Predicting the Readmission and Mortality in Older Patients Hospitalized with Pneumonia with Preadmission Frailty.

BACKGROUND: In older people, frailty has been recognized as an important prognostic factor. However, only a few studies have focused on multidimensional frailty as a predictor of mortality and readmission among inpatients with pneumonia. OBJECTIVE: The present study aimed to assess the association between preadmission frailty and clinical outcomes after the hospitalization of older patients with pneumonia. DESIGN: Single-center, retrospective case-control study. SETTING: Acute phase hospital at Kobe, Japan. PARTICIPANTS: The present study included 654 consecutive older inpatients with pneumonia. MEASUREMENTS: Frailty status before admission was assessed using total Kihon Checklist (KCL) score, which has been used as a self-administered questionnaire to assess comprehensive frailty, including physical, social, and cognitive status. The primary outcome was a composited 6-month mortality and readmission after discharge. RESULTS: In total, 330 patients were analyzed (median age: 79 years, male: 70.4%, median total KCL score: 10 points), of which 68 were readmitted and 10 died within 6 months. After multivariate analysis, total KCL score was associated with a composited 6-month mortality and readmission (adjusted hazard ratio, 1.07; 95% confidence interval, 1.02-1.12; p = 0.006). The cutoff value for total KCL score determined by receiver operating characteristic curve analysis was 15 points (area under the curve = 0.610). The group with a total KCL score ≥ 15 points had significantly higher readmission or mortality rates than the groups with a total KCL score < 15 points (p < 0.001). CONCLUSIONS: Preadmission frailty status in older patients with pneumonia was an independent risk factor for readmission and survival after hospitalization.

Possible observation of the quadrupolar Kondo effect in dilute quadrupolar system Pr(x)La(1-x)Pb3 for x

We have studied non-Fermi-liquid (NFL) behavior in Pr(x)La(1-x)Pb3 with Gamma3 quadrupolar moments in the crystalline-electric-field ground state. The specific heat C/T shows NFL behavior in the very dilute region for x

Inhibition by combined therapy with ticlopidine and aspirin of enhanced platelet aggregation during physical exercise in patients with coronary artery disease.

BACKGROUND: Strenuous exercise can be a major trigger for coronary thrombosis and it enhances platelet aggregation. METHODS: We evaluated the effect of antiplatelet therapy on shear stress-induced platelet aggregation (SIPA), in addition to agonist-induced aggregation, before and immediately after ergometer exercise in patients with stable coronary artery diseases (CAD). Forty-eight patients with stable CAD were randomly distributed into 3 groups: no antiplatelet drug (patient control, n = 16), aspirin (ASA) monotherapy (n = 16), and combined therapy with ticlopidine (TIC) and ASA (n = 16). RESULTS: There were significant increases in not only adenosine phosphate (ADP)- and collagen-induced platelet aggregation but also in SIPA during exercise by the patient control group. ASA monotherapy did not attenuate the enhanced ADP-induced aggregation nor SIPA. Combined ASA + TIC therapy significantly inhibited SIPA as well as ADP-induced aggregation both before and after exercise. Significant increases in levels of plasma von Willebrand factor (vWF) occurred during exercise, and these antiplatelet therapies had no apparent effect on increased vWF levels during exercise. Exercise induced a significant increase in the plasma thrombin-antithrombin III complex level with no significant changes in the level of plasmin-plasmin inhibitor complex level in all 3 groups. CONCLUSIONS: Combined therapy with ASA + TIC effectively inhibited increased platelet aggregability in response to acute exercise, with no effects on coagulant or fibrinolytic potentials in patients with CAD. The data suggest that TIC combined with ASA may be superior to ASA alone in preventing acute coronary events during exercise in patients with coronary atherosclerotic disease.

Pneumoperitoneum following the spontaneous rupture of a gas-containing pyogenic liver abscess: report of a case.

