Appropriate Anthropometric Indices for Geriatric Nutritional Risk Index in Predicting Mortality in Older Japanese Patients: A Comparison of the Lorentz Formula and Body Mass Index

The Geriatric Nutritional Risk Index (GNRI) is a popular nutritional screening tool. However, the calculation of ideal body weight (IBW) differs among studies. We aimed to compare GNRI calculated using the Lorentz formula (LF) with a body mass index (BMI) and to investigate the cutoffs based on original or quartile criteria for the association with mortality in elderly patients in Japan. This retrospective study enrolled patients aged 65 and older in a long-term care hospital. The GNRI was calculated using two different IBW methods: the LF and a BMI of 22 kg/m2. We categorized GNRI results based on the original criteria or quartile criteria. Mortality outcomes were analyzed using the GNRI based on IBW (LF or BMI) and its classification (original criteria or quartile) through Cox proportional hazard regression. There were 262 participants, including 160 women, with a median age of 86. There was a notable difference between GNRI-BMI and GNRI-LF. The GNRI-LF original and quartile criteria did not show an association with mortality. A significant association with mortality was found between Q1 and Q4 in the GNRI-BMI quartile criteria (hazard ratio: 2.60; 95% confidence interval: 1.66-4.07, p < 0.01), but not the GNRI-BMI original criteria. The GNRI calculated using BMI with quartile criteria proved to be a reliable predictor of mortality for Japanese elderly inpatients. The calculation method of GNRI and the appropriate cutoff point should be considered based on the patient's background.

Magnesium intake by enteral formulation affects serum magnesium concentration in patients undergoing hemodialysis

Decreased serum magnesium levels are associated with mortality and fractures in patients with chronic kidney disease; however, there is no recommendation for Mg intake in these populations. This study used cross-sectional analysis to examine the association between Mg intake and serum Mg levels in patients undergoing hemodialysis. Sixty-one patients were included. The daily Mg intake was 185 mg (IQR: 151-203 mg), and serum Mg level was 2.4 mg/dL (IQR: 2.2-2.7 mg/dL). Multiple regression analysis showed that intake of enteral formulation by tube feeding was an independent factor associated with serum Mg level (B = 0.90 [95% confidence interval: 0.61-1.20], p < 0.01). These findings may aid in serum Mg level management through diet and enteral formulation in patients undergoing hemodialysis.

Locomotive syndrome in hemodialysis patients and its association with quality of life—a cross-sectional study

Background

Locomotive syndrome (LS) is defined as impairment of mobility function.

This study aimed to clarify LS and its association with quality of life in hemodialysis patients.

Methods

This is a cross-sectional study. The subjects were chronic kidney disease patients undergoing maintenance hemodialysis treatment. LS was assessed using two physical tests (two-step test, stand-up test) and one self-reported test (Geriatric Locomotive Function Scale-25). LS has two stages of severity; the beginning of the decline in mobility function is known as Locomo stage 1, and the progression of the decline of mobility function is known as Locomo stage 2. We used SF-36 to assess quality of life and examined their relationships with the Locomo stages. Chi-square test, Kruskal-Wallis test, Jonckheere-Terpstra test, and Mantel-Haenszel test were used for analysis. Multiple linear regression was used to model the cross-sectional association of Locomo stages with each component and summary score of SF-36.

Results

A total of 76 hemodialysis patients were included. The number of subjects with Locomo stage 1 and stage 2 were 19 (25%) and 53 (70%), respectively, while only four (5%) subjects did not have mobility dysfunction. Each component and summary score of the SF-36 for physical function, role emotional, physical component summary, and mental component summary were significantly associated with Locomo stages.

Conclusion

A high prevalence and severity of LS in hemodialysis patients was found, and the severity was associated with quality of life.

