Study protocol for The GOAL Trial: comprehensive geriatric assessment for frail older people with chronic kidney disease to increase attainment of patient-identified goals-a cluster randomised controlled trial.

BACKGROUND: An increasing number of older people are living with chronic kidney disease (CKD). Many have complex healthcare needs and are at risk of deteriorating health and functional status, which can adversely affect their quality of life. Comprehensive geriatric assessment (CGA) is an effective intervention to improve survival and independence of older people, but its clinical utility and cost-effectiveness in frail older people living with CKD is unknown. METHODS: The GOAL Trial is a pragmatic, multi-centre, open-label, superiority, cluster randomised controlled trial developed by consumers, clinicians, and researchers. It has a two-arm design, CGA compared with standard care, with 1:1 allocation of a total of 16 clusters. Within each cluster, study participants ≥ 65 years of age (or ≥ 55 years if Aboriginal or Torres Strait Islander (First Nations Australians)) with CKD stage 3-5/5D who are frail, measured by a Frailty Index (FI) of > 0.25, are recruited. Participants in intervention clusters receive a CGA by a geriatrician to identify medical, social, and functional needs, optimise medication prescribing, and arrange multidisciplinary referral if required. Those in standard care clusters receive usual care. The primary outcome is attainment of self-identified goals assessed by standardised Goal Attainment Scaling (GAS) at 3 months. Secondary outcomes include GAS at 6 and 12 months, quality of life (EQ-5D-5L), frailty (Frailty Index - Short Form), transfer to residential aged care facilities, cost-effectiveness, and safety (cause-specific hospitalisations, mortality). A process evaluation will be conducted in parallel with the trial including whether the intervention was delivered as intended, any issue or local barriers to intervention delivery, and perceptions of the intervention by participants. The trial has 90% power to detect a clinically meaningful mean difference in GAS of 10 units. DISCUSSION: This trial addresses patient-prioritised outcomes. It will be conducted, disseminated and implemented by clinicians and researchers in partnership with consumers. If CGA is found to have clinical and cost-effectiveness for frail older people with CKD, the intervention framework could be embedded into routine clinical practice. The implementation of the trial's findings will be supported by presentations at conferences and forums with clinicians and consumers at specifically convened workshops, to enable rapid adoption into practice and policy for both nephrology and geriatric disciplines. It has potential to materially advance patient-centred care and improve clinical and patient-reported outcomes (including quality of life) for frail older people living with CKD. TRIAL REGISTRATION: ClinicalTrials.gov NCT04538157. Registered on 3 September 2020.

[Cardiovascular surgery with multiple myeloma].

There are few case reports of cardiovascular surgery with multiple myeloma. We report 3 cases of cardiovascular surgery with multiple myeloma. CASE 1: A 73-year-old male hemodialytic patient with multiple myeloma was performed off-pump coronary artery bypass grafting (OPCAB) for angina. He was dead on the 72th postoperative day because of sepsis. CASE 2: A 68-year-old female patient with multiple myeloma was performed mitral valve replacement for mitral regurgitation. The postoperative course was uneventful. CASE 3: A 78-year-old male patient, the aorta was replaced with a artificial graft for impending rupture of thoracoabdominal aortic aneurysm. He was diagnosed with multiple myeloma after surgery. He was dead on the 99th postoperative day because of sepsis. One of the affecting prognosis factors is infection and it is intractable.

Autoradiographic analysis of lymphopoiesis and lymphocyte migration in mice bearing multiple thymus grafts.

