple liver metastases, who showed a high serum level of CEA and CA19-9 underwent simple D1 gastrectomy. Thereafter, he received per os 1,200 mg/day of 5'-DFUR intermittently (5 days a week) and TAI every four months postoperatively. The serum levels of both CEA and CA19-9 fell dramatically to within the normal range and were maintained thereafter until the present. The size and number of the liver metastases dramatically decreased, judging from CT and angiography findings.

Nitric oxide-dependent vasodilator mechanism is not impaired by hypertension but is diminished with aging in the rat aorta

This study was designed to elucidate the effects of hypertension and aging on nitric oxide (NO)-mediated relaxation response to acetylcholine in the rat aorta. NO-mediated relaxation response was assessed as the relaxation response to acetylcholine after treatment with cyclooxygenase inhibitor in KCl-precontracted aortic rings. The endothelium-dependent relaxation responses to acetylcholine were lower in aortic rings isolated from spontaneously hypertensive rats (SHRs) at ages 16-20 and 55-60 weeks compared with those seen in age-matched Wistar-Kyoto (WKY) rats. Aging induced a reduction of the relaxation response to acetylcholine in aortic rings from WKY rats but not from SHRs. Pretreatment with indomethacin enhanced the relaxation response to acetylcholine in only SHRs at ages 16-20 and 55-60 weeks, thereby cancelling the difference in the relaxation response between WKY rats and SHRs. Simultaneous administration of indomethacin and NG-nitro-L-arginine methyl ester abolished the relaxation response to acetylcholine in both strains. Thus NO-mediated relaxation response to acetylcholine was similar between WKY rats and SHRs at ages 16-20 and 55-60 weeks, respectively, and was attenuated with aging to the same degree in both strains. In conclusion, NO-mediated relaxation response to acetylcholine in the aorta is attenuated with aging but not impaired by hypertension.

[Combination use of second generation cephem and isepamicin for the treatment of post-surgical infection of the lower digestive tract]

Effects of combination use of a second generation cephem and an aminoglycoside antibiotic isepamicin (ISP), for the treatment of post-surgical infections of the lower digestive tract were examined from a laboratory and clinical perspective. Thirty-three out of total 35 cases were included in the analysis of the test, while the other 2 cases did not meet the criteria for analysis. ISP was administered in combination with one of the second generation cephems among cefotiam (CTM), cefmetazole (CMZ), or cefuroxime (CXM) for 26 cases of wound infection and 7 cases of peritonitis. The overall efficacy rate was 88%; 92% in wound infection and 71% in peritonitis individually. There was no significant difference in efficacy among different groups. Bacteriological study showed the combination use of any one of the second generation cephems and ISP was very effective in all 14 cases of infections with a single species of bacterium, the efficacy rate was 100%. It was also effective in 9 out of 10 cases with mixed infections of 2 species of bacteria (90%), but effectiveness was diminished in only 6 out of 9 cases with mixed infections of 3 species (67%). Sixty-nine strains were isolated from the 35 cases, more than half of which (44 strains) were Gram-negative; 14 strains of E. coli (20%), 13 strains of E. faecalis (13%) and 6 strains of P. aeruginosa (9%). The MIC50 and MIC90 were, respectively, 1.56 micrograms/ml and 100 micrograms/ml for ISP, 6.25 micrograms/ml and 100 micrograms/ml for CTM, 12.5 micrograms/ml and 100 micrograms/ml for CMZ, and 25 micrograms/ml and 100 micrograms/ml for CXM. The MICs in any combination uses decreased synergistically according to ISP concentration. Adverse events were observed in 3 out of 35 cases, but they were not severe. The results indicated that the combination use of a second generation cephem and ISP was useful and should be one of the choices for the treatment of post-operative infections of the lower digestive tract.

Undifferentiated carcinoma of the duodenal ampulla

This report demonstrates a case of undifferentiated carcinoma of the duodenal ampulla. A 74-year male experienced jaundice lasting for 3 weeks. An upper gastrointestinal series demonstrated a polypoid, ovoid filling defect in the second portion of the duodenum, and duodenoscopy disclosed a protruding mass involving the orifice of the papilla of Vater. Cholangiography demonstrated obstruction due to compression in the terminal common bile duct. Pylorus-preserving pancreatoduodenectomy was performed on the diagnosis of ampullary carcinoma. The gross specimen showed a polypoid mass, measuring 3.5 cm in diameter, in the ampulla, located mainly in the duodenal submucosal layer and invading the terminal common bile duct. Histologically, the tumor was small cell type, undifferentiated carcinoma, arising from the duodenal epithelium adjacent to the ampulla.

Peptide synthesis with halophenylalanines by thermolysin

Thermolysin was able to catalyze enantioselective peptide synthesis with non-natural amino acids, halophenylalanines. However, the reactivity of thermolysin was considerably influenced by the kind and position of halogen substituents on these analogues. The manner of the recognition of the amino component by the enzyme was different from that of the carboxyl component in the synthesis of peptides with non-natural phenylalanine analogues. The phenomena observed are discussed, based on the kinetic parameters obtained.

Valvuloplasty plus fundoplasty to prevent esophageal regurgitation in esophagogastrostomy after proximal gastrectomy

To prevent regurgitation esophagitis in esophagogastrostomy after proximal gastrectomy, valvuloplasty plus fundoplasty was carried out in 17 patients with stomach cancer or cancer of the abdominal esophagus. For this purpose, an equilateral triangular flap of 2.5 cm per side was formed at the upper margin of the remaining stomach along the greater curvature. The flap was inverted into the stomach only to serve as a valve. After the esophagogastrostomy was properly performed, fundoplasty was carried out, lifting and suturing the uppermost edge of the stomach to the esophagus along the greater curvature. To prevent pylorospasm as a result of reduced gastric volume, pyloromyotomy was also performed. The results were excellent in those followed for more than 1 year. The technique is simple and effective and, we believe, deserves further clinical evaluation.

[Pathophysiology of duodenal papillitis in cholelithiasis]

Pathological features of duodenal papillitis relative to cholelithiasis were analyzed in terms of dilatation of the bile duct, intracholedochal pressure, and histopathological pictures of papillitis, and the following conclusions were drawn: The principal causes of bile duct dilatation appeared to be pathological changes in the papilla per se; Papillitis accompanying choledocholithiasis with cholesterol stone were secondary to those gallstones evacuated from the gallbladder; Calcium bilirubinate stones seemed to be formed primarily as the result of papillitis. In some cases, ascariasis in their past history was thought responsible for the papillitis; and 4. It is suggested that as the papillitis advances, papillary incompetence will emerge.

Oral ammonia tolerance test in patients with portal hypertension

Eighty patients with portal hypertension due to various hepatic diseases were subjected to the oral ammonia tolerance test (OATT). Blood samples were collected before and at 30-min intervals after the administration of ammonium chloride (50 mg/kg). The ammonia levels, and the OATT curve patterns and sigma NH3-N values were determined and it was investigated whether there are correlations between these values and various other parameters of hepatic function. The results of OATT correlated with the plasma disappearance rate of indocyanine green and the molar ratio of branched chain amino acids to aromatic amino acids. Our findings suggest that the OATT may reflect the degree of hepatic parenchymal disorders rather than the hepatic circulatory abnormalities and that they may represent a valuable aid in the differential diagnosis of hepatic diseases and in determining the operative indication.