We report herein the case of a ruptured liver abscess that resulted in pneumoperitoneum. A patient with diabetes mellitus presented with symptoms of acute abdomen. The plain abdominal radiograph and computed tomography findings revealed abdominal free air and a gas-containing liver abscess, whereby a diagnosis of a ruptured liver abscess was made. An emergency operation was performed, and the abscess was drained followed by peritoneal lavage and the administration of appropriate antibiotics. To the best of our knowledge, very few cases of spontaneous pneumoperitoneum occurring secondary to the rupture of a gas-containing liver abscess have been encountered in Japan.

Increased platelet aggregability in response to shear stress in acute myocardial infarction and its inhibition by combined therapy with aspirin and cilostazol after coronary intervention.

Although antiplatelet therapy with a specific inhibitor of phosphodiesterase-3 cilostazol improves stent patency compared with use of aspirin (ASA) alone, the specific role of cilostazol on platelet aggregation in patients with acute myocardial infarction (AMI) is less well understood. Thirty-six patients with AMI who were successfully treated with primary angioplasty were randomized to 3 antiplatelet regimens: ASA alone (n = 12), ASA + ticlopidine (n = 12), and ASA + cilostazol (n = 12). We measured shear stress-induced platelet aggregation (SIPA) using a modified cone-plate viscometer on admission and on day 7, and evaluated the inhibitory effects of combination therapy with ASA + cilostazol on SIPA. Compared with cases of stable coronary artery disease, significant increases in SIPA and plasma von Willebrand factor activity were observed in patients with AMI before they received antiplatelet therapy. On day 7 after primary angioplasty, ASA did not inhibit SIPA (65 +/- 15% vs 57 +/- 11%, p = 0.086), whereas both combination therapies of ASA + ticlopidine and ASA + cilostazol significantly inhibited SIPA in patients with AMI (ASA + ticlopidine: 61 +/- 15% vs 45 +/- 13%, p <0. 0001; ASA + cilostazol: 64 +/- 14% vs 43 +/- 9%, p <0.005). There was a significant correlation of SIPA with adenosine diphosphate (ADP)-induced platelet aggregation (r = 0.412, p = 0.003) and with plasma von Willebrand factor activity (r = 0.461, p = 0.0008). These data suggest that patients with AMI have increased platelet aggregability in response to high shear stress. Combined antiplatelet therapy with ASA + cilostazol appears to be as effective as therapy with ASA + ticlopidine for reducing SIPA in patients with AMI who are undergoing primary angioplasty.

Application of near-infrared time-resolved spectroscopy to rat liver--a preliminary report for surgical application.

The applicability of near-infrared time-resolved spectroscopy to rat liver surgery was investigated. First, the technical reliability in determining the absorption coefficient (mu(a)) and reduced scattering coefficient (mu'(s)) of the liver was checked. Next, boundary effects in determining mu(a) and mu'(s) of the rat liver were examined. Finally, changes in mu(a) and mu'(s) of rat liver with ischaemia were directly measured by TRS. Our TRS system showed that the mu(a) value held a linear correlation with the ink concentration in a lipid emulsion until mu(a) reached 1.2 cm(-1), while the mu'(s) was fairly independent. The mu(a) values of blood-free rat liver and blood-containing rat liver at 780 nm were observed to be 0.43 cm(-1) and 0.67 cm(-1) by using the matching method, indicating that TRS is reliable in determining mu(a) and mu'(s) of the liver. Possible errors in mu(a) and mu'(s) determination due to the boundary effects of the rat liver were as small as 7%, when the mu(a) value was as high as observed for the liver. The oxygen saturation of haemoglobin (SO2) was changed from 64.9% to 8.0%, and the haemoglobin content (THB) from 189.1 microM to 131.6 microM by ischaemia. Mu'(s) dynamically changed in the range 7.06 cm(-1) to 11.36 cm(-1). We conclude that time-resolved measurement is applicable in the high-mu(a) region observed in the liver, and can give quantitative estimations of SO2 and THB in the liver.