Lymphopoiesis was studied in 3-month-old normal C57Bl mice and in 3-month-old C57Bl mice carrying from 12 to 48 C57Bl thymus grafts using tritiated thymidine labeling. Thymus graft lymphopoiesis was found to be identical with that of normal thymus tissue and the presence of thymus grafts was found to have no influence on host thymus lymphopoiesis. No evidence was found that the massive amounts of thymus graft tissue in the mice affected any parameter of host lymph node lymphopoiesis nor was any evidence detected for the migration of thymic lymphocytes from these massive deposits of thymus graft tissue either to host lymph nodes and blood or to other organs in the host animal. It is concluded that the majority of small lymphocytes produced in the thymus and thymus graft tissue do not migrate from these tissues but die locally at the end of their intrathymic life span of 3 to 4 days.

Development of multiple organ-localized autoimmune diseases in nude mice after reconstitution of T cell function by rat fetal thymus graft.

Restoration of T cell function of athymic BALB/c nu/nu mice was investigated after transplantation of xenogeneic thymic rudiments from 15-d-old embryonic rats into kidney subcapsule. The rudiments developed well and formed a proper thymus structure composed of donor epithelia and host lymphocytes. Examination of antibody responses to SRBC revealed that approximately half the normal number of indirect PFCs were observed. Skin grafts from syngeneic BALB/c mice and thymic donor rat strains were accepted, whereas those from allogeneic mice and the rats of other than donor strains were vigorously rejected. Thymus-grafted nude mice under a conventional environment survived without any evident infectious diseases. Histological and immunofluorescence studies, however, showed a high incidence of multiple organ-localized autoimmune diseases in thyroid, salivary gland, stomach, adrenal, prostate, ovary, and testis in mice that produced the corresponding autoantibodies. These results together suggested that rat thymic grafts reconstituted T cell functions of nu/nu mice to a considerable degree, but that organ-localized autoimmune diseases developed, probably because certain auto-antigens of the recipients were recognized by the newly reconstituted host immunity.

Differentiation of immature mucous cells into parietal, argyrophil, and chief cells in stomach grafts.

Microscopic and submicroscopic studies on regenerating gastric mucosa neonatally grafted in the subcutaneous tissue of littermate mice have revealed that immature mucous cells are totipotent; ultimately they transform into mature mucous, parietal, argyrophil, and chief cells in the gastric glands.

The role of cysteinyl-LT(1)receptor (CysLT(1)R) in renal ischemia-reperfusion injury.

The pathogenesis of ischemia-reperfusion (I/R) injury is known to involve cytokines and particularly surface adhesion molecules, the expression of which initiates the attachment of inflammatory cells. Renal I/R injury, a clinically important problem, is an invariable consequence of renal transplantation. The problem begins at the onset of acute tubular necrosis (ATN), when the transplantation includes a long ischemic interval or by use of a cardiac arrest donor's kidney. The cysteinyl leukotriene-1 (CysLT(1)), a potent lipid mediator in allergic disease, acts through the CysLT(1)R receptor. We researched the expression of CysLT(1)R in rat renal I/R injury as well as correlations with the degree of ATN. The right kidney was harvested and the left renal artery and vein were clamped at laparotomy. The kidney was reperfused after 90 minutes of ischemia; rats were sacrificed at 0, 3, 5, 12, and 24 hours after reperfusion. CysLT(1)R expression was analyzed by immunohistochemistry. CysLT(1)R expression was observed only in endothelial cells of a normal kidney. CysLT(1)R expression was most intense on endothelial cells at 3 hours after reperfusion, and CysLT(1)R expression on endothelial cells gradually became weaker. Twelve hours after reperfusion, ATN extended throughout the ischemic kidney. Renal I/R injury gradually progressed at time after reperfusion. Several hours after the maximal CysLT(1)R expression, we observed the maximum renal I/R injury.

[Cardiac surgery in an octogenarian with idiopathic thrombocytopenic purpura: report of a case].

