The Respiratory Adjusted Shock Index at Admission Is a Valuable Predictor of In-Hospital Outcomes for Elderly Emergency Patients with Medical Diseases at a Japanese Community General Hospital.

Background: The respiratory adjusted shock index (RASI) is a risk score whose usefulness in patients with sepsis and trauma has previously been reported. However, its relevance in elderly emergency patients with medical diseases is yet to be clarified. This study assessed the usefulness of the RASI, which can be evaluated without requiring special equipment, to provide objective and rapid emergency responses. Methods: In this retrospective study, we recruited patients with medical diseases, aged 65 years or older, who were transported to the emergency room from Tokushima Prefectural Kaifu Hospital and underwent arterial blood gas testing from 1 January 2022 to 31 December 2023. We investigated the association of the RASI with other indices, including the lactate level, National Early Warning Score 2 (NEWS2), Shock Index (SI), Sequential Organ Failure Assessment (SOFA) score, quick SOFA (qSOFA) score, and systemic inflammatory response syndrome (SIRS). Results: In this study, we included 260 patients (mean age, 86 years), of whom 234 were admitted to the hospital; 27 and 49 patients died within 7 and 30 days of admission, respectively. The RASI was positively correlated with the lactate level, NEWS2, SI, and increase in the SOFA score (p < 0.001). The RASI was higher in patients with a SIRS or qSOFA score ≥ 2 than in those without (p < 0.001). It predicted death within 7 and 30 days of admission with an area under the curve (AUC) of 0.80 (95% confidence interval [CI]: 0.73-0.87), sensitivity of 96.3%, and specificity of 53.6% when the cutoff value was set to 1.58 and with an AUC of 0.73 (95% CI: 0.66-0.81), sensitivity of 69.4%, and specificity of 70.6% when the cutoff value was set to 1.83, respectively. Conclusions: The RASI is a simple indicator that can be used for predicting in-hospital outcomes in elderly emergency patients with medical diseases. Larger prospective studies based on this study are needed.

Usefulness of Palliative Prognostic Index, Objective Prognostic Score, and Neutrophil-Lymphocyte Ratio/Albumin Ratio As Prognostic Indicators for Patients Without Cancer Receiving Home-Visit Palliative Care: A Pilot Study at a Community General Hospital.

Background: Although the palliative prognostic index (PPI), objective prognostic score (OPS), and neutrophil-lymphocyte ratio/albumin ratio (NLR/Alb) are well-known prognostic indicators for cancer patients, they do not provide clarity when it comes to predicting prognosis in patients without cancer who receive home-visit palliative care. Objective: The aim of this study was to determine whether PPI, OPS, and NLR/Alb can predict prognosis for patients without cancer who received home-visit palliative care. Design: This is a retrospective study. Setting/Subjects: We recruited 58 patients without cancer who received home-visit palliative care from Tokushima Prefectural Kaifu Hospital, Japan, and died at home or at the hospital within seven days of admission between January 2009 and March 2023. Measurements: The PPI, OPS, and NLR/Alb of the study patients were evaluated at regular intervals, and statistical analysis was performed on the relationship between these indices and the time to death. Results: Simple regression analysis showed that PPI, OPS, and NLR/Alb were negatively correlated with the period until death (p < 0.001). The survival curves of the groups classified according to PPI, OPS, and NLR/Alb were significantly stratified. The predictive capacities of PPI, OPS, and NLR/Alb for death within 21 days were as follows: PPI (area under the curve [AUC]: 0.71; sensitivity: 59%; specificity: 68%), OPS (AUC: 0.73; sensitivity: 88%; specificity: 47%), and NLR/Alb (AUC: 0.72; sensitivity: 72%; specificity: 73%). Conclusions: PPI, OPS, and NLR/Alb were useful in predicting the survival period and short-term prognosis within 21 days for patients without cancer who received home-visit palliative care.

