Predictive factors and radiological findings of adrenohepatic adhesion during laparoscopic adrenalectomy.

Purpose: This retrospective study aimed to identify predictive factors and imaging features of adrenohepatic adhesion found during laparoscopic right adrenalectomy. Materials and Methods: Altogether, 77 patients underwent laparoscopic right adrenalectomy between January 2005 and December 2018. Adrenohepatic adhesion was defined as strict adhesion that required either partial adrenalectomy with coagulation of residual tissue or partial hepatectomy to accomplish complete resection. We assessed their surgical video records to determine if adrenohepatic adhesion was present. Age, sex, body mass index, tumor size, tumor diagnosis and radiological findings (attachment between the liver and the adrenal gland, diameters of the right and left adrenal veins and its ratio) were evaluated as preoperative variables. Results: Adrenohepatic adhesion was present in 11 of the 77 patients (14.3%). Age, sex, and body mass index were not statistically significant factors. Tumor size was significantly small in adhesion group (14.2 mm vs. 25.9 mm, p=0.02). Attachment to the liver and adrenal gland was frequently seen regardless of the adhesion. The mean right/left adrenal veins diameters ratio was significantly lower in the adhesion group (0.8 vs. 1.1, p=0.01). Multivariate logistic regression analysis demonstrated the right/left adrenal veins diameters ratio was the only significant predictor of adhesion. The sensitivity, specificity, negative predictive value and positive predictive value were 0.82, 0.76, 0.43, and 0.95 respectively when the optimal cutoff value for the ratio was 0.9 (area under the curve, 0.75; 95% confidence interval, 0.60-0.90). Conclusions: The right/left adrenal veins diameters ratio was possible predictor of adrenohepatic adhesion.

Active Participation in Outpatient Cardiac Rehabilitation Is Associated With Better Prognosis After Coronary Artery Bypass Graft Surgery　- J-REHAB CABG Study.

BACKGROUND: There is little evidence regarding the effect of outpatient cardiac rehabilitation (CR) on exercise capacity or the long-term prognosis in patients after coronary artery bypass graft surgery (CABG). This study aimed to determine whether participation in outpatient CR improves exercise capacity and long-term prognosis in post-CABG Japanese patients in a multicenter cohort.Methods and Results:We enrolled 346 post-CABG patients who underwent cardiopulmonary exercise testing during early (2-3 weeks) and late (3-6 months) time points after surgery. They formed the Active (n=240) and Non-Active (n=106) CR participation groups and were followed for 3.5 years. Primary endpoint was a major adverse cardiac event (MACE): all-cause death or rehospitalization for acute myocardial infarction/unstable angina/worsening heart failure. Peak oxygen uptake at 3-5 months from baseline was significantly more increased in Active than in Non-Active patients (+26±24% vs. +19±20%, respectively; P<0.05), and the MACE rate was significantly lower in Active than Non-Active patients (3.4% vs. 10.5%, respectively; P=0.02). Multivariate Cox proportional hazard analysis showed that participation in outpatient CR was a significant prognostic determinant of MACE (P=0.03). CONCLUSIONS: This unique study showed that a multicenter cohort of patients who underwent CABG and actively participated in outpatient CR exhibited greater improvement in exercise capacity and better survival without cardiovascular events than their counterparts who did not participate.

d-amino acid oxidase promotes cellular senescence via the production of reactive oxygen species.

d-amino acid oxidase (DAO) is a flavin adenine dinucleotide (FAD)-dependent oxidase metabolizing neutral and polar d-amino acids. Unlike l-amino acids, the amounts of d-amino acids in mammalian tissues are extremely low, and therefore, little has been investigated regarding the physiological role of DAO. We have recently identified DAO to be up-regulated in cellular senescence, a permanent cell cycle arrest induced by various stresses, such as persistent DNA damage and oxidative stress. Because DAO produces reactive oxygen species (ROS) as byproducts of substrate oxidation and the accumulation of ROS mediates the senescence induction, we explored the relationship between DAO and senescence. We found that inhibition of DAO impaired senescence induced by DNA damage, and ectopic expression of wild-type DAO, but not enzymatically inactive mutant, enhanced it in an ROS-dependent manner. Furthermore, addition of d-amino acids and riboflavin, a metabolic precursor of FAD, to the medium potentiated the senescence-promoting effect of DAO. These results indicate that DAO promotes senescence through the enzymatic ROS generation, and its activity is regulated by the availability of its substrate and coenzyme.

[A Case of Nivolumab-Induced Isolated Adrenocorticotropic Hormone Deficiency Presenting Dyspnea].

A 66-year-old man had undergone multiple treatments for metastatic renal cell carcinoma, including 11 cycles of nivolumab, which was discontinued because of disease progression. About three weeks after discontinuing nivolumab, he reported suffering from worsening of dyspnea. Pulse oximetry showed no desaturation. His cardiovascular and pulmonary functions were normal. His dyspnea slowly worsened with no underlying diagnosis. Two months after symptoms developed, he was diagnosed with isolated adrenocorticotropic hormone deficiency. His dyspnea disappeared soon after receiving hydrocortisone. Nivolumab-induced isolated adrenocorticotropic hormone deficiency may not present with typical symptoms, and can occur even after discontinuing nivolumab. Cortisol levels should be routinely monitored in patients who receive nivolumab.

Effects of Intradialytic Resistance Exercise on Protein Energy Wasting, Physical Performance and Physical Activity in Ambulatory Patients on Dialysis: A Single-Center Preliminary Study in a Japanese Dialysis Facility.

Patients under hemodialysis present protein-energy wasting (PEW), which is related with higher mortality rates. The study aimed to determine whether intradialytic resistance exercise training could improve physical performance, physical activity, and PEW in hemodialysis patients. In single center study, 75 hemodialysis patients were enrolled in an intradialytic resistance exercise training consisting of 20 min of adapted leg press, with a gymnastic ball, 3 days/week, during 9 months on the same day of hemodialysis therapy. Physical performance by short physical performance battery (SPPB), physical activity by life space assessment (LSA), and PEW score based on the nomenclature proposed by the International Society of Renal Nutrition and Metabolism in 2008 were assessed at baseline and after 9 months. Intradialytic resistance exercise training significantly improved SPPB score, LSA score, and PEW score (all, P < 0.05). In addition, intradialytic resistance exercise training improved SPPB score in patients with moderate and severe PEW subgroups (P < 0.05), associated with reduced prevalence of the patients with moderate to severe PEW (53% vs. 36%, P < 0.05). Intradialytic resistance exercise training was safe and effective to improve physical performance, physical activity, and PEW in hemodialysis patients.

[A case report of Cowper's syringocele in an adult treated with transurethral unroofing].

We present an adult case of Cowper's syringocele. A 19-year-old male presented with the chief complaint of persistent post-voiding dribbling 5 months after onset. Urethroscopy demonstrated a thin membrane with a small orifice on the ventral aspect distal to the external sphincter. Magnetic resonance imaging showed a restiform shadow on the left side of the corpus spongiosum. Retrograde urethrogram showed filling of diverticulum-like structure in the region of urethral bulb terminating in the urogenital diaphragm. Considering the results mentioned above, we diagnosed the patient with Cowper's syringocele. Transurethral unroofing of the Cowper's syringocele was performed with a cold knife, and the excessive tissue on the edge of syringocele was electroresected to avoid recurrence. His post-voiding dribbling resolved completely after the procedure and has not recurred in 13 months postoperatively. Cowper's syringocele is typically diagnosed presenting with hematuria, urinary tract infection, and disuria in male infants and children. Adult cases of Cowper's syringocele are rare, and only 32 cases including the present case have been reported. Proper awareness of this entity and careful evaluation are important if patients present with persistent adult-onset voiding dysfunction.

Oxygen uptake kinetics during and after exercise are useful markers of coronary artery disease in patients with exercise electrocardiography suggesting myocardial ischemia.

BACKGROUND: The aim of the current study was to determine if the slowed exercise oxygen uptake (VO(2)) kinetics, which is developed by myocardial ischemia, would be accompanied by delayed recovery VO(2) kinetics in patients with coronary artery disease (CAD). METHODS AND RESULTS: Thirty-seven patients with significant ST depression during treadmill exercise underwent cardiopulmonary exercise testing with cycle ergometer. Measurements performed are the ratios of change in increase in oxygen (O(2)) uptake relative to increase in work rate (DeltaVO(2)/DeltaWR) across anaerobic threshold (AT) and 1 mm ST depression point (ST-dep), the time constants of VO(2) during recovery (T(1/2) VO(2)), stress radio-isotope scintigraphy and coronary angiography. Patients were divided into CAD positive (CAD+) and CAD negative (CAD-) groups, based on coronary angiography. In CAD+, DeltaVO(2)/DeltaWR decreased above AT and ST-dep, in contrast to CAD- patients. The T(1/2) VO(2) in CAD+ (103.1 +/-13.0 s) was greater than that of CAD- (76.5 +/-8.7 s) and showed negative correlations to the ratios of DeltaVO(2)/DeltaWR across AT and ST-dep. These parameters improved in the patients who underwent coronary bypass surgery. CONCLUSIONS: Exercise and recovery VO(2) kinetics were slowed when myocardial ischemia was provoked by exercise. Measurement of exercise and recovery VO(2) kinetics improve the accuracy of the exercise electrocardiogram diagnosis of CAD.