Optical analysis of cirrhotic liver by near infrared time-resolved spectroscopy.

The severity of liver cirrhosis was related with the optical properties of liver tissue. Various grades of liver cirrhosis were produced in rats by intraperitoneal injection of thioacetamide (TAA) for different periods: 4 weeks, 8 weeks, 12 weeks, and 16 weeks. Optical properties of the liver, absorption coefficient (µa) and scattering coefficient (µs'), were measured by near-infrared time-resolved spectroscopy. Histological examination confirmed cirrhotic changes in the liver, which were more severe in rats with TAA administration for longer periods. The µa increased in 4- and 8-week rats, and then decreased in 12- and 16-week rats. The µa of blood-free liver decreased as liver cirrhosis progressed. The hemoglobin content in the liver calculated from the µa values increased in 4- and 8-week rats and decreased in 12- and 16-week rats. The µs' decreased in the cirrhotic liver, probably reflecting the decrease in the mitochondria content. It was shown that µa and µs' determination is useful to assess the severity of liver cirrhosis. © 1999 Society of Photo-Optical Instrumentation Engineers.

The beneficial effect of phosphocreatine accumulation in the creatine kinase transgenic mouse liver in endotoxin-induced hepatic cell death.

Purpose. The purpose of this study was to investigate the relationship between hepatic energy status and liver injury during sepsis, using transgenic mice which express creatine kinase in the liver catalyzing the phosphocreatine/creatine system. Methods. Creatine kinase transgenic mice were fed with normal rodent chow or chow containing 10% creatine for 5 days. Lipopolysaccharide (0.2 mg/kg) combined with d-galactosamine (600 mg/kg) was administered intraperitoneally. Results. Eighty percent of the creatine-fed transgenic mice had survived at 48 h post-d-galactosamine and lipopolysaccharide administration, compared with none of the normally fed transgenic mice. Hepatic phosphocreatine and ATP levels in the normally fed transgenic mice were significantly lower than those in the creatine-fed transgenic mice before and after lipopolysaccharide combined with d-galactosamine was administered. Massive hepatic hemorrhagic necrosis with apoptosis was seen in response to d-galactosamine and lipopolysaccharide in normally fed transgenic mice. These results are consistent with a significant increase in serum aminotransferase at 8 h. In contrast, there were faint necrotic changes in the liver with minimal cellular infiltration in creatine-fed transgenic mice. Conclusions. Maintenance of hepatic ATP levels protects from sepsis-induced liver injury and mortality.

Three patients with bilateral breast tumors examined by technetium-99m-sestamibi scintimammography.

We presented three patients with bilateral breast tumors (one with breast cancers, one with breast cancer and fibroadenoma, and one with fibroadenomas) examined by 99mTc-hexakis 2-methoxy-isobutylisonitrile (MIBI) scintimammography. In all cases 99mTc-MIBI uptake was recognized only in the breast cancers. 99mTc-MIBI scintimammography was useful in evaluating bilateral breast tumors since preoperative diagnosis is valuable in determining correct surgical treatment.

Hepatic preservation with histidine-tryptophan-ketoglutarate solution in living-related and cadaveric liver transplantation.

1. Living-related liver transplantation has some advantages in the evaluation of novel clinical protocols, since many complicated factors affecting initial graft function are almost uniform in grafts obtained from healthy donors. 2. To compare histidine-tryptophan-ketoglutarate (HTK) and University of Wisconsin (UW) solution in terms of tissue oxygenation in living-related liver transplantation, oxygen saturation of haemoglobin (SO2) in hepatic tissue and its heterogeneity (CV, coefficient of variation) were measured by near-infrared spectroscopy. The HTK and UW groups consisted of 15 and 49 successful transplants respectively, in which no statistical differences in background were observed. 3. In the HTK group, hepatic SO2 after portal vein reflow was higher (P < 0.01) than that in the UW group, as was that after hepatic artery reflow (P < 0.05). In the UW group, hepatic SO2 remained at the lower level at the end of the operation. 4. Furthermore, the increase in CV after portal vein reflow was normalized after hepatic artery reflow in the HTK group. However, the CV remained at a high level at the end of the operation in the UW group. 5. Postoperative peak aspartate aminotransferase level in the HTK group was lower than that in the UW group (P < 0.05). 6. In cadaveric liver transplantation, higher hepatic SO2 and lower CV of hepatic SO2 in the early phase after reperfusion compared with the UW group (n = 18) were also observed in the HTK group (n = 30) (P < 0.05). 7. In conclusion, recovery of tissue oxygenation and its heterogeneity after reperfusion in HTK-preserved livers were more rapid and homogeneous than in UW-preserved livers in living-related liver transplantation. Accordingly, HTK solution may be a potential alternative to UW solution.

Technetium-99m-sestamibi scintimammography of benign and malignant phyllodes tumors.

We presented two cases of phyllodes tumor of the breast examined by 99mTc-sestamibi (MIBI) two-phase scintimammography. In the case with malignant phyllodes tumor, 99mTc-MIBI accumulation was recognized on both early and delayed images. In the case with benign phyllodes tumor, however, 99mTc-MIBI accumulation was recognized on only the early image. 99mTc-MIBI delayed imaging may have the potential to distinguish between benign and malignant phyllodes tumors.

Giant malignant phyllodes tumor with(99m)Tc-Ses-tamibi accumulation: Report of a case.

We report a case of a giant malignant phyllodes tumor examined by(99m)Tc-ses-tamibi (MIBI) mammoscintigraphy. The patient was a 51 year-old woman who complained of bleeding from a large mass in her right breast. The tumor was well circumscribed, with an ulcerized surface. The accumulation of(99m)Tc-MIBI in the tumor was recognized on(99m)Tc-MIBI scintigraphy. A standard radical mastectomy was performed with a wide margin of skin. The resected specimen measured 20 X 17 X 13 cm, weighed 2100 g and was histologically diagnosed as a malignant phyllodes tumor. The skin defect was reconstructed by a rectus abdominis musculocutaneous flap, with good cosmetic results.(99m)Tc-MIBI scintigraphy may have the potential to distinguish a malignant from benign phyllodes tumors.

Giant Malignant Phyllodes Tumor with &sup99m;Tc-Sestamibi Accumulation: Report of a Case.

We report a case of a giant malignant phyllodes trmor examinde by &sup99m; Tc-sestamibi (MIBI) mammoscintigraphy. The patient was a 51 yera-old woman who complainedof bleeding from a large mass in her right breast. The tumor was well circumscribed, with an ulcerized surface. The accumulation of &sup99m; Tc-MIBI in the tumor was recognized on &sup99m; Tc-MIBI scintigraphy. A standard radical mastectomy was performed with a wide margin of skin. The resected specimen measured 20x17x13cm, weighed 2100g and was histologically diagnosed as a malignant phyllodes tumor. The skin defect was reconstructed by a rectus abdominis musculocutaneous flap, with good cosmetic results. &sup99m; Tc-MIBI scintigraphy may have the potential to distinguish a malignant from benign phyllodes tumors.

Oxygenation and blood volume changes in flaps according to near-infrared spectrophotometry.

OBJECTIVE: To test the ability of near-infrared spectrophotometry (NIRS) to predict vascular compromise in flaps postoperatively. DESIGN: Pilot study. SUBJECTS: Eleven denervated latissimus dorsi flaps were assessed in 8 pigs. INTERVENTIONS: Flaps were isolated on their vascular pedicle. We used NIRS to demonstrate tissue oxygen saturation and quantities of deoxygenated hemoglobin and oxygenated hemoglobin when flaps underwent venous or arterial occlusions. Oxygen saturation (percentage of oxygenated hemoglobin) was calculated as the difference between the 2 light intensities (860-750 nm) with the use of 2 time periods: preoperative (80%) oxygen saturation and during arterial occlusion (0%) oxygen saturation with NIRS. Blood volume changes within the flap were also measured. RESULTS: Arterial occlusion resulted in significant decreases in oxygen saturation and in blood volume with immediate recovery. Venous occlusion resulted in an initial rapid increase in blood volume with no appreciable early deoxygenation. CONCLUSIONS: Near-infrared spectrophotometry appears promising as a noninvasive, low-cost, portable bedside monitor that can demonstrate in real time changes in blood volume and oxygen saturation within a flap at a variety of tissue depths.

