Prevention of ventriculoperitoneal shunt complications after intraperitoneal urological surgeries.

PURPOSE: To evaluate perioperative management for the prevention of postoperative shunt infection and malfunction after intraperitoneal urological surgery in patients with myelodysplasia and a ventriculoperitoneal shunt. METHODS: From 2005 to 2015, 20 consecutive patients with myelodysplasia and a ventriculoperitoneal shunt who underwent intraperitoneal urological surgeries were managed with the same perioperative regimen. Intraperitoneal surgeries involved opening gastrointestinal tracts, including bladder augmentation by enterocystoplasty, creating continent catheterizable channels and Malone antegrade continent enema. We compared results with those from seven previous reports regarding postoperative shunt complications, surgical histories of previous shunt revisions, management of bacteriuria before surgery preoperative bowel preparation, antibiotic regimens, and duration of indwelling drain. RESULTS: Of 20 patients, 18 received prior shunt revisions, and 14 had positive urine culture before surgery that was managed with oral antibiotics. Thirteen patients underwent bladder augmentation with ileum, and one underwent augmentation with sigmoid colon. Nineteen patients underwent Malone antegrade continent enema using the appendix. All parenteral antibiotics were stopped on postoperative day 2.5. Mean duration of indwelling peritoneal drain was 2.7days. Mean follow-up period was 59.8months. Neither postoperative shunt infections nor intraperitoneal shunt malfunctions were recognized during follow-up period. CONCLUSIONS: This is the first study to evaluate postoperative ventriculoperitoneal shunt complications in patients with myelodysplasia who underwent intraperitoneal urological surgeries with a specific perioperative regimen. Shunt complications are greatly reduced by rigorous perioperative management, including preoperative control of bacteriuria, appropriate administration of prophylactic antibiotics, and early removal of intraperitoneal drains. LEVELS OF EVIDENCE: The type of study: Case series with no comparison group, IV.

Novel nonsecosteroidal vitamin D3 carboxylic acid analogs for osteoporosis, and SAR analysis.

Novel vitamin D(3) analogs with carboxylic acid were explored, focusing on a nonsecosteroidal analog, LG190178, with a bisphenyl skeleton. From X-ray analysis of these analogs with vitamin D receptor (VDR), the carboxyl groups had very unique hydrogen bonding interactions in VDR and mimicked 1α-hydroxy group and/or 3ß-hydroxy group of 1α,25-dihydroxyvitamin D(3). A highly potent analog, 6a, with good in vitro activity and pharmacokinetic profiles was identified from an SAR study. Compound 6a showed significant prevention of bone loss in a rat osteoporosis model by oral administration.

Influence of lipid emulsion for the hematocrit value measured with continuous hematocrit monitor.

Continuous monitoring of hematocrit with a CRIT-LINE monitor (CLM) is used to prevent excess ultrafiltration during hemodialysis and continuous renal replacement therapy. The presence of substances affecting the scattering and absorption rates of multiple wavelengths of near infrared rays of CLM in the blood may affect the measured values with CLM. We examined the influences of lipid emulsion (LE) on hematocrit and relative blood volume (RBV) which were measured with CLM using an in vitro experimental model with human blood. Additions of 10% or 20% of LE increased the hematocrit measured by LCM and decreased the percent change of RBV in proportion to the dose. One percentage of 20% LE in the plasma increased the expected hematocrit measured with CLM by 2.9%. The decrease of initial hematocrit from 48.1% to 43.4% decreased the expected percent change of RBV from -3.4% to -3.7% with the addition of 1 ml of 20% LE to 100 ml blood. These findings indicate that additions of LE increase hematocrit that is measured with CLM in proportion to the dose of LE. Low levels of initial hematocrit will increase the degree of expected percent change of RBV. Attention should be paid to the influence of LE during monitoring with CLM.

Historical changes of hospitalization in patients with hepatocellular carcinoma considering for clinical path preparation.

We examined the hospitalization time in 346 patients with hepatocellular carcinoma who were treated between January 1991 and March 2002 (486 admissions). A newly introduced IVR CT system and an advanced catheter shortened the mean time from 65.0 (1991) to 35.6 (2001) days in patients who underwent transcatheter arterial embolization (TAE). For patients having TAE combined with percutaneous ethanol infusion (PEI), the mean time was shortened from 156.5 to 48.7 days. In those who underwent PEI, the values were 56.0 and 36.8 days, respectively. In those who underwent radio frequency ablation (RFA), the mean time in 2001 was 25.3 days. Overall, the mean time was shortened from 60.5 to 38.0 days. In particular, the mean time (41.0 days) after 1999, when the IVR CT system and RFA were introduced, was significantly shorter than that before their introduction (58.9 days). Advances in instruments and procedures for TAE have greatly shortened the hospitalization period. In patients who underwent PEI, the rate of decrease in the mean time was small and it is difficult decrease their length of hospital stay; therefore, RFA may be frequently employed in the future.

BCAA-enriched snack improves nutritional state of cirrhosis.