Does the severity of central sleep apnea correlate with respiratory gas indexes during cardiopulmonary exercise testing?

Central sleep apnea (CSA) is thought to arise as a consequence of chronic heart failure. We have attempted to determine the relationship between the severity of CSA and the respiratory gas indexes during cardiopulmonary exercise testing (CPX), indexes well-known to reflect the severity of heart failure. Twenty consecutive cardiac patients (59.0 +/- 15.3 years) with CSA underwent CPX. End-tidal PCO(2)(PETCO(2)) was measured at rest and at peak exercise as a substitute for PaCO(2), along with the peak oxygen uptake (V(.)O(2)) and the ratio of the increase in ventilation to the increase in CO(2)output (V(.)E/V(.)CO(2) slope). Peak VO(2), % peak VO(2), and the VE/V(.)CO(2) slope of the subjects were 15.5 +/- 5.8 mL/min/kg, 52.8 +/- 16.7%, and 37.9 +/- 12.5, respectively, showing moderate to severely decreased exercise capacity. While PETCO(2) at both rest and peak exercise significantly correlated with peak VO(2) (r = 0.63 and r = 0.51, respectively) and the VE/V(.)CO(2) slope (r = -0.77 and r = -0.91, respectively), none of these 3 parameters correlated with the apnea-hypopnea index. The apnea-hypopnea index in the subjects with lower resting PETCO(2) was not notably different from that in the subjects with relatively high PETCO(2). Although the severity of CSA is assumed to correlate with the severity of heart failure, and a lowering of PaCO(2) during wakefulness is considered to be one of the mechanisms behind CSA, the severity of CSA does not correlate with the respiratory gas indexes of CPX or the level of PETCO(2) in cardiac patients with moderate to severely decreased exercise capacity.

[Relationship between exercise capacity and brain natriuretic peptide in patients after cardiac surgery].

OBJECTIVES: Physical training in cardiac patients can increase exercise capacity and reduce plasma brain natriuretic peptide(BNP) concentration, but these effects may depend on the etiology of cardiac disease. The change in exercise capacity and BNP during the training period were investigated in patients with different cardiac diseases. METHODS: Ninety-one patients after coronary artery bypass grafting(CABG) and 78 patients after valve replacement (VR) underwent a symptom-limited incremental cardiopulmonary exercise test before (1 month) and 6 months after physical training. Anaerobic threshold and peak oxygen uptake(peak-Vo2) were measured during the cardiopulmonary exercise test. Before each cardiopulmonary exercise test, a blood sample was obtained in the resting condition for measuring BNP. RESULTS: Anaerobic threshold and peak-Vo2 were increased significantly from 1 month to 6 months in both groups. BNP in the CABG group indicated a tendency to decrease (194.6 +/- 155.3-->144.2 +/- 232.2 pg/ml, p < 0.1) from 1 month to 6 months. BNP in VR group was significantly decreased (159. 9 +/- 115.5-->112.8 +/- 131.7 pg/ml, p < 0.05) during the training period. The CABG group showed a significant negative correlation between peak-Vo2 and BNP at 1 month(r = -0.28, p < 0.01) and at 6 months(r = -0.39, p = 0.001). The VR group showed a significant negative correlation between peak-Vo2 and BNP at 6 months(r = -0.32, p < 0.01), but not at 1 month. CONCLUSIONS: Six months of physical training in patients after cardiac surgery may improve exercise capacity and reduce BNP. BNP concentration in the VR group before physical training did not reflect functional capacity.

Short-term physical training improves vasodilatory capacity in cardiac patients.

There have been no previous studies that clearly demonstrate the effects of training on the relation between exercise capacity and vasodilatory capacity in skeletal muscle. This study was performed to clarify the effects of short-term, moderate-intensity physical training on exercise tolerance and vasodilatory capacity in cardiac patients. We studied 21 patients after acute myocardial infarction, coronary artery bypass grafting, or valve replacement. Each patient performed symptom-limited incremental exercise tests before and after a 2-week training program of moderate-intensity exercise. A cycle ergometer was used for both the training and exercise tests. Blood pressure measurement and respiratory gas analysis were continuously performed during the tests. Cardiac output was also measured using a dye-dilution method at rest and every 2 minutes during incremental exercise. Reactive hyperemic calf blood flow was measured at rest. After the training program, the subjects attained a significant decrease in systemic vessel resistance and significant increases in oxygen uptake and cardiac output at peak exercise. Changes in reactive hyperemic calf blood flow were significantly correlated with the changes in cardiac output, systemic vascular resistance, and the kinetics of oxygen uptake during warm-up exercise. By improving the peripheral vasodilatory capacity in these patients, short-term, moderate-intensity physical training was found to improve the cardiovascular adaptation not only at peak exercise, but also during the onset of exercise.