Prediction of pouchitis after ileal pouch-anal anastomosis in patients with ulcerative colitis using artificial intelligence and deep learning.

BACKGROUND: Pouchitis is one of the major postoperative complications of ulcerative colitis (UC), and it is still difficult to predict the development of pouchitis after ileal pouch-anal anastomosis (IPAA) in UC patients. In this study, we examined whether a deep learning (DL) model could predict the development of pouchitis. METHODS: UC patients who underwent two-stage restorative proctocolectomy with IPAA at Keio University Hospital were included in this retrospective analysis. The modified pouchitis disease activity index (mPDAI) was evaluated by the clinical and endoscopic findings. Pouchitis was defined as an mPDAI ≥ 5.860; endoscopic pouch images before ileostomy closure were collected. A convolutional neural network was used as the DL model, and the prediction rates of pouchitis after ileostomy closure were evaluated by fivefold cross-validation. RESULTS: A total of 43 patients were included (24 males and 19 females, mean age 39.2 ± 13.2 years). Pouchitis occurred in 14 (33%) patients after ileostomy closure. In less than half of the patients, mPDAI scores matched before and after ileostomy closure. Most of patients whose mPDAI scores did not match before and after ileostomy closure had worse mPDAI scores after than before. The prediction rate of pouchitis calculated by the area under the curve using the DL model was 84%. Conversely, the prediction rate of pouchitis using mPDAI before ileostomy closure was 62%. CONCLUSION: The prediction rate of pouchitis using the DL model was more than 20% higher than that using mPDAI, suggesting the utility of the DL model as a prediction model for the development of pouchitis. It could also be used to determine early interventions for pouchitis.

Safety and feasibility of laparoscopic surgery for elderly rectal cancer patients in Japan: a nationwide study.

BACKGROUND: This study aimed to analyse the perioperative results from a national dataset of rectal cancer resections in elderly patients. METHODS: The clinical records of patients undergoing rectal cancer surgery between 2012 and 2014 were retrieved from the Japanese National Clinical Database and analysed retrospectively. Patients were categorized according to age and those 80 years or older were defined as elderly. Subgroups were also defined according to the surgical approach (laparoscopy versus open surgery). The short-term outcomes, including mortality, anastomotic leak, surgical site infections and medical complications were compared between subgroups. RESULTS: Of 56 175 patients undergoing rectal cancer surgery, some 6717 patients were elderly and laparoscopy was performed in 46.8 per cent of the sample. When comparing laparoscopy and open surgery in elderly patients, the operative mortality rate (1.5 versus 2.8 per cent; P < 0.001), the incidence of anastomotic leakage (5.2 versus 6.5 per cent; P = 0.026), surgical site infections (6.0 versus 8.0 per cent; P = 0.001), pneumonia (1.4 versus 2.5 per cent; P = 0.001), renal failure (0.7 versus 1.3 per cent; P = 0.016) and cardiac events (0.3 versus 0.8 per cent; P = 0.008) were lower for laparoscopy than for open surgery. The overall complication rate in elderly patients (19.5 per cent) was comparable to that in the younger group (P = 0.07). However, incidence of systemic complications was significantly higher in elderly than in younger patients (all P < 0.001). CONCLUSION: Laparoscopy was safe and feasible in elderly patients compared with open surgery. However, the rates of systemic complications were significantly higher than in younger patients.

Effect of high ligation on survival of patients undergoing surgery for primary colorectal cancer and synchronous liver metastases.