Postoperative monitoring of the oxygenation state of the graft liver in cases with hepatopulmonary syndrome.

Postoperative changes in the oxygen saturation of hemoglobin in the graft liver (graft SO2) were monitored by near-infrared spectroscopy in four cases complicated by hepatopulmonary syndrome. A plastic cylinder was placed in the abdominal wall, and optical measurements of the graft liver were obtained through this window. Our findings were as follows; (1) graft SO2 decreased after abdominal wall closure, and decreased further 1 day after surgery. (2) Graft SO2 was maintained despite severe hypoxemia, with partial pressure of oxygen in arterial blood as low as 50 mmHg. High hematocrit was beneficial for oxygenating the graft. (3) Graft livers could tolerate hypoxia with a graft SO2 as low as 20%. (4) It may be useful to monitor graft SO2 during the critical period after transplantation for the assessment of graft function.

Optical determination of fatty change of the graft liver with near-infrared time-resolved spectroscopy.

A novel method for quantifying the fatty change of the graft liver by characterizing the optical property of the tissue was introduced. A wide range of lipid content in the rat liver was obtained by using different feeding regimens, with lipotropic chow (choline/methionine deficient or low chow). The liver was removed and flushed with Krebs-Ringer buffer solution with 3% albumin, and the optical properties of the liver, i.e., absorption and reduced scattering coefficients (mu(a) and mu(s)'), were measured by time-resolved spectroscopy. The fatty liver showed lower mu(a) and higher mu(s)' than the normal liver. Lower mu(a) and lower succinate dehydrogenase activity of the fatty liver suggested that the decrease in mu(a) might indicate a decrease in the mitochondrial content. The value of mu(s)' was positively correlated with the lipid content of the liver, which indicates that fat droplets inside the hepatocyte act as dominant scatterers. To subtract the contribution of the mitochondrial compartment to mu(s)', the ratio of mu(s)' to mu(a) (mu(s)':mu(a)) was useful for the assessment of the lipid content of the liver. These findings were also relevant with prediction of light scattering by the Mie theory. It was concluded that mu(a) and mu(s)' of the graft liver, measured by time-resolved spectroscopy, can be useful parameters for quantifying the fatty change of the graft liver.

Extension of surgical indication for advanced hepatocellular carcinoma: is it possible to prolong life span or improve quality of life?

BACKGROUND/AIMS: We have tried to break through the limitations of treatment for advanced hepatocellular carcinoma (HCC), which has been regarded as a contraindication for surgical treatment. MATERIALS AND METHODS: In 640 cases of hepatic resection for Liver cancer, we analyzed 55 cases of HCC with tumor thrombi in the trunk or first branch of the portal vein (PV) which required additional PV thrombectomy, 5 cases with direct invasion or compression to the inferior vena cava (IVC) which required replacement of IVC with a polytetrafluoroethylene (PTFE) tube, 9 cases with involvement of the extrahepatic bile duct (BD) which required additional extirpation of tumor fragments in the BD, 6 cases with tumor thrombi in the IVC which required IVC thrombectomy, and 4 cases of huge main tumor with intrahepatic metastasis in the entire liver which required intraoperative ethanol injection. RESULTS: Mean survival times in these groups were 796, 717, 650, 220, and 147 days, respectively. All patients with IVC thrombi and large tumor with intrahepatic metastasis in the entire liver died of early recurrence in spite of surgical treatment. By contrast, half of the patients with PV thrombi, BD involvement and IVC invasion or compression survived approximately 500 days because of a combination of hepatic resection, additional intraoperative treatment and postoperative treatment, and some patients could enjoy a longer life. CONCLUSIONS: Multimodality treatment including hepatic resection should be encouraged for advanced HCC patients with PV thrombi, BD involvement or compression or invasion of the IVC, as long as the remnant liver can overcome postoperative liver failure.

Analysis of factors affecting the graft oxygenation state in living related liver transplantation.

BACKGROUND/AIMS: In liver transplantation, graft dysoxia after reperfusion may lead to graft failure. The aim of this study is to investigate the relationship between the factors, which were supposed to affect the oxygen supply to the graft, and the oxygenation state of the graft in order to determine which factor is important to prevent the graft from dysoxia. MATERIALS AND METHODS: The relationship between oxygen supply and oxygenation state of the graft was investigated in 56 successful cases of living related liver transplantation. Factors affecting the oxygen supply to the graft were considered as follows; portal venous flow (PVF), mean velocity of the hepatic artery (HA-Vm), hemoglobin concentration in the peripheral blood (Hb), size of the graft liver relative to the recipient body weight (G/R ratio), partial oxygen pressure in the arterial blood (PaO2), and rate-pressure product (BP*PR). Oxygenation state of the graft was estimated by oxygen saturation of hemoglobin in the graft tissue (graft SO2) as measured by tissue near infrared spectroscopy. RESULTS: 1) Graft SO2 was rather independent of PVF and HA-Vm probably due to compensatory interrelation between the portal venous flow and hepatic arterial flow. 2) Significant correlation between G/R ratio and graft SO2 was observed after portal reflow (p < 0.01), but the correlation diminished after hepatic arterial reflow. Positive correlation between G/R ratio and AKBR after portal reflow suggested that the graft with large G/R ratio is likely to suffer dysoxia early after reperfusion. 3) Graft SO2 was positively correlated with Hb (p < 0.05), while there was no significant correlation between graft SO2 and PaO2 or BP*PR. CONCLUSION: This study clarified the contribution of the factors which were supposed to affect the oxygen supply to the graft and the oxygenation state of the graft, and which factor is important to prevent the graft from dysoxia.

Induction of endotoxin tolerance in transgenic mouse liver expressing creatine kinase.

The liver plays an important role in maintaining homeostasis during endotoxin-triggered systemic inflammatory response. To study the effects of phosphocreatine on hepatic energy metabolism after endotoxin administration, we used transgenic mice whose livers express creatine kinase (CK). CK catalyzes a phosphocreatine/creatine reaction, that is, an adenosine triphosphate (ATP) reservoir system. Because dietary supplementation with creatine leads to an accumulation of creatine and phosphocreatine in transgenic livers, we compared the CK transgenic mice fed with creatine with the normally fed CK transgenic mice. In the creatine-fed mice, hepatic ATP, energy charge ([ATP + 0.5 adenosine diphosphate (ADP)]/[ATP + ADP + adenosine monophosphate (AMP)]), and mitochondrial oxidative phosphorylation activities remained at high levels after injection of 10 mg/kg of lipopolysaccharide (LPS) as compared with those in normally fed mice. Furthermore, there were beneficial effects on the functional reserve for ATP synthesis and work-cost performance, as calculated by free cytoplasmic ADP and the Michaelis constant (Km). Interestingly, a reduction of tissue necrosis factor alpha and interleukin-lalpha (IL-lalpha), and suppression of the decrease in glucose levels after LPS injection were observed in the creatine fed mice. Survival rates at 72 hours after injection of 10 mg/kg of LPS significantly increased in the creatine fed mice compared with the normally fed mice (80% vs. 24%, P < .001). Therefore, we concluded that the presence of phosphocreatine in the liver maintains energy metabolism and attenuates cytokine response, resulting in endotoxin tolerance.