Configurationally Nonselective Aquation of a Mononuclear Ru(II) Chloro Complex to Aquo Complex Isomers with Distinctive Aspects in Photoisomerization, Redox, and Catalytic Water Oxidation.

distal-[Ru(EtOtpy)(pynp)Cl]+ (d-EtO1Cl) (EtOtpy = 4'-ethoxy-2,2':6',2″-terpyridine, pynp = 2-(2-pyridyl)-1,8-naphthyridine), and distal/proximal-[Ru(EtOtpy)(pynp)OH2]2+ (d/p-EtO1H2O) complexes were newly synthesized to investigate the synergistic influence of the geometric configuration coupled with substituent introduction of an ethoxy (EtO) group on the physicochemical properties and reactions of the Ru(II) complexes. Configurationally nonselective aquation of d-EtO1Cl was uniquely observed to form d/p-EtO1H2O isomers in water, in contrast to configurationally selective aquation of distal-[Ru(tpy)(pynp)Cl]+ (d-1Cl, tpy = 2,2':6',2″-terpyridine) without the EtO group [Yamazaki, H. . J. Am. Chem. Soc. 2011, 133, 8846-8849].The kinetic profiles of the aquation reactions of d-EtO1Cl were well analyzed using a sequential reversible reaction model assuming the reversible interconversion between d/p-EtO1H2O isomers via d-EtO1Cl. The observed equilibrium constant (Kiso) of isomerization between p/d-EtO1H2O was calculated from the kinetic analysis as Kiso = 0.45, which is consistent with the final concentration ratio (1:0.43) of p/d-EtO1H2O generated in the aquation reaction of d-EtO1Cl. The irreversible photoisomerization from d-EtO1H2O to p-EtO1H2O was observed in water with an internal quantum yield (Φ) of 0.44% at 520 nm. Electrochemical measurements showed that d-EtO1H2O undergoes a 2-step oxidation reaction of 1H+-coupled 1e- processes of RuII-OH2/RuIII-OH and RuIII-OH/RuIV═O at pH 1.3-9.7, whereas p-EtO1H2O undergoes a 1-step oxidation reaction of a 2H+-coupled 2e- process of RuII-OH2/RuIV═O in the pH range of 1.8-11.5. Any redox potential of d/p-EtO1H2O isomers was decreased by the electro-donating EtO substitution, compared with distal/proximal-[Ru(tpy)(pynp)OH2]2+ (d/p-1H2O). The turnover frequency (kO2 = 1.7 × 10-2 s-1) of d-EtO1H2O for water oxidation catalysis is higher than that (3.5 × 10-4 s-1) of p-EtO1H2O by a factor of 48.6. The kO2 value (1.7 × 10-2 s-1) for d-EtO1H2O is 4.5-fold higher than those of d-1H2O (3.8 × 10-3 s-1). The higher kO2 value of d-EtO1H2O compared with d-1H2O could be explained by the fast oxidation rate from RuIV═O to RuV═O involved in the rate-determining step due to the electron-donating EtO group.

Comparison of therapeutic responses between polymyalgia rheumatica and remitting seronegative symmetrical synovitis with pitting edema syndrome.

Polymyalgia rheumatica (PMR) and remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome are common inflammatory rheumatic diseases in the elderly. In this study, we investigated the difference of the therapeutic responses between patients with PMR and RS3PE syndrome. Twenty-four patients with PMR and 12 patients with RS3PE syndrome were treated with initial dosages of 10-20 mg per day oral prednisolone, and the dosages were then tapered. Percentages of patients with negative c-reactive protein (CRP) after 8-week treatment were significantly more in RS3PE syndrome than in PMR. Percentages of patients with relapse during one-year treatment were less likely to be in RS3PE syndrome than in PMR. These differences observed between the two disorders were not associated with the level of initial CRP. There was no significant difference in percentages of patients with prednisolone-free remission after two-year treatment between PMR and RS3PE syndrome. These results indicate that the early response to the treatment is greater in RS3PE syndrome than in PMR. J. Med. Invest. 70 : 145-149, February, 2023.

Distinctive Aspects in Aquation, Proton-Coupled Redox, and Photoisomerization Reactions between Geometric Isomers of Mononuclear Ruthenium Complexes with a Large-π-Conjugated Tetradentate Ligand.