BACKGROUND: Although R0 surgery is recommended for stage IV colorectal cancer, the degree of required lymphadenectomy has not been established. The aim of this study was to investigate the prognostic impact of high ligation (HL) of the feeding artery and the number of retrieved lymph nodes after R0 surgery for colorectal cancer and synchronous colorectal cancer liver metastasis (CRLM). METHODS: This was a multi-institutional retrospective analysis of patients with colorectal cancer and synchronous CRLM who had R0 surgery between January 1997 and December 2007. Clinical and pathological features were compared in patients who underwent HL and those who had a low ligation (LL). Kaplan-Meier analysis was performed to estimate the effect of HL on overall survival (OS). The impact of several risk factors on survival was analysed using the Cox proportional hazards model. RESULTS: Of 549 patients, 409 (74·5 per cent) had HL. Median follow-up was 51·4 months. HL significantly improved the 5-year OS rate (58·2 per cent versus 49·3 per cent for LL; P = 0·017). Multivariable analysis revealed HL to be a significant prognostic factor compared with LL (5-year mortality: hazard ratio (HR) 0·68, 95 per cent c.i. 0·51 to 0·90; P = 0·007). In subgroup analysis, the positive effect of HL on OS was greatest in patients with lymph node metastasis. CONCLUSION: HL of the feeding artery was associated with improved OS in patients with colorectal cancer and synchronous CRLM after R0 surgery.

ANTECEDENTES: Aunque se recomienda una cirugía R0 para el cáncer colorrectal (colorectal cancer, CRC) en estadio IV, no se ha establecido el grado de linfadenectomía requerida. El objetivo de este estudio fue investigar el impacto pronóstico de la ligadura alta (high ligation, HL) de la arteria que irriga el tumor y el número de ganglios linfáticos (lymph nodes, LN) identificados después de cirugía R0 en pacientes con cáncer colorrectal y metástasis hepáticas sincrónicas (colorectal cancer liver metastasis, CRLM). MÉTODOS: En este estudio se realizó un análisis retrospectivo multicéntrico de pacientes con CRC y CRLM sincrónicas en los que se realizó una cirugía R0 desde enero de 1997 hasta diciembre de 2007. Se compararon las características clínicas y patológicas entre los pacientes a los que, durante la cirugía R0, se practicó una HL frente a los que no se practicó esta técnica. El análisis de Kaplan-Meier se realizó para estimar el efecto de la HL en la supervivencia global (overall survival, OS). El impacto de varios factores de riesgo sobre la supervivencia se analizó utilizando el modelo de Cox de riesgo proporcional. RESULTADOS: Sobre un total de 549 pacientes, se realizó una HL en 409 (74,5%), y el período de seguimiento medio en esta cohorte fue de 51,4 meses. La HL mejoró significativamente la tasa de OS a los 5 años (HL 37,7% versus no HL 27,1%, P = 0,02). El análisis multivariable mostró que la HL era un factor pronóstico significativo en comparación con la no realización de una HL (cociente de riesgos instantáneos, hazard ratio, HR de muerte a 5 años = 0,68 (i.c. del 95% 0,51-0,90), P < 0,01)). En el análisis de subgrupos, el efecto positivo de la HL sobre la OS fue mayor en pacientes con metástasis ganglionares. CONCLUSIÓN: La ligadura alta de la arteria que irriga el tumor se asoció con una mejor OS en pacientes con CRC y CRLM sincrónicas después de una cirugía R0.

Coil Embolization for Ruptured Cerebral Aneurysms of 2x3 mm Diameter.

SUMMARY: Small ruptured cerebral aneurysms, such as those of 2x3 mm diameter, are considered to be difficult to embolize by detachable coils because of the risk of procedural perforation of the aneurysms. We have treated these small aneurysms and report the techniques and pitfalls of these embolizations. Twenty-four patients with ruptured cerebral aneurysms of 2x3 mm diameter were intended for treatment by coil embolization. Before coil embolization, three-dimensional digital subtraction angiography was performed, and the simulation of the volume embolization ratio (VER) was performed in all patients, except for the first basilar artery aneurysm patient. The tip of the microcatheter was steam-shaped several times and was placed on the neck of the aneurysm. A balloon neck remodeling technique was used for two aneurysms. GDC 10 softs and soft SRs were used for the first ten aneurysms, and Ultrasofts were used for the last eleven aneurysms. Out of twentyfour aneurysm embolizations, we aborted the procedure in three cases, because of a failure in catheterization; we performed clipping surgery for these cases. For the first case of a basilar tip aneurysm, the aneurysm was perforated, due to the use of too long a coil and the insertion of the tip of the microcatheter into the aneurysmal dome. Minor infarction occurred in one patient. The mean VER was 33.9%, and two aneurysms recanalized, and out of these one needed a second embolization. Six months postoperatively, 81% of patients had made in a good recovery or had a moderate disability.We recommend the following techniques to embolize aneurysms of 2x3 mm diameter: the tip of the microcatheter should be stabilized on the aneurysmal neck by steam shaping of the microcatheter, GDC 10 soft and Ultrasoft should be selected for use, and the simulation of the VER should be performed before embolization to select coils of a suitable length.