An 81-year-old woman was referred to our hospital for surgical treatment for mitral valve regurgitation, tricuspid valve regurgitation and atrial fibrillatory bradycardia. The platelet count on admission was 4.9 x 10(4)/microl. and the results of other studies were compatible with idiopathic thrombocytopenic purpura. Although we performed high-dose transvenous immunoglobulin infusion (400 mg/kg/day) for 5 consecutive days, the platelet count showed no remarkable change. Because of progression of heart failure, we underwent cardiac operation under thrombocytopenic condition. Intra and post-operative platelet transfusion might contribute to postoperative course uneventful without bleeding tendency. In this case, high-dose immunoglobulin therapy was not effective. However the operative course was satisfactory with adequate surgical hemostasis and platelet transfusion.

[Thoracoabdominal aorta replacement for penetrating atherosclerotic ulcers of suprarenal abdominal aorta].

A 58-year-old man with a complaint of a feeling of fullness and constipation was admitted to our hospital. Enhanced computed tomography (CT) images demonstrated sacral aneurysm with multiple penetrating atherosclerotic ulcer (PAU) at the abdominal aorta above the renal artery. The aneurysm was expanded for 2 weeks progressively. An urgent thracoabdominal aorta replacement was performed. Pathological findings showed that the media of aorta was destroyed and dissected, and intramural hematoma was found. The postoperative course was good. He has been from any aortic events 12 months after surgery.

Breastfeeding: a key modulator of gut microbiota characteristics in late infancy.

The objective of this study was to investigate the impact of the most commonly cited factors that may have influenced infants' gut microbiota profiles at one year of age: mode of delivery, breastfeeding duration and antibiotic exposure. Barcoded V3/V4 amplicons of bacterial 16S-rRNA gene were prepared from the stool samples of 52 healthy 1-year-old Australian children and sequenced using the Illumina MiSeq platform. Following the quality checks, the data were processed using the Quantitative Insights Into Microbial Ecology pipeline and analysed using the Calypso package for microbiome data analysis. The stool microbiota profiles of children still breastfed were significantly different from that of children weaned earlier (P<0.05), independent of the age of solid food introduction. Among children still breastfed, Veillonella spp. abundance was higher. Children no longer breastfed possessed a more 'mature' microbiota, with notable increases of Firmicutes. The microbiota profiles of the children could not be differentiated by delivery mode or antibiotic exposure. Further analysis based on children's feeding patterns found children who were breastfed alongside solid food had significantly different microbiota profiles compared to that of children who were receiving both breastmilk and formula milk alongside solid food. This study provided evidence that breastfeeding continues to influence gut microbial community even at late infancy when these children are also consuming table foods. At this age, any impacts from mode of delivery or antibiotic exposure did not appear to be discernible imprints on the microbial community profiles of these healthy children.

Study of cysteinyl leukotriene-1 receptor in rat renal ischemia-reperfusion injury.

Renal ischemia-reperfusion (I/R) injury is a major cause of renal transplant dysfunction. Recent studies of I/R injury have focused on the function of neutrophils, the mechanisms of action of inflammatory cytokines, and oxygen free radicals, as well as other mediators. However, few reports address the cysteinyl leukotriene-1 receptor (CysLT1R), an important mediator of bronchial asthma in human beings. We examined the expression of CysLT1R in rat renal I/R injury. At laparotomy, the right kidney was harvested and the left renal artery and vein were clamped. The kidney was reperfused after 90 minutes of ischemia, and the rats were killed after 0, 3, 5, 12, or 24 hours. Expression of CysLT1R analyzed at immunohistochemistry was observed only in endothelial cells in nonischemic kidney. At 0 to 3 hours after reperfusion, CysLT1R expression on endothelial cells gradually became stronger, being most intense at 3 hours after reperfusion. Twelve hours after reperfusion, necrosis extended throughout the ischemic kidney; nearly all of the tubular epithelial cells were destroyed. At 3 to 12 hours after reperfusion, CysLT1R expression gradually became weaker on endothelial cells. At 24 hours after reperfusion, CysLT1R expression was almost at the level of that in nonischemic kidney. Expression of CysLT1R was noted in a rat model of renal I/R injury. Several hours after the maximal CysLT1R expression, we observed the maximum renal I/R injury. These results may suggest a relationship between the CysLT1R and renal I/R injury.

Use of ATP bioluminescence to survey the spread of aerosol and splatter during dental treatments.

Aerosol and splatter produced during dental treatments (ultrasonic scaling and professional mechanical tooth cleaning) are potential sources of infection. Contamination patterns on the mask, goggles, chest and gowned right arm of operators, and on the goggles of patients before and after dental treatments were investigated using ATP bioluminescence analysis. Contamination on every surface tested increased significantly after dental treatment. Maximum contamination was found on the goggles of patients. Aerosol and splatter produced during dental treatments therefore have the potential to spread infection to operators and patients. ATP bioluminescence is a useful tool for monitoring surface contamination.

Mechanism of activation of the ret proto-oncogene by multiple endocrine neoplasia 2A mutations.

Transforming activity of the c-ret proto-oncogene with multiple endocrine neoplasia (MEN) 2A mutations was investigated by transfection of NIH 3T3 cells. Mutant c-ret genes driven by the simian virus 40 or cytomegalovirus promoter induced transformation with high efficiencies. The 170-kDa Ret protein present on the cell surface of transformed cells was highly phosphorylated on tyrosine and formed disulfide-linked homodimers. This result indicated that MEN 2A mutations induced ligand-independent dimerization of the c-Ret protein on the cell surface, leading to activation of its intrinsic tyrosine kinase. In addition to the MEN 2A mutations, we further introduced a mutation (lysine for asparaginic acid at codon 300 [D300K]) in a putative Ca(2+)-binding site of the cadherin-like domain. When c-ret cDNA with both MEN 2A and D300K mutations was transfected into NIH 3T3 cells, transforming activity drastically decreased. Western blot (immunoblot) analysis revealed that very little of the 170-kDa Ret protein with the D300K mutation was expressed in transfectants while expression of the 150-kDa Ret protein retained in the endoplasmic reticulum was not affected. This result also demonstrated that transport of the Ret protein to the plasma membrane is required for its transforming activity.

Treatment with edaravone improves the survival rate in renal warm ischemia-reperfusion injury using rat model.

Renal ischemia-reperfusion (I/R) injury during renal transplantation is a significant cause of renal dysfunction. The pathological role of free radicals in this process is a major concern. We investigated the effect of a free radical scavenger, edaravone (MCI-186), in renal I/R injury. Male Lewis rats (270 to 320 g) were used for the model. The right kidney was harvested and left renal artery and vein were clamped as laparotomy. The kidney was reperfused after 90 minutes of ischemia. Edaravone (10 mg/kg) was delivered intravenously before ischemia and after reperfusion to prevent the neutrophil activation. In the nontreatment I/R group, no rat survived beyond 4 days. However, in the edaravone I/R treatment group, one among five rats survived more than 7 days. These results suggested that treatment with edaravone ameliorated renal I/R injury, and that the agent has the potential to ameliorate preservation injury in renal transplantation.

Benefical effect of neutrophil elastase inhibitor on renal warm ischemia-reperfusion injury in the rat.

Renal ischemia-reperfusion (I/R) injury is a significant problem in renal transplantation. Neutrophils play an important role in renal I/R injury. Several reports have demonstrated that neutrophil elastase derived from the activated neutrophils might play an important role in this injury. We investigated the effect of a neutrophil elastase inhibitor in renal I/R injury. Male Lewis rats (270-320 g) were used in the model. The right kidney was harvested and the left renal artery and vein were clamped at laparotomy. The kidney was reperfused after 90 minutes of ischemia. Neutrophil elastase inhibitor (ONO-5046: 30 mg/kg) was delivered intravenously before ischemia and after reperfusion to prevent neutrophil activation. In the nontreatment I/R group, no hosts survived 4 days. However, after treatment with neutrophil elastase inhibitor, 3 of 10 rats in the I/R group, survived more than 7 days. These results demonstrated that treatment with neutrophil elastase inhibitor ameliorated renal I/R injury.

Risk factor analysis for ascending aorta and aortic arch repair using selective cerebral perfusion with open technique: role of open-stent graft placement.

AIM: The present study was designed to identify risk factors that may induce adverse outcome defined as permanent neurological dysfunction and mortality after aortic arch surgery using selective cerebral perfusion by logistic regression analysis and to reveal the role of open stent-graft placement. METHODS: One hundred and nineteen consecutive patients underwent ascending aorta and/or aortic arch operation with open technique between 1995 and 2005 were examined. Ascending aorta and/or hemiarch was replaced in 28 patients, total arch in 75 patients, and proximal or distal aortic arch replacement in 16 patients. Open stent-graft placement was used in 25 patients. RESULTS: The in-hospital mortality rate was 9.2%. Permanent neurological dysfunction occurred in 10 patients (8.4%). Thoracotomy (P=0.0331) and cardiopulmonary bypass time (P=0.0238) were significant risk factors for permanent neurological dysfunction. Preoperative shock (P=0.0266) was significant independent risk factor for mortality. Emergent operation (P=0.0454), thoracotomy (P=0.0232), and cardiopulmonary bypass time (P=0.0379) were significant independent risk factors for adverse outcome. The duration of selective cerebral perfusion was not associated with adverse outcome. Open stent-graft placement has no need of thoracotomy for aneurysm extending descending thoracic aorta and time variables concerning the operation were significantly shorter in the patients with open stent-graft placement than in patients with standard operation for total arch replacement. RESULTS: Thoracotomy was significant risk factor for adverse outcome after aortic arch repair using selective cerebral perfusion. Total arch replacement with open stent-graft placement can avoid the need of thoracotomy and reduce time variables concerning the operation to improve the surgical

Morphologic characteristics of thymic lymphomas induced by N-nitroso-N-propylurea in F344 rats.

Eighty-two thymic tumors induced by N-nitroso-N-propylurea in inbred F344/DuCrj rats were examined by light and electron microscopy. These tumors were diagnosed as malignant lymphomas and classified according to light microscopic features into three types: 1) lymphoblastic (57%), 2) large cell (32%), and 3) pleomorphic (11%). Electron microscopy revealed no epithelial cells in all 82 malignant lymphomas, except for 2, in which one sheet of epithelial cells was found under the capsule. This finding confirmed that all of these thymic tumors were malignant lymphomas, not thymomas. The tumors of the lymphoblastic and large cell types consisted of lymphoid cells with a few macrophages. Lymphoid cells of the lymphoblastic type were medium sized and contained a moderate amount of polyribosomes and a few clustered dense bodies; cells of the large cell type were much larger than those of the lymphoblastic type and contained many more polyribosomes and larger nucleoli. The tumors of the pleomorphic type consisted of lymphoid cells with severely infolded nuclei and interdigitating reticulum cells that were thought to be nonneoplastic in nature. No viral particle was found in these cells among the three types of thymic lymphomas.

Histochemical patterns in early lesions and infiltrating adenocarcinomas induced in mouse duodenum by n-ethyl-n'-nitro-n-nitrosoguanidine.

Intravillous, microcrater, and macroscopic invasive lesions induced in the mouse duodenum by N-ethyl-N'-nitro-N-nitrosoguanidine were examined histochemically. The cells of these neoplastic lesions and the proliferative zones of the normal crypts showed similar staining reactions in leucine aminopeptidase, alkaline and acid phosphatases, adenosine 5'-triphosphatase, and glucose-6-phosphate dehydrogenase. However, a slight decrease in succinic dehydrogenase activity and a slight increase in lactic dehydrogenase activity were observed in the intravillous and microcrater lesions compared to the activity in the proliferative zones of the crypts. The neoplastic cells of these lesions showed no mucus secretion. We discussed the origin of the neoplastic lesions using these and other findings.

Lipid analysis of isolated plasma membranes of lymphoid cells in benign thymomas of Buffalo/Mna rats.

Plasma membranes were isolated from lymphoid cells of benign thymomas obtained from inbred BUF/Mna rats (21 mo old) and from normal thymocytes obtained from young rats (7 wk old) of the same strain. The isolated plasma membranes were electron microscopically pure, and the specific activities of Na+, K+-ATPase, and 5'-nucleotidase were enhanced. The lipid compositions of the plasma membranes from these two sources were analyzed and compared. The cholesterol and plasmalogen contents of membranes from both sources were similar, but the phospholipid content of the benign thymoma lymphoid cell membranes was slightly lower than that of the normal thymocytes, resulting in a somewhat higher molar ratio of cholesterol to phospholipid. The plasma membranes of the thymoma lymphoid cells also exhibited a slightly higher microviscosity as measured with fluorescence polarization. No significant differences were observed in the phospholipid compositions of the two membrane preparations.

Ultrastructure of spontaneous and urethan-induced thymomas in buffalo rats.

Normal thymuses from Buffalo and Long-Evans rats of various ages, and spontaneous and urethan-induced thymomas in Buffalo rats, were examined by electron microscopy. Histological variabilities among thymomas of the lymphoid, mixed, and epithelial cell types were a reflection of the number of lymphoid cells within the network composed of neoplastic epithelial reticular cells. In the cytoplasm of these cells, development of tonofilaments and membrane-bound bodies and inverse development of the rough-surfaced endoplasmic reticulum were recognized in the sequential process from the lymphoid cell type to the epithelial cell type. An important role of the development of the rough-surfaced endoplasmic reticulum for thymic function was suggested. Phagocytic activity of the neoplastic epithelial reticular cells was revealed, and some of the membrane-bound bodies in these cells, especially those with moniliform structures, were regarded as remnants of damaged lymphocytes. Evidence for neoplastic epithelial reticular cell-lymphoid cell transformation could not be established from study of the thymoma tissue. No virus-like structures were observed in these thymomas.

Involvement of transforming growth factor beta1 in autocrine enhancement of gelatinase B secretion by murine metastatic colon carcinoma cells.

We have reported previously that highly metastatic LuM1 cells derived from colon carcinoma colon 26 secrete larger amounts of gelatinase B than NM11 cells with poor metastatic potential, and that an increase in this gelatinase B secretion can be induced by autocrine factors (Hyup et A, Cancer Res., 54: 3611-3616, 1994). In the present study, a partial characterization was achieved by comparison of the autocrine factor preparation (fraction G) from serum-free medium conditioned with metastatic LuM1 cells with soluble factors known to stimulate gelatinase B secretion. Secretion of gelatinase B by LuM1 cells was augmented by tumor necrosis factor alpha, transforming growth factor beta1 (TGF-beta1), interleukin 1beta, or epidermal growth factor, and specific neutralizing antibodies abolished the induced increases. Platelet-derived growth factor and insulin-like growth factor 1 had no effect on gelatinase B secretion by LuM1 cells. The enhancement of gelatinase B secretion by fraction G was partially inhibited by the antibody to TGF-beta1. TGF-beta1 was detected in both active and latent forms in serum-free medium conditioned with LuM1 or NM11 cells, with the amount of TGF-beta1 higher in the former case. Gelatinase B secretion by LuM1 cells was enhanced by the addition of TGF-beta1 to the culture medium, but that by NM11 cells was not seriously affected, although the latter bound more of the factor. These results indicate the involvement of this growth factor in the autocrine stimulation of gelatinase B secretion by LuM1 cells. However, the autocrine factor effect was not fully explained by TGF-beta1 in the medium, and the involvement of some other unknown factor(s) was thus indicated.