Efficacy of Early Rehabilitation for Severe Coronavirus Disease 2019 Pneumonia: Factor Analysis Using Machine Learning.

Objectives: Patients with severe coronavirus disease 2019 (COVID-19) who develop pneumonia face the risk of ventilatory muscle disuse in the acute phase, which can result in persistent respiratory impairments in the subacute phase. Although rehabilitation during the acute phase is considered effective, there are limited reports on this topic. Therefore, this study aimed to investigate the effectiveness of acute-phase rehabilitation in patients with severe COVID-19. Methods: The study included 57 patients (45 men and 12 women; mean age: 63.2±12.1 years) admitted between April and June 2021, all of whom required intubation for respiratory management. Among them, 34 patