Abstract Context Plasma C-reactive protein (CRP) levels are elevated in patients with advanced cancer. Objectives To investigate CRP as a prognostic marker in palliative settings. Methods This ...multicenter prospective cohort study comprised 2426 patients. Laboratory data were obtained at baseline, and all patients were followed until death or six months after their enrollment. A total of 1511 patients were eligible for the analyses. They were divided into four groups: low-CRP (CRP < 1 mg/dL), moderate-CRP (1 ≤ CRP <5 mg/dL), high-CRP (5 ≤ CRP <10 mg/dL), and very high-CRP (10 mg/dL ≤ CRP) groups. Survival was investigated by the Kaplan-Meier method with the log-rank test. The 30-, 60-, and 90-day mortality rates were tested by Chi-squared tests. Univariate- and multivariate-adjusted hazard ratios (HRs) and 95% CIs in each group were calculated using Cox proportional hazard models. Results Survival rate decreased and mortality rate increased with increasing CRP level. The differences in survival and 30-, 60-, and 90-day mortality rates among the groups were statistically significant ( P < 0.001). Baseline CRP level was significantly associated with a higher risk of mortality after adjustment for age, gender, primary tumor site, metastasis, chemotherapy, Eastern Cooperative Oncology Group Performance Status, and setting of care (moderate-CRP: HR 1.47 95% CI 1.24–1.73, high-CRP: HR 2.09 95% CI 1.74–2.50, and very high-CRP: HR 2.55 95% CI 2.13–3.05 vs. low-CRP). Conclusion Clear dose-effect relationships between elevated CRP levels and prognoses indicate that CRP could be useful in predicting prognoses in patients with advanced cancer.
Abstract Context Oral administration of medication is often difficult in terminally ill cancer patients, and a subcutaneous route is traditionally one of the most preferred parenteral routes. Recent ...studies suggest, however, that some patients and families prefer the intravenous route, and peripherally inserted central venous catheters (PICCs) are actively used in oncology settings. Nonetheless, in the palliative care setting, no empirical studies have investigated the patient-perceived usefulness of PICCs. Objectives The primary aim of this prospective observational study was to clarify the levels of patient-perceived comfort and convenience, in addition to procedure-related distress, resulting from the use of PICCs by terminally ill cancer patients. Results Among 219 patients admitted to a palliative care unit during the one-year study period, 39 (18%) patients underwent a PICC insertion trial (a total of 44 procedures were performed because five patients underwent PICC insertion twice). Of the 44 procedures, 38 (86%) were successful, requiring a mean of 23 ± 7.9 minutes, without serious procedure-related complications. Patient-reported levels of procedure-related distress were not distressing (68%), slightly distressing (8%), and distressing (24%). Patient-reported comfort levels with parenteral access were becoming more comfortable (94%) and no change (6%). Patient-reported convenience levels of parenteral access were becoming more convenient (94%) and no change (6%). Complications were reversible catheter coagulation (10%), irreversible catheter coagulation (8%), and mild levels of edema of the upper extremity (8%). The PICCs remained in place in 82% of the patients until death. The median period of placement was 15 days, with the longest placement being 81 days. Conclusion PICCs were safely inserted in about 90% of terminally ill cancer patients within about 20 minutes. Although 30% of the patients experienced transient mild procedure-related distress, more than 90% of the patients felt that the parenteral route was more comfortable and convenient after the procedure. PICCs may provide a safe, comfortable, and convenient alternative for terminally ill cancer patients, if placement of the PICC is individualized to the patient situation and after alternatives are considered. Further studies are needed to compare the superiority of the PICC and traditional subcutaneous route to clarify what types of patients are the most suitable for each procedure.
BACKGROUND Lung-dominant connective tissue disease (LD-CTD) is a disease concept for interstitial pneumonia; however, it has not been robustly validated. /p study was conducted to elucidate the ...clinical, radiologic, and histologic features of LD-CTD. METHODS We retrospectively reviewed 44 consecutive patients with serologically defined LD-CTD who underwent surgical lung biopsy. Six were identified as having LD-CTD if they had specific autoantibodies but did not meet the criteria for connective tissue disease. We conducted a multidisciplinary diagnosis and evaluated major histologic patterns according to the current idiopathic interstitial pneumonias (IIPs) classification of 2013. Characteristic histologic features for LD-CTD (eg, prominent plasmacytic infiltration, lymphoid aggregates with germinal centers), high-resolution CT (HRCT) scan patterns, and prognosis were also assessed. METHODS The major histologic patterns were usual interstitial pneumonia (UIP) in 25 patients and nonspecific interstitial pneumonia (NSIP) in 13 patients. Two or more characteristic histologic features for LD-CTD were observed in 15 patients with histologic UIP (h-UIP) and 11 patients with histologic NSIP (h-NSIP). Fifteen patients with h-UIP (60%) showed an inconsistent UIP pattern on HRCT scan multidisciplinary discussion (MDD), 18 patients with h-UIP were labeled as having unclassifiable IIP. The annual change in percent predicted FVC improved significantly in patients with h-NSIP (P = .002), who also had better survival than those with h-UIP (P = .031). In contrast, survival was not associated with HRCT scan pattern (P = .79). CONCLUSIONS The major histologic patterns in LD-CTD were UIP followed by NSIP. Two-thirds of patients had characteristic histologic features for LD-CTD. A majority of patients with h-UIP were considered to have unclassifiable IIP based on MDD. Patients with h-UIP had worse survival than those with h-NSIP. CHEST 2015;148(6):1438-1446
Inadvertent renal artery obstruction during endovascular aortic repair is a rare but serious complication. In such cases, endovascular recanalization is typically attempted; however, it can be ...challenging, leading to many severe cases. Moreover, if treatment is delayed, the blockage time of the renal artery poses a problem. We encountered a case of inadvertent renal artery occlusion during endovascular aortic repair. In this case, bailout stent implantation through a gap between the aortic wall and a stent graft made by a balloon catheter was effective in reducing the renal ischemia time and facilitating the revascularization procedure.