Geometric isomers of mononuclear ruthenium(II) complexes, distal-/proximal-[Ru(tpy)(dpda)Cl]+ (d-/p-RuCl, tpy = 2,2':6',2″-terpyridine, dpda = 2,7-bis(2-pyridyl)-1,8-diazaanthracene), were newly synthesized to comprehensively investigate the geometric and electronic structures and distinctive aspects in various reactions between isomers. The ultraviolet (UV)-visible absorption spectra of d-/p-RuCl isomers show intense bands for metal-to-ligand charge transfer (MLCT) at close wavelengths of 576 and 573 nm, respectively. However, time-dependent density functional theory (TD-DFT) calculations suggest that the MLCT transition of d-RuCl involves mainly single transitions to the π* orbital of the dpda ligand in contrast to mixing of the π* orbitals of the dpda and tpy ligands for p-RuCl. The aquation reaction (1.5 × 10-3 s-1) of p-RuCl to yield proximal-[Ru(tpy)(dpda)(OH2)]2+ (p-RuH2O) is faster than that (5.3 × 10-6 s-1) of d-RuCl in D2O/CD3OD (4:1 v/v) by three orders of magnitude, which resulted from the longer Ru-Cl bond by 0.017 Å and the distorted angle (100.2(3)°) of Cl-Ru-N (a nitrogen of dpda, being on a tpy plane) due to the steric repulsion between Cl and dpda for p-RuCl. Electrochemical measurements showed that d-RuH2O undergoes a 2-step oxidation reaction of 1H+-coupled 1e- processes of RuII-OH2/RuIII-OH and RuIII-OH/RuIV═O at pH 1-9, whereas p-RuH2O undergoes a 1-step oxidation reaction of a 2H+-coupled 2e- process of RuII-OH2/RuIV═O in the pH range of pH 1-10. The irreversible photoisomerization from d-RuH2O to p-RuH2O was observed in aqueous solution with an internal quantum yield (Φ) of 5.4 × 10-3% at 520 nm, which is lower compared with Φ = 1.1-2.1% of mononuclear Ru(II) aquo complexes with similar bidentate ligands instead of dpda by three orders of magnitude. This is possibly ascribed to the faster nonradiative decay rate from the excited 3MLCT state to the ground state for d-RuH2O due to the lower π* level of dpda ligands according to the energy-gap law: the rate decreases exponentially with the increasing energy gap.

Geospatial Assessments of DNA Adducts in the Human Stomach: A Model of Field Cancerization.

BACKGROUND: Field cancerization is a popular concept regarding where cancer cells arise in a plane, such as the opened-up gastrointestinal mucosa. The geospatial distribution of DNA adducts, some of which are believed to initiate mutation, may be a clue to understanding the landscape of the preferred occurrence of gastric cancer in the human stomach, such that the occurrence is much more frequent in the lesser curvature than in the greater curvature. METHODS: Seven DNA adducts, C5-methyl-2'-deoxycytidine, 2'-deoxyinosine, C5-hydroxymethyl-2'-deoxycytidine, N6-methyl-2'-deoxyadenosine, 1,N6-etheno-2'-deoxyadenosine, N6-hydroxymethyl-2'-deoxyadenosine, and C8-oxo-2'-deoxyguanosine, from different points and zones of the human stomach were semi quantitatively measured by liquid chromatography/tandem mass spectrometry. The differences in the quantity of these DNA adducts from the lesser and greater curvature, the upper, middle and lower third zones, the anterior and posterior wall of the stomach, and the mucosae distant from and near the tumor were compared to determine whether the location preference of cancer in the stomach could be explained by the distribution of these DNA adducts. Comparisons were conducted considering the tumor locations and operation methods. CONCLUSIONS: Regarding the DNA adducts investigated, significant differences in quantities and locations in the whole stomach were not noted; thus, these DNA adducts do not explain the preferential occurrence of cancer in particular locations of the human stomach.

Mass spectrometric profiling of DNA adducts in the human stomach associated with damage from environmental factors.

BACKGROUND: A comprehensive understanding of DNA adducts, one of the most plausible origins of cancer mutations, is still elusive, especially in human tissues in clinical settings. Recent technological developments have facilitated the identification of multiple DNA adducts in a single experiment. Only a few attempts toward this "DNA adductome approach" in human tissues have been reported. Geospatial information on DNA adducts in human organs has been scarce. AIM: Mass spectrometry of human gastric mucosal DNA was performed to identify DNA adducts associated with environmental factors. MATERIALS AND METHODS: From 59 subjects who had received gastrectomy for gastric cancer, 306 samples of nontumor tissues and 15 samples of tumors (14 cases) were taken for DNA adductome analysis. Gastric nontumor tissue from autopsies of 7 subjects without gastric cancer (urothelial cancer, hepatocellular carcinoma, lung cancer each; the other four cases were without any cancers) was also investigated. Briefly, DNA was extracted from each sample with antioxidants, digested into nucleosides, separated by liquid chromatography, and then electrospray-ionized. Specific DNA adducts were identified by mass/charge number and column retention time compared to standards. Information on lifestyle factors such as tobacco smoking and alcohol drinking was taken from the clinical records of each subject. RESULTS: Seven DNA adducts, including modified bases, C5-methyl-2'-deoxycytidine, 2'-deoxyinosine, C5-hydroxymethyl-2'-deoxycytidine, N6-methyl-2'-deoxyadenosine, 1,N6-etheno-2'-deoxyadenosine, N6-hydroxymethyl-2'-deoxyadenosine, and C8-oxo-2'-deoxyguanosine, were identified in the human stomach and characterized. Intraindividual differences according to the multiple sites of these adducts were noted but were less substantial than interindividual differences. N6-hydroxymethyl-2'-deoxyadenosine was identified in the human stomach for the first time. The amount of C5-hydroxymethyl-2'-deoxycytidine was higher in the stomachs of subjects without gastric cancer than in the nontumor and tumor portions of the stomach in gastric cancer patients. Higher levels of 1,N6-etheno-2'-deoxyadenosine were detected in the subjects who reported both smoking and drinking than in those without these habits. These DNA adducts showed considerable correlations with each other. CONCLUSIONS: We characterized 7 DNA adducts in the nontumor portion of the human stomach in both gastric cancer subjects and nongastric cancer subjects. A reduction in C5-hydroxymethyl-dC even in the nontumor mucosa of patients with gastric cancer was observed. Smoking and drinking habits significantly influenced the quantity of one of the lipid peroxidation-derived adducts, etheno-dA. A more expansive DNA adductome profile would provide a comprehensive understanding of the origin of human cancer in the future.

Past infections are associated with low levels of anti-citrullinated protein autoantibodies in rheumatoid arthritis.

Background : Rheumatoid arthritis (RA), an autoimmune disease of unknown etiology, is believed to occur as the result of actions of genetic and environmental factors. In this study, we examined the relation of past histories about infectious diseases with the levels anti-citrullinated protein autoantibodies (ACPA) in RA. Methods : Results of a questionnaire about histories of infectious diseases were obtained from 85 patients with RA, and were analyzed. Results : Significantly lower level of ACPA was detected in patients with the history of tonsillitis, otitis media or urinary cystitis than in those without it. There was no difference in the level of ACPA in RA patients between with and without cold / influenza, rubella, chickenpox, herpes labialis or herpes zoster. When RA patients were divided into two groups, high-level and low-level ACPA, multiple logistic regression analysis revealed that the history of otitis media was a significantly independent factor for the low level of ACPA. There was no significant relation between the level of rheumatoid factor and histories of infectious diseases. Conclusion : This study clarified that the past history of otitis media is associated with the low level of ACPA in RA. J. Med. Invest. 67 : 182-188, February, 2020.

Japanese elderly individuals wish for enteral tube feeding more strongly for their parents than for themselves.

[Introduction] The purpose of this study was to investigate the differences in the preference of enteral tube feeding between elderly inhabitants of Mugi town, Tokushima Prefecture, Japan, and their parents in various physical conditions. [Methods] This population-based questionnaire survey studied 300 randomly selected participants aged 65-80 years. Respondents were to consider a situation where eating was difficult, and were questioned on their desire for tube feeding, using a visual analogue scale (VAS) ranging from "do not want tube feeding (0)" to "want tube feeding (100)." [Results] Valid responses of 103 (34.4%) participants were analyzed. Under conditions of being "healthy," "bedridden," "with dementia," and "bedridden and with dementia," the median (IQR) of the VAS values for the desire for tube feeding were 31.8 (3.3 to 83.8), 19.3 (2.4 to 52.3), 5.2 (0.7 to 18.9), 4.0 (0.3 to 15.2) for respondents and 55.2 (11.6 to 92.2), 48.7 (5.5 to 85.5), 9.0 (1.2 to 46.8), 5.1 (0.1 to 36.5) for parents, respectively. The VAS values for the parents were significantly higher (p=0.001, 0.002, 0.001, and 0.01, respectively for the four conditions described) for the same items. [Conclusion] Surrogate decisions made by family members often differ from what the patients would have desired. J. Med. Invest. 66 : 258-263, August, 2019.

Predictive factors associated with the therapeutic response in patients with polymyalgia rheumatica and remitting seronegative symmetrical synovitis with pitting edema syndrome.

Polymyalgia rheumatica (PMR) and remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome are common inflammatory rheumatic diseases in the elderly. In this study, we investigate predictive factors which correspond to subsequent disease control of PMR and RS3PE syndrome. Twenty four patients, which contained 18 PMR and 6 RS3PE syndrome, were treated with initial dosages of 10-20 mg per day oral prednisolone, and the dosage of prednisolone was then tapered. Significantly higher initial CRP was observed in patients with poor disease control than in those with good disease control afterwards. The number of patients with negative CRP after 4 weeks was significantly more in patients with good disease control after 1 year than in those with poor disease control. Patients were shown to be in good disease control status after 1 year when CRP after 4 weeks became negative even if they had initial high CRP. Our study clarify that to make CRP negative after 4 weeks is associated with subsequent suppression of the disease activity and with decreased dosages of corticosteroids. J. Med. Invest. 66 : 112-118, February, 2019.

Characteristics of medical students who would like to be a generalist physician and contribute to remote area medicine.

We administered a questionnaire to 5th grade medical students to examine the effect of community-based clinical practice on their attitudes to remote area medicine and their course after the graduation. Data from 192 students were obtained. The intensity of students' attitudes was estimated by using visual analogue scale. The intensities of the interest and a sense of fulfillment in remote area medicine were significantly increased after the practice. A significantly lower level of the intensity to become a generalist than that to become a specialist was seen in the students with low intensity in a sense of fulfillment. The percentages of the students who answered that they can work for 5 years or more in remote area were significantly lower in students with low intensity of a sense of fulfillment than in those with high intensity. A significantly higher percentage in students who worked at a familiar prefecture to them after the graduation was seen in female than in male. This study shows that the community-based practice is meaningful in increasing motivation which desire to work in remote area medicine, and that the motivation may affect their course after the graduation. J. Med. Invest. 64: 210-216, August, 2017.

A rare collision tumor composed of follicular lymphoma and adenocarcinoma in the ampulla of vater: a case report.

The duodenum is infrequently affected by malignant lymphoma, and follicular lymphomas of the duodenum are rare histological subtypes. There are no reported cases of collision of follicular lymphoma and other tumors in the ampulla of Vater. A 57-year-old Japanese man presented with jaundice, and abdominal computed tomography revealed a tumor of the ampulla of Vater invading the pancreatic head with biliary dilatation and a thickened duodenal wall. The patient underwent subtotal stomach-preserving pancreaticoduodenectomy. Histopathology of the resected specimen revealed lymphoid follicular formations with small-to-medium-sized centrocyte-like cells and some centroblast-like cells. The atypical lymphoid cells were immunohistochemically positive for CD10, CD20, and CD79a but negative for CD5 and cyclin D1. BCL2 protein was highly expressed in the follicle centers. The diagnosis was duodenal follicular lymphoma, Grade 1. The follicular lymphoma, 40 mm in diameter, involved duodenal submucosa and regional lymph nodes without distant metastasis. This duodenal follicular lymphoma was partially overlapped by adenocarcinoma of the ampulla of Vater, measuring 25 × 20 mm, which involved the lower common bile duct, pancreas, and duodenum. We report the first case of a surgically treated collision tumor composed of a rare mass-forming follicular lymphoma and adenocarcinoma of the ampulla of Vater.

Pancreatic metastases of cerebellar hemangiopericytoma occurring 24 years after initial presentation: report of a case.

Hemangiopericytoma (HPC) preferentially developing in soft tissues and the meninges has been gradually recognized to be an aggressive, highly metastatic tumor. We herein report the case of a 65-year-old male with pancreatic metastases of cerebellar HPC that developed following two resections of intracranial local recurrent foci, 24 years after the initial craniotomy and 7 years after resection of metastases to the lungs and kidneys. Follow-up abdominal computed tomography scanning and magnetic resonance imaging revealed a solitary tumor in the pancreatic body. Since no other recurrent foci were detectable, distal pancreatectomy was performed. Another metastasis was incidentally found in the resected pancreas. Both foci were pathologically proven to be metastases of HPC. Among the 12 reported cases of pancreatic metastases of HPC, including ours, this case showed the longest duration between initial onset and the development of pancreatic metastases, suggesting that providing long-term follow-up is necessary for HPC patients.