Comparison of emptying between gastric and colonic conduits following esophagectomy

The emptying of gastric and colonic conduits following esophagectomy was evaluated. Ten consecutive patients who underwent esophagectomy for malignant diseases were divided into two groups as follows: Group I which consisted of 5 patients who underwent pyloroplasty and in whom the gastric greater curvature was used for reconstruction; and Group II which consisted of 5 patients in whom the colonic conduit was used because of previous gastrectomy. The conduits were placed in the retrosternal spaces in all the patients. The radiopaque markers swallowing test and digestive tract scintigraphy were performed to evaluate emptying two months after surgery. The radiopaque markers swallowing test demonstrated that marker rings quickly disappeared from the gastric conduits but remained in the colonic conduits for as long as three hours. Digestive tract scintigraphy demonstrated that there was no significant difference in the 60-minute clearance rate of 99mTc-DTPA from the conduits between the two groups. The results suggested that tiny food fragments remained in the haustral pockets of the colonic conduits, which may be a disadvantage of these conduits.

Perineal rectosigmoidectomy (Altemeier's procedure): a review of physiology, technique and outcome

Perineal rectosigmoidectomy (Altemeier's procedure), as used for the surgical treatment of full-thickness rectal prolapse, has a long history. The physiological derangement in patients with rectal prolapse is complex, frequently showing impairment of the rectoanal inhibitory reflex, intermittent high-pressure rectal motor activity, disturbances in anorectal sampling and attendant pudendal neuropathy. There are currently few defined preoperative factors in patients presenting with rectal prolapse and fecal leakage which predict for the restoration of continence after surgery. This review describes our technique of Altemeier's procedure and analyzes the reported results of this operation, presenting those studies which assessed postoperative continence and prolapse recurrence in particular. The lack of prospective randomized data regarding this perineal approach makes clinical interpretation difficult at the present time.

Multicentric occurrence of esophageal cancer after gastrectomy: a preliminary report

The effect of gastrectomy on the subsequent development of esophageal cancer was investigated, focusing on its multicentric occurrence. We retrospectively evaluated 28 patients who underwent subtotal esophagectomy for intrathoracic esophageal cancer between 1985 and 1999. They were divided into two groups according to whether or not they had previously undergone a gastrectomy: group 1, comprising 7 patients who had undergone gastrectomy and group 2, comprising 21 patients who had not. Clinical profiles of the patients were obtained from the medical records and the whole resected esophagus was histopathologically examined. The interval between gastrectomy and esophagectomy in group 1 was significantly shorter in the patients who had undergone gastrectomy for gastric cancer than in those who had undergone gastrectomy for a peptic ulcer, and also in the patients for whom anastomosis had been performed by Billroth I compared with Billroth II. The patients in group 1 were significantly younger than those in group 2. The multiple occurrence of esophageal cancer was found in 4 of 5 patients (80%) in group 1, and in 2 of 18 patients (11%) in group 2, with significantly higher frequency being seen in group 1. More than two coexisting cancer lesions apart from the primary tumor were detected in all four patients. Histological examination of all the coexisting cancer lesions showed well-differentiated squamous cell carcinoma confined within the superficial mucosal layer. No significant differences were noted in the location of the coexisting lesions between the oral and anal side of the primary tumors. Squamous dysplasia was randomly observed, especially around the cancer lesions. These findings suggest that gastrectomy precipitated subsequent chronic gastroesophageal reflux which in turn induced the development of squamous dysplasia and carcinoma at multiple locations in the esophagus.

A spontaneously ruptured gastric stromal tumor presenting as generalized peritonitis: report of a case

Among the diverse clinical presentations of gastrointestinal stromal tumor (GIST), spontaneous rupture with peritonitis is extremely rare. We report herein the unusual case of a 75-year-old man found to have a spontaneously ruptured gastric stromal tumor after presenting with generalized peritonitis. The patient was brought to the emergency department of our hospital by ambulance, with generalized severe abdominal pain. On examination, his abdomen was extensively distended with generalized severe rebound tenderness. Abdominal computed tomography scan showed a giant mass arising from the anterior gastric wall with an irregular internal low-density area and a small amount of ascites. An emergency laparotomy revealed a ruptured gastric tumor with dissemination of its necrotic tissue throughout the peritoneal cavity. The tumor was excised together with normal gastric tissue around its base. The tumor, which was 15 x 11 x 4.4cm in size, had a coarse laceration over its well-capsulated smooth serosal surface with massive necrosis and clotted blood inside. Immunohistochemical examination revealed positive reactivity to C-kit protein, which was consistent with the newly introduced diagnostic criteria of GIST. The patient had an uneventful postoperative course and remains well.