Simultaneous voiding cystourethrography and voiding urosonography: an in vitro and in vivo study.

AIM: To compare the diagnostic accuracy of fluoroscopic voiding cystourethrography (VCUG) and voiding urosonography (VUS) under identical conditions. We performed VUS and VCUG simultaneously with the total time for both examinations taking no longer than the time required for either examination individually. MATERIALS AND METHODS: X-ray contrast medium and echo-contrast agent were mixed together in vitro, and echogenicity of the mixture was confirmed. A clinical study was then performed on 33 children who had a history of urinary tract infection. The bladder was filled using simultaneous administration of X-ray contrast medium and echo-contrast agent. VCUG and VUS were then performed simultaneously and evaluated separately by two specialists. RESULTS: Equivalent results were obtained for the two examinations in 61 of 66 renal tracts. Sensitivities of VUS and VCUG for the detection of VUR were 86% and 79%, respectively. The average time from catheterization to the completion of the study was 9.1 minutes - approximately as long as performing VCUG alone. CONCLUSIONS: First, the present simultaneous study is superior to previous comparisons, because the two examinations were performed under identical physiologic conditions. Second, our results suggest that the two techniques demonstrate similar sensitivity in the detection of reflux.

[Responses to a questionnaire on laboratory examinations performed by graduates of Jichi Medical School in rural practice].

Graduates from Jichi Medical School are obligated to work at rural clinics or hospitals, where most of them are the only medical doctor in the house. Our need to continuously improve medical education, including the learning that takes place in the clinical setting, requires us to understand how these graduates actually use laboratory examinations and what examinations they find most important in their practice. We designed a questionnaire to address these questions. Three hundred sixty-eight graduate physicians working at clinics or hospitals in both rural or urban areas were asked to complete the questionnaire, providing information on the size of their institution, the laboratory equipment and examinations that they have direct access to, and what examinations they find most important. Two hundred seventy-eight (75.5%) of the 368 recipients responded. More than seventy percent of the respondents reported that their institutions had electrocardiographs, abdominal and cardiac ultrasonographs, urinalysis test paper, and portable blood glucose meters; and more than half of them reported having used these instruments without assistance in emergency situations and outside of ordinary office hours. Moreover, a majority of the respondents said that they considered it important that a physician is able to use these instruments without the help of other staff members. These responses clearly show the importance and usefulness of covering examination techniques and the principles of laboratory medicine in medical education.

Enhancement of developmental competence after in vitro fertilization of porcine oocytes by treatment with ascorbic acid 2-O-alpha-glucoside during in vitro maturation.