OBJECTIVE: A late evening snack improves the catabolic state in patients with advanced liver cirrhosis. We tested whether long-term (3 mo) late evening snacking that included a branched-chain amino acid (BCAA)-enriched nutrient mixture produces a better nutritional state and better quality of life than ordinary food in patients with hepatitis C virus-positive liver cirrhosis. METHODS: In a multicenter, randomized study, 48 patients with liver cirrhosis received late-evening supplementation with the BCAA-enriched nutrient mixture or ordinary food, such as a rice ball or bread, for 3 mo. During the study period, each patient was instructed on energy and protein intake. Blood biochemical data, nitrogen balance, respiratory quotient, and health-related quality of life (Short Form 36 questionnaire) were evaluated at baseline and at the end of the study. RESULTS: Total and late-evening energy intakes were similar in the two groups at 3 mo. Serum albumin level, nitrogen balance, and respiratory quotient were significantly improved by the BCAA mixture but not by ordinary food. The parameters of the Short Form 36 did not statistically significantly improve over 3 mo in either group. CONCLUSION: Long-term oral supplementation with a BCAA mixture is better than ordinary food in a late evening snack at improving the serum albumin level and the energy metabolism in patients with cirrhosis.

Oral delivery of diclofenac sodium using a novel solid-in-oil suspension.

The present work reports on a new pharmaceutical formulation for oral delivery of diclofenac sodium (DFNa), a non-steroidal anti-inflammatory drug (NSAID). Although DFNa itself is water-soluble at neutral pH, it was readily suspended in soybean oil via complex formation with an edible lipophilic surfactant and a matrix protein. The resulting solid-in-oil (S/O) suspension containing stably encapsulated DFNa in an oil phase markedly reduced the risks for gastrointestinal ulcers upon oral administration even at the LD(50) level in rats (ca. 50 mg/kg DFNa). In addition, plasma concentration of DFNa upon administration of an S/O suspension was comparable with that of the aqueous counterpart at the same DFNa dose. These results indicate the potential use of S/O suspensions as novel oil-based pharmaceutical formulations for oral delivery of water-soluble drugs without causing severe mucitis.

Supplementation of L-arginine improves hypertension and lipid metabolism but not insulin resistance in diabetic rats.

Nitric oxide (NO) plays an important role in glucose and lipid metabolism. We previously reported that NO synthesis inhibitors, such as NG-nitro-L-arginine methyl ester (L-NAME), deteriorate insulin sensitivity and lipid metabolism, while the addition of L-arginine reverses this deterioration. L-arginine is a precursor of NO, and is used as a supplement in the US. In the present study, we evaluated whether the administration of L-arginine alone improves insulin resistance and serum lipid levels in insulin-resistant and hypertriglycemic rat models. Diabetic rats were divided into 3 groups: the control (Cont) group (standard diet), the L-NAME group (diet containing L-NAME), and the Arg group (diet containing L-arginine). After 4 weeks of breeding, urinary NOx, glucose infusion rate (GIR), glucose and lipid tolerance tests were performed. Urinary NOx levels were significantly lower in the L-NAME group than in the Cont group. The GIR in the L-NAME group was significantly lower than that in the Cont group, suggesting increased insulin resistance. However, the administration of L-arginine did not influence insulin resistance in the Arg group. Oral lipid administration significantly increased plasma triglyceride levels in the L-NAME group and plasma triglyceride levels were significantly lower in the Arg group than in the Cont group. The area under the curve of plasma triglyceride levels after oral lipid administration was larger in the L-NAME group than in the Cont group. The administration of L-NAME increased insulin resistance and decreased lipid metabolism. L-arginine significantly increased urinary NO secretion but did not improve insulin resistance, although it did improve lipid metabolism. These findings suggest that supplementation of L-arginine cannot improve insulin resistance in diabetic rats probably due to increased insulin secretion by L-arginine.

Severe catabolic state after prolonged fasting in cirrhotic patients: effect of oral branched-chain amino-acid-enriched nutrient mixture.

BACKGROUND: Cirrhotic patients frequently undergo various medical procedures, such as diagnostic gastrointestinal endoscopy, without taking breakfast. The aim of the present study was to clarify the effect of longer fasting (> 12 h) on energy metabolism, and to test whether supplementation of an oral branched-chain amino-acid-enriched nutrient mixture (BCAA mixture), which contains various nutrients in addition to BCAA, could improve the catabolic state. METHODS: Metabolic measurement was performed in 30 cirrhotic patients and 13 normal subjects, using indirect calorimetry. RESULTS: Compared with that in the normal subjects, the respiratory quotient (RQ) was significantly lower after an overnight fast in the cirrhotic patients, indicating accelerated fat oxidation and a catabolic state. In addition, RQ in cirrhotic patients (n = 7) decreased rapidly with longer fasting, whereas that in the normal subjects (n = 5) showed relatively stable values. These results indicate that special care should be taken with medical procedures that are carried out in patients who have fasted. The effect of oral glucose, a carbohydrate-rich snack (rice ball), and the BCAA mixture (each, 210 kcal) on RQ was studied in 6 normal subjects and 6 patients with liver cirrhosis after an overnight fast. Supplementation of the carbohydrate-rich snack and the BCAA mixture (210 kcal each) elevated RQ and blood glucose levels to a similar degree in the cirrhotic patients. Oral administration of glucose (210 kcal) led to significantly greater elevation of blood glucose levels than the other snacks, which may be unfavorable for cirrhotic patients, who frequently have glucose intolerance. In the 30 cirrhotic patients, supplementation with the BCAA mixture in the late evening significantly improved RQ in the early morning. CONCLUSIONS: Carbohydrate-rich meals are used as a late evening snack in cirrhotic patients, but our study indicates that supplementation with a BCAA mixture can also be used to reduce fat oxidation in the early morning, with results similar to those with carbohydrate-rich snacks.