Successful liver transplantation from a donor with brodifacoum intoxication

We describe our use of a liver allograft from a donor who died of intracranial hemorrhage after brodifacoum ingestion. Because brodifacoum can remain in the human body for months, the recipient's posttransplantation coagulation profiles and serum brodifacoum levels were monitored closely. Her posttransplantation course was excellent, with no coagulation problem. At 15 months posttransplantation, she is well, with normal liver function and coagulation profile. We conclude that brodifacoum toxicity is not a strict contraindication to liver donation.

Gastric cancer occurring in a patient with Plummer-Vinson syndrome: report of a case

We report herein the unusual case of a 59-year-old woman with Plummer-Vinson syndrome who developed gastric cancer. The patient had a longstanding history of dysphagia and iron deficiency anemia, for which she had sporadically taken iron supplements that improved the dysphagia to some extent, but not completely. Owing to her tolerance of the dysphagia, she had not been taking iron supplements for the past 17 years. On admission, she was in fair nutritional condition and not anemic. Blood chemistry results were all normal, including the serum iron level. Gastrointestinal radiographic series demonstrated cervical esophageal webs and advanced gastric cancer. Her dysphagia was successfully treated by endoscopic bougienage through the webs, and a distal partial gastrectomy with nodal dissection was performed. Histology of the resected stomach revealed atrophic mucosal change and, by chance, an adenomatous lesion in addition to adenocarcinoma. Her postoperative course was uneventful and she is now well, without any signs of recurrence. Although Plummer-Vinson syndrome is known to be associated with upper alimentary tract cancers, gastric cancer is extremely rare. A discussion on the etiology of Plummer-Vinson syndrome and its link with potential carcinogenesis follows this case report.

Anomalous junction of the pancreaticobiliary duct accompanied by gallbladder cancer and obstructive jaundice in a patient with high serum and bile cytokine levels

We report a case of anomalous junction of the pancreaticobiliary duct (AJPBD) associated with gallbladder cancer and obstructive jaundice in a patient with high serum and bile cytokine levels. The patient was a 63-year-old woman who complained of right hypochondralgia. Ultrasound, computed tomography, percutaneous transhepatic cholangiography, and endoscopic retrograde cholangio-pancreatatography revealed dilation of the bile ducts, an elevated lesion of the gallbladder, and AJPBD. She underwent percutaneous transhepatic cholangio-drainage (PTCD) for obstructive jaundice. However, the total bilirubin concentration remained high 7 days after PTCD. Her serum interleukin 6 level was 57,359 pg/ml before PTCD, and gradually decreased to 10 pg/ml after PTCD. Bile interleukin 6 level was 10 pg/ml before PTCD, 8997 pg/ ml 3 h after PTCD and gradually decreased there after. Serum and bile levels of tumor necrosis factor alpha and hepatocyte growth factor were high before and after PTCD. The patient underwent an extended cholecystectomy and resection of the extrahepatic bile duct. The resected specimen showed two elevated lesions of the gallbladder which, microscopically, revealed moderately differentiated tubular adenocarcinoma. These findings suggest that pre-existing inconspicuous inflammation of the biliary tract due to reflux of pancreatic juice is involved in elevation of serum and bile cytokines, and that cytokines may participate in gallbladder carcinogenesis associated with AJPBD.

[Changes in serum and bile tumor necrosis factor alpha before and after percutaneous transhepatic cholangio-drainage for obstructive jaundice]

The aim of this study was to evaluate the correlation between tumor necrosis factor alpha (TNF alpha) and jaundice reduction by percutaneous transhepatic cholangio-drainage (PTCD) in patients with obstructive jaundice. Thirty patients who had undergone PTCD were divided into two groups: those with rapidly decreasing bilirubin (the fast group; n = 21) and those with slowly decreasing bilirubin (the slow group; n = 9). We compared clinical features before PTCD between groups. We also compared serum and bile TNF alpha before and after PTCD in the fast group with those in the slow group. The rate of patients with recurrence of malignancy in other organs involved in the etiology of obstructive jaundice was significantly higher in the slow group than in the fast group. Before and after PTCD, serum and bile TNF alpha were significantly higher in the slow group than in the fast group. These results suggest that TNF alpha may play an important role in the protracted recovery from obstructive jaundice after PTCD.

Increased graft survival by utilization of 15-deoxyspergualin in a canine pancreatic allotransplantation model

The purpose of this study was to evaluate the effectiveness of 15-deoxyspergualin (DSG) administration against acute rejection of canine pancreatic allografts. Subsequent to partial pancreatic allotransplantation and total extirpation of the pancreas, 20 adult mongrel dogs were divided into four groups and treated with saline (group 1, controls, n = 5), DSG at 1.0 mg/kg/day (group 2, n = 5), DSG at 3.0 mg/kg/day (group 3, n = 5), or DSG at 5.0 mg/kg/day (group 4, n = 5) on postoperative days 4-7. The graft survival, defined by a fasting serum glucose level < 150 mg/dl, was significantly prolonged from 6.2 +/- 1.2 days in group 1 to 12.4 +/- 2.7 days in group 3 (p < 0.05) and to 16.8 +/- 3.2 days in group 4 (p < 0.05). Graft survival was not significantly prolonged in group 2, however. Two normoglycemic dogs in group 4 died due to gastrointestinal toxicity, one of the most serious side effects of DSG. The observation that the serum insulin levels increased in dogs treated with DSG was compatible with dose-dependent graft survival and suggested that DSG had no toxic effects on pancreatic endocrine function. In group 1 significantly increased thromboxane B2 (TXB2) levels and TXB2/6-keto-prostaglandin F1 alpha (PGF1 alpha) ratios were observed on postoperative days 3-5 which was thought to reflect acute rejection. Following administration of DSG, both TXB2 levels and TXB2/PGF1 alpha ratios were decreased on the 5th postoperative day in groups 2-4.(ABSTRACT TRUNCATED AT 250 WORDS)

[Evaluation of intraoperative intraperitoneal administration on anti-cancer drug for gastric cancer]

This study was undertaken in order to evaluate the effect of intraoperative intraperitoneal (IP) administration of cisplatin (CDDP) and/or mitomycin C (MMC) on patients who underwent an operation for gastric cancer, compared with an untreated group. There were no differences between the effect of CDDP and that of MMC. No differences were found between the survival rate of IP and untreated group in no liver and no peritoneal metastasis cases, nor in non-resection cases. However, the median survival time was longer at 377 days in IP group than at 213 days in the untreated group (p less than 0.1). The free CDDP levels in the serum after 50 mg IP injection remained effective for 15-30 min. On the other hand, the MMC levels in the serum after 20 mg IP proved in effective.

Receptor sequence in the terminal protein of bacteriophage M2 that interacts with an RGD (Arg-Gly-Asp) sequence of the primer protein

At the initiation of protein-primed DNA replication of bacteriophages M2 and phi 29, the Arg-Gly-Asp (RGD) sequence of primer protein participates in the recognition of terminal protein (TP), where the initiation site for protein-primed DNA replication of template DNA is located. We compared the sequences of M2 and phi 29 TP with those of the members of the integrin superfamily and found the highly homologous sequences Lys-Lys-Ile-Pro-Pro-Asp-Asp (KKIPPDD) in M2 and phi 29 TP and Lys-Lys-Gly-Cys-Pro-Pro-Asp-Asp (KKGCPPDD) in the beta-subunit of fibronectin receptor protein. A synthetic 20mer peptide that contained the KKIPPDD sequence interfered with the inhibitory effect of the RGD peptide on both transfection and the protein-priming reaction in vitro. We propose that the sequence KKIPPDD of M2 TP is the receptor sequence for RGD.

Primer protein of bacteriophage M2 exposes the RGD receptor site upon linking the first deoxynucleotide

Primer protein (PP) of bacteriophages M2 and phi 29 contains an Arg-Gly-Asp (RGD) sequence. The RGD-mediated protein-protein interaction in protein-primed DNA replication of M2 was studied in vitro using three purified and indispensable components: PP, DNA polymerase (POL) and template DNA linked to terminal protein (TP). PP competed with a synthetic RGD peptide for binding to the template DNA-TP complex (TP-DNA). In addition, POL bound to template TP-DNA only when complexed with PP. These results indicate that the RGD sequence of PP is responsible for the interaction of the PP-POL complex with TP-DNA, which contains the initiation site for the protein priming of DNA synthesis. At the moment when PP converts to TP upon linking the first deoxynucleotide, a conformational change results in exposure of the RGD binding site.

[Spread of surgical indication for hepatoma with postoperative transcatheter arterial infusion]

We evaluated the reduction surgery and the postoperative TAI for unresectable hepato-cellular carcinoma (HCC). Eight patients underwent reduction surgery and postoperative TAI (group I). Twenty-five patients underwent combination therapy with TAI, TAE, EI, hyperthermia and irradiation, who had not undergone reduction surgery (group II). Nine patients underwent a relative noncurative operation (group III). We studied the prognosis of these three groups.

RESULTS

The one-year survival rates were 85.7% in group I, 38.6% in group II and 55.5% in group III. The three-year survival rates were 42.9% in group I, 10.7% in group II and 55.5% in group III. There was a significant difference of prognosis between group I and group II (p less than 0.05, generalized Wilcoxon). These results suggest that reduction surgery and post operative TAI for unresectable HCC improve the prognosis.

[Analysis of prognostic factors in patients with hepatocellular cancer treated by hepatic arterial infusion chemotherapy]

Analyses of the prognoses of thirty-four patients with hepatocellular cancer, who were treated by hepatic arterial infusion chemotherapy and/or transcatheter arterial embolization (TAE) and/or hyperthermotherapy, were performed by multivariate analysis using Cox's proportional hazard model and generalized Wilcoxon test. In the multivariate analysis on the conditions of patients, nine of fifteen variables were associated with the prognosis of patients who received regional cancer chemotherapy. The variables are: sex, liver cirrhosis, esophageal varices, GOT, GPT, albumin and gamma-globulin. One of three variables was associated with the prognosis in the therapy analysis, and the variable is TAE. Significant differences in survival curves which were estimated by generalized Wilcoxon test were noted in age, portal vein invasion, ascites, GOT and TAE. From these results it is suggested that the conditions of patients with unresectable hepatocellular cancer must be carefully investigated before regional cancer chemotherapy and the good therapy effects is obtained by hepatic arterial infusion chemotherapy combined with transcatheter arterial embolization therapy.

[A case report of hyperlipemia with giant fatty liver during adjuvant endocrine therapy by tamoxifen]

A 36-year-old woman was treated with tamoxifen for lung metastasis of breast cancer and had marked hyperlipoproteinemia with giant fatty liver, high plasma triglyceride levels (3673 mg/dl), and increased levels of very low density lipoprotein (VLDL) and intermediate density lipoprotein (UDL). A low level of activity of both plasma lipoprotein lipase (LPL) and hepatic triglyceride lipase (HTGL) was also noted. Our observations support the concept that, in some patients, the weak estrogen-like activity of tamoxifen is amplified and, in severe lipemia, reduction of the activities of LPL and HTGL might impede the conversion of VLDL to LDL, thus causing the amplification of the effect.