Detection of intrahepatic veno-venous shunts by three-dimensional venography using multidetector-row computed tomography during angiography.

PURPOSE: The hepatic vein (HV) can be removed during hepatectomy if there is an effective intrahepatic veno-venous shunt (vv-shunt). We evaluated the efficacy of vv-shunt detection by three-dimensional (3D) venography reconstructed from multidetector-row computed tomography (MDCT) during angiography. METHODS: 3D venography was reconstructed using computer software in 88 patients with intrahepatic tumors. RESULTS: We found that 12 patients had one shunt [4 right hepatic vein (RHV)-middle hepatic vein (MHV) and 12 RHV- inferior right hepatic vein (IRHV)] and 1 patient had 2 shunts (RHV-MHV and -IRHV), confirming a clinically efficient vv-shunt in 14.8% of the patients. In one patient with an RHV-IRHV shunt, the preserved RHV-IRHV shunt worked well and prevented congestion of the postero-caudal subsegment after central bisegmentectomy with partial resection of the RHV ventral trunk for huge hepatocellular carcinoma (HCC). CONCLUSIONS: Although the vv-shunt detection rate by 3D venography is low, a visualized vv-shunt proved to be efficient. Thus, invasive occlusion venography is avoidable if a vv-shunt is seen on 3D venography.

Lysophosphatidylcholine acyltransferase 1 altered phospholipid composition and regulated hepatoma progression.

BACKGROUND & AIMS: Several lipid synthesis pathways play important roles in the development and progression of hepatocellular carcinoma (HCC), although the precise molecular mechanisms remain to be elucidated. Here, we show the relationship between HCC progression and alteration of phospholipid composition regulated by lysophosphatidylcholine acyltransferase (LPCAT). METHODS: Molecular lipidomic screening was performed by imaging mass spectrometry (IMS) in 37 resected HCC specimens. RT-PCR and Western blotting were carried out to examine the mRNA and protein levels of LPCATs, which catalyze the conversion of lysophosphatidylcholine (LPC) into phosphatidylcholine (PC) and have substrate specificity for some kinds of fatty acids. We examined the effect of LPCAT1 overexpression or knockdown on cell proliferation, migration, and invasion in HCC cell lines. RESULTS: IMS revealed the increase of PC species with palmitoleic acid or oleic acid at the sn-2-position and the reduction of LPC with palmitic acid at the sn-1-position in HCC tissues. mRNA and protein of LPCAT1, responsible for LPC to PC conversion, were more abundant in HCCs than in the surrounding parenchyma. In cell line experiments, LPCAT1 overexpression enriched PCs observed in IMS and promoted cell proliferation, migration, and invasion. LPCAT1 knockdown did viceversa. CONCLUSIONS: Enrichment or depletion of some specific PCs, was found in HCC by IMS. Alteration of phospholipid composition in HCC would affect tumor character. LPCAT1 modulates phospholipid composition to create favorable conditions to HCC cells. LPCAT1 is a potent target molecule to inhibit HCC progression.

Detection of hepatocellular carcinomas with near-infrared fluorescence imaging using indocyanine green: its usefulness and limitation.

BACKGROUND: Indocyanine green (ICG), an agent for measuring liver function, becomes fluorescent under near-infrared (NIR) light after binding to serum proteins. Hepatocellular carcinoma (HCC) with a deposit of preoperatively administered ICG becomes clearly detectable under ICG fluorography; however, it remains unclear whether this detection method is always reliable. This case series study was designed to clarify the reliability of this method. METHODS: ICG (0.5 mg/kg) was injected from the 3rd to 28th preoperative day to evaluate hepatic function in 58 patients with HCCs. Preoperative imaging modalities identified 76 HCC foci. The operative fields and resected specimens were observed with an NIR camera system. Preoperatively detected lesions and lesions newly detected by the ICG fluorography were histologically investigated. RESULTS: ICG fluorography identified 73 of 76 preoperatively diagnosed HCC lesions. Intraoperative ICG fluorography visualized 47 lesions in 40 patients. The other 26 lesions showing emission were found in the sectioned specimens under NIR observation. Other than preoperatively diagnosed foci, ICG fluorography visualized 35 new lesions, including 6 HCCs, 2 dysplastic nodules and 27 non-neoplastic lesions, such as bile plugs and cysts. The sensitivity of ICG fluorography for HCCs was 96% and its positive predictive value was 71.5%. CONCLUSIONS: Indocyanine green fluorography is useful to detect HCCs; however, attention should be paid to the fact that HCCs may be occasionally overlooked by this imaging method and that lesions detected by this method are not always neoplastic lesions.

Anomalous arterial ramification in the right liver.

PURPOSE: The aim of this study was to investigate whether individual arterial and portal venous division during hepatectomy is always safe by examining the presence of the anomalous arterial ramification in the right liver. METHODS: The ramifications of the right hepatic artery (RHA) were investigated by three-dimensional (3D) reconstruction imaging using a computer software program in 87 patients undergoing computed tomography during angiography as a preoperative assessment of intrahepatic tumors. RESULTS: The anterior view showed that the RHA bifurcated into the anterior and posterior sector arteries at the hilum in 76 patients. Sector-intersecting arteries from the posterior to the anterior sector and vice versa were found in 7 and 4 of those patients, respectively. The RHA in the other 11 patients was divided in a complex manner into more than 2 arteries: e.g., the first branch to the cranial part of the posterior sector, the second to the anterior sector, and the third to the caudal part of the posterior sector. A total of 22 patients showed anomalous ramification of RHA. CONCLUSION: Preoperative observation of the hepatic artery by 3D imaging is very useful to detect anomalous ramification. Arterial dissection during the intrafascial approach should be cautiously performed based on the 3D images.

[Impact on opioid precipitation of opioid-starting titration path].

To investigate the effect clinical path of cancer pain treatments for opioid naive patients has on physician practice, a prepost quasi-experimental study was performed. The primary outcome measure was the percentage of patients who received 'recommended pain treatments' during the study periods. We determined the treatment to be the treatment of choice, if the physician 1) ordered a rescue dose, 2) prescribed a laxative, and 3) prescribed antiemetics when starting opioids. The secondary outcome measure was the number of newly consulted patients for our palliative care team. The end-points were measured before and after disseminating the clinical path. The rate of patients receiving recommended pain treatments significantly increased after disseminating the clinical path(p=0.03): 17%(33/18)to 61%(19/31). Patients who received a rescue order, laxative, or antiemetic when starting opioids were: 44% vs. 68%, 77% vs. 90%, and 66% vs. 77%, respectively. The number of patients newly consulting the palliative care team was increased(21 cases to 42 cases/4 month). In conclusion, the clinical path of cancer pain treatments is useful for improving the physician's practice when starting opioids for cancer pain, and might contribute to enhancing palliative care team availability.

Peripancreatic arterial anatomy analyzed by 3-dimensional multidetector-row computed tomography.

BACKGROUND/AIMS: Since the anatomy of the peripancreatic vessel system is complex, it is important to preoperatively clarify the running aspects of such vessels, especially when pancreatoduodenectomy is performed. METHODOLOGY: In 166 patients undergoing multidetector-row computed tomography, peripancreatic vessels were three-dimensionally reconstructed using computer software. RESULTS: The dorsal pancreatic artery branched from the splenic artery (45.4%), common hepatic artery (24.8%), superior mesenteric artery (SMA, 15.6%), celiac axis (9.9%) and other arteries such as the middle colic artery (4.3%). Branching of the inferior pancreatoduodenal artery (IPDA) was categorized into two types: a single main IPDA branching from one artery, such as the first jejunal artery (J1a, 55.2%) and SMA (25.1%) and two IPDAs branching from one artery (J1a, 7.0% or SMA, 2.8%) or separately from two arteries (3.5%). Most IPDAs (129 of identified 168 IPDAs) ran behind the SMA at the right edge of the SMA. In 52 patients, superior mesenteric vein tributaries ran above the SMA and mask the IPDA's ramification. CONCLUSIONS: Peripancreatic vessel anatomy is very complex. The preoperative 3D arteriography and portography enables us to obtain precise information about peripancreatic vessels.