The present study was conducted to examine the effect of ascorbic acid 2-O-alpha-glucoside (AA-2G), a stable ascorbate derivative, on the sustenance of cytoplasmic maturation responsible for subsequent developmental competence after in vitro fertilization of porcine oocytes. Cumulus-oocyte complexes were cultured for 44 h in North Carolina State University 37 medium supplemented with cysteine, gonadotropins, 10% (v:v) porcine follicular fluid, and 0-750 microM AA-2G. When oocytes were matured in the presence of 250 microM AA-2G, their ability to promote transformation of the sperm nucleus into the male pronucleus (MPN) was strongly enhanced after in vitro fertilization. Similarly, the presence of 25 microM beta-mercaptoethanol (ME) enhanced the degree of progression to MPN of penetrated sperm by associating with the increase in intracellular glutathione (GSH) content. Although the AA-2G treatment during oocyte maturation showed no influence on the GSH concentration, significantly higher levels of ascorbic acid (AsA) were detected in these oocytes than in those oocytes cultured without AA-2G (P < 0.05). The length of DNA migration encompassed by reactive oxygen species (ROS), generated by the hypoxanthine-xanthine oxidase system, was not increased in the oocytes treated with AA-2G, whereas ME treatment could not block the DNA damage by ROS. These findings indicate that AA-2G in maturation medium can potentiate the cellular protection of oocytes against oxidative stress by continuously supplying AsA. The proportion of development to the blastocyst stage after in vitro insemination was significantly increased in oocytes matured with AA-2G (P < 0.05), and this proportion showed no difference in comparison with that of oocytes treated with ME. These findings suggest that a critical concentration of intracellular AsA, supplied by AA-2G during in vitro maturation, plays an important role in supporting the cytoplasmic maturation responsible for developmental competence after fertilization by prevention of oxidative stress against porcine oocytes.

Temporomandibular disorders: MR assessment of inflammatory changes in the posterior disk attachment during the menstrual cycle.

PURPOSE: Our goal was to correlate the menstrual cycle with joint pain, MR evidence of the disk, and posterior disk attachment in patients with temporomandibular disorders. METHOD: Forty-two women underwent MRI involving conventional T1-and T2-weighted gadolinium-enhanced fat-suppressed SE imaging sequences. RESULTS: There was a strong statistical difference in the degree of joint pain between proliferated phase and secretory phase groups (p < 0.005). Joint pain had a tendency to increase at the secretory phase. Significantly less contrast enhancement of the posterior disk attachment was observed in the proliferated phase than in the secretory phase (p < 0.001) or menstrual phase (p < 0.01). In addition, anterior disk displacement without reduction of the temporomandibular joint was closely associated with joint pain. CONCLUSION: Our results suggest that positional changes of the disk and the menstrual cycle may play a role in the degree of joint pain and inflammatory pathology of the posterior disk attachment.

[Simultaneous surgery for unstable angina and gastric cancer: a case report].

This report describes a case in which an 81-year-old male underwent two operations simultaneously for unstable angina and gastric cancer. Successfully performed procedures were off pump CABG with bilateral IMA, and total gastrectomy. The post operative course was uneventful. Off pump CABG is an effective procedure in patient with malignant neoplasm.

Sonographic detection of diffuse peripheral nerve hypertrophy in chronic inflammatory demyelinating polyradiculoneuropathy.

Chronic inflammatory demyelinating polyradiculoneuropathy is an autoimmune disease characterized by recurrent demyelination and remyelination with resultant thickening of the peripheral nerves. We report a case in which sonography was instrumental in demonstrating diffuse peripheral nerve hypertrophy. On sonography, both brachial plexuses were found to be diffusely hypertrophic and hypoechoic. Similar findings were noted for the median, sciatic, and femoral nerves. The brachial plexus findings were confirmed by MRI.

Cubic-Phase-Based Concentrated Emulsions.

The effect of different types of added oil on the formation of a discontinuous micellar-type cubic phase was investigated in water-polyoxyethylene dodecyl ether (C(12)EO(25)) systems by phase study and small-angle X-ray scattering. The thermal stability of the cubic phase increases upon addition of oil, especially short-chain hydrocarbons. However, in the heptane system, the maximum melting temperature of the cubic phase is lower than that for decane due to the formation of a different liquid crystal phase. The effect of polyols on C(12)EO(25) cubic phases was also investigated. It was found that the thermal stability of the cubic phase decreases with polyol concentration. The destabilizing effect becomes large as the polyol molecule penetrates further into the surfactant palisade layer. Although the solubilization of oil in the cubic phase is very low, a large amount of excess oil can be incorporated and a transparent cubic-phase-based concentrated emulsion is formed. The transparency is attributed to the very small difference in the refractive indices between the cubic and excess-oil phases. Copyright 2000 Academic Press.