Abstract Minimally invasive surgery (MIS) in total knee arthroplasty (TKA) reportedly yields decreased patient morbidity and a rapid return of function, but how much deformity can be accepted for ...MIS-TKA remains unclear. This study investigated 238 knees from 218 consecutive patients who underwent MIS-TKA. Patients were divided into groups with tibiofemoral mechanical axis (TFM) 195° or greater and TFM less than 195°, then clinical and radiographic results were compared. Similar improvements in knee score at 3 months postoperatively were obtained in the both groups, whereas radiographic accuracy of the coronal alignment in the TFM ≥195° group was inferior to that in TFM <195° group. Postoperative TFM was significantly worsened in patients with lateral bowing angle of the femoral shaft (LBFS) 4° or greater, and 53% of patients in the TFM ≥195° group displayed LBFS 4° or greater, explaining the inferior radiographic accuracy in this group compared with the TFM <195° group. These results indicate that use of MIS techniques decreases radiographic accuracy, particularly in patients with severe genu varum and increased LBFS.
In organ transplantation, the University of Wisconsin (UW) solution has been the gold standard for organ preservation. Quercetin (Que) has numerous antioxidant and anti-inflammatory activities, and ...sucrose (Suc) may be effective for cold storage (CS). This study aimed to investigate the in vitro protective effect of Que and Suc on cold injury to the kidney and to determine whether Que + Suc could improve ischemia-reperfusion injury during CS and hypothermic oxygenated perfusion (HOPE) in autologous transplantation models.
BHK-21 cells were stored at 4°C for 3 days in UW solution for CS/machine perfusion (CS/MP-UW) with Que (33.1 μM, 3.3 μM, 0.33 μM) and Suc (0.1 M). In a porcine model of renal autologous transplantation, left kidney grafts were preserved under 3 conditions: group 1, CS preservation for 24 hours; group 2, CS preservation for 22 hours and HOPE with CS/MP-UW solution for 2 hours; and group 3, identical preservation as group 2, with Que and Suc added to the solution. Animals were euthanized on day 7 after autologous transplantation.
After 3 days of CS preservation, the CS/MP-UW solution with Que (33.1 μM, 3.3 μM) and Suc showed significant cell protection against cold injury. In the porcine model of renal autologous transplantation, the last blood Cre level and the blood lipid hydroperoxide on posttransplantation day 2 were significantly different between group 1 and group 3. Moreover, the total endothelial, glomerular, tubular, interstitial (EGTI) histology score in the kidney tissue was also significantly different. Regarding the change in renal resistance in HOPE, the decrease observed in group 3 was significantly larger than that in group 2.
Our results suggest that the addition of Que and Suc to a UW solution can improve kidney preservation and could potentially enhance the outcome of kidney transplantation.
A 69-year-old man was transferred to our hospital for massive hemorrhage from a right hepatic artery pseudoaneurysm 5 months after surgery for gastric cancer. Stent-graft placement was planned to ...avoid fatal hepatic infarction, and a guiding sheath was advanced deeply into the tortuous and stenotic right hepatic artery beyond the pseudoaneurysm for safe deployment of a stent-graft. However, this advancement caused arterial dissection of the right hepatic artery. After the guiding sheath was pulled back, a Viabahn stent-graft was successfully advanced over a guidewire to exclude the pseudoaneurysm. We consider that a Viabahn stent-graft is more flexible than a guiding sheath and that advancing a Viabahn stent-graft directly from a proximally placed guiding sheath is safer than advancing a guiding sheath into a tortuous and stenotic abdominal artery.
A 77-year-old man was transferred to our hospital for endoscopically uncontrollable active bleeding from a duodenal ulcer. Soon after his arrival, he became hemodynamically unstable and resuscitative ...endovascular balloon occlusion of the aorta was performed using a 7-F aortic occlusion balloon catheter (Rescue Balloon; Tokai Medical Products, Aichi, Japan). He became hemodynamically stable and was transferred to the CT room. CT demonstrated that the distal part of the catheter shaft had made a loop in the aorta and the balloon was located at the level of the upper abdomen. We consider the low-profile occlusion balloon catheter to be less rigid than large ones, and care should be taken to prevent balloon migration and catheter shaft bending.
A 77-year-old woman with liver cirrhosis was admitted to our hospital for marked hemorrhage in her ileal conduit stoma. She had a history of cystectomy and urinary diversion for bladder carcinoma 2 ...years ago. Contrast-enhanced CT demonstrated varices in the ileal conduit stoma. We accessed the varices via a recanalized paraumbilical vein to avoid pain from the transhepatic approach, and selectively embolized the varices with N-butyl cyanoacrylate (NBCA). We consider antegrade embolization of ileal conduit stomal varices with NBCA to be effective and feasible. Access via a paraumbilical vein is a useful alternative to the transhepatic approach.
A 59-year-old man was admitted to our hospital for hematemesis. A hematoma was found in the posterior wall of the stomach, but the source of bleeding was not identified. One month later, ...contrast-enhanced computed tomography revealed a pseudoaneurysm in the short gastric artery. Embolization of the pseudoaneurysm was difficult due to vessel tortuosity. Usage of a distal access catheter improved catheter stability and enabled successful embolization. We consider a distal access catheter to be useful for embolization of an aneurysm beyond a tortuous artery.
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