8-(3-oxo-4,5,6-trihydroxy-3h-xanthen-9-yl)-1-naphthoic acid inhibits MAPK phosphorylation in endothelial cells induced by VEGF and bFGF.

Angiogenesis is regulated by various factors. In particular, VEGF and basic FGF are of much importance. We found that 8-(3-oxo-4,5,6-trihydroxy-3h-xanthen-9-yl)-1-naphthoic acid inhibited the binding of VEGF to KDR/Flk-1 (VEGF receptor-2) or Flt-1 (VEGF receptor-1) and that it inhibited the MAPK phosphorylation in HUVEC induced by VEGF or basic FGF but not by EGF. 8-(3-oxo-4,5,6-trihydroxy-3h-xanthen-9-yl)-1-naphthoic acid might be used as an inhibitor of VEGF and basic FGF signal transduction.

Sck interacts with KDR and Flt-1 via its SH2 domain.

Vascular endothelial growth factor (VEGF) is one of the major angiogenesis regulators. It binds to its tyrosine kinase receptors, KDR and Flt-1. However, little is known about their downstream signal transduction properties. We screened human brain cDNA library using the yeast two-hybrid system with the KDR cytoplasmic region as bait to find KDR binding proteins. After 6.2 x 10(6) clones were screened, we identified Sck, one of the Shc homologues, as a KDR binding protein. Sck also binds to Flt-1 and their binding is dependent on the kinase activities of KDR and Flt-1. Extensive site-directed mutagenesis of KDR revealed that Y1175 of KDR is a major binding site for Sck. As Sck contains the SH2 domain and PTB domain, we tested whether they bind to KDR and Flt-1. The SH2 domain of Sck binds to both of them. Deletion of the SH2 domain from Sck resulted in the complete loss of binding. On the other hand, the PTB domain of Sck does not bind to KDR and Flt-1. These results indicate that Sck binds to KDR and Flt-1 via its SH2 domain and might play an important role in VEGF signal transduction.

Examination of the diagnostic value and estimation of the chaos phenomenon in masticatory movement using fractal dimension in patients with temporomandibular dysfunction syndrome.

The aim of this study was to estimate the chaos phenomenon (chaos) in masticatory movements using the fractal dimension (FD), and to examine the diagnostic value of the fractal dimension in comparing stomatognathic functional disturbances with normal stomatognathic function. The subjects were all high school students and included nine subjects presenting with acceptable normal occlusion, 18 subjects with TMJ dysfunction syndrome and seven subjects with tooth crowding. Masticatory movements were obtained during free, right side, and left side gum-chewing and were used to calculate the capacity dimension in the FD. Chaos in the masticatory movement was estimated by the FD saturated with some constant value to an increase of embedding dimension (approached a plateau). In the crowding group, the FD was also significantly high on the sagittal plane in comparison with the normal. In the patients with pain, the FD on the sagittal plane was significantly high. In the patients with pain and closed lock, the FD on the frontal plane was significantly high. However, in the patients with pain and with reduction of anterior disc displacement, the FD was significantly low on the horizontal plane. These findings suggest that chaos is present in masticatory movements and the difference in the FD are of diagnostic value in evaluation of the relationship between FD and stomatognathic functional disturbance.

Tyrosine 1213 of Flt-1 is a major binding site of Nck and SHP-2.

Vascular endothelial growth factor (VEGF) binds to its receptor tyrosine kinase Flt-1 and KDR/Flk-1 and stimulates their autophosphorylation. However, little is known about their downstream signal transduction properties. We examined the interactions of certain proteins with a SH2-domain with Flt-1 and KDR using the yeast two-hybrid system and found that Nck, SHP-2, PLC gamma, and PI3K p85 bind to Flt-1. Extensive site-directed mutagenesis of Flt-1 revealed their major binding sites. Nck, SHP-2, and PI3K bind to Y1213 of Flt-1. Nck also binds to Y1333 of Flt-1. These results suggest that Nck, SHP-2, PLC gamma, and PI3K play important roles in Flt-1 signal transduction and that Y1213 of Flt-1 is a major binding site of PI3K, Nck, and SHP-2.

[A case of advanced gastric cancer with virchow's metastasis responding remarkably to combination chemotherapy of low-dose CDDP and 5-FU].

The patient was a 72-year-old female who had Stage IVb advanced gastric cancer with Virchow's and paraaortic lymph node metastases. She was considered nonresectable and placed on neoadjuvant chemotherapy consisting of low-dose CDDP and 5-FU. After 1 course of administration, Virchow's metastasis disappeared, and the tumor was remarkably reduced in size. However, this chemotherapy was interrupted by toxicity of grade 3 appetite loss, nausea and vomiting, so that total gastrectomy and splenectomy were performed, which were non-curative operation because of paraaortic lymph node metastases. Histopathological examination of the section of the primary tumor revealed that cancer cells had almost disappeared, and only a few atypical cells remained in the granulation tissue. Eleven months after the surgery, there has been no progression of Virchow's and paraaortic lymph node metastases. Combination chemotherapy of low-dose CDDP and 5-FU appears useful as an inductive approach to advanced gastric cancer.

Thrombin activates NF-kappa B through thrombin receptor and results in proliferation of vascular smooth muscle cells: role of thrombin in atherosclerosis and restenosis.

We investigated the role of thrombin in the pathogenesis in atherosclerosis and restenosis. First we examined the effect of thrombin on cultured human vascular smooth muscle cells (VSMC). We showed that thrombin acts as a mitogen on VSMC through thrombin receptor. The expression of thrombin receptor was increased in the cell lines of VSMC established from directional coronary atherectomy (DCA). This is more pronounced in the cells from patients with restenosis after PTCA. Next we investigated the signaling pathway from thrombin/thrombin receptor. Thrombin activates thrombin receptor resulting in the exposing of the agonist peptide domain (thrombin receptor agonist peptide, TRAP). The signal from thrombin/thrombin receptor activated protein C kinase, tyrosine kinase, and MAP kinase and resulted in NF-kappa B activation. Furthermore, treatment of the cells with antisense p65 oligodeoxynucleotides of NF-kappa B inhibited the thrombin-stimulated growth of VSMC in vitro. These results suggest that thrombin may have a role in the pathogenesis of atherosclerosis and restenosis after PTCA through the thrombin receptor.

[Relation of sputum and feces and methicillin-resistant Staphylococcus aureus (MRSA) detection].

Thirty cases with MRSA in the sputum (carrier state) were studied in relation to fecal MRSA detection. The back ground of the cases (disease, nasogastric tube, tracheostomy, antibiotics, H2-blocker) and typing of MRSA (coagulase type, Pulse Field Gel Electrophoresis (PFGE) type), and gastric pH were studied. Almost all of the patients were given antibiotics of the cephem series of the third generation. None of the cases had abdominal operations. Fecal MRSA was positive in 14 cases (47%). H2-receptor antagonists (H2-blocker) was administered to 6 cases, and all cases (100%) had positive fecal MRSA. Eighteen cases had a history of H2-blocker administration and 5 cases had positive fecal MRSA. Duration after stopping the H2-blocker in the 5 cases was shorter than the other 13 cases. (4.5 to 20.8 months). Nasogastric tube had no significant effect in detection of fecal MRSA. And gastric pH was of no significant difference between MRSA positive cases and negative cases. These results suggest that in patient with MRSA in the sputum receiving a H2-blocker may produce MRSA enteritis because of MRSA passage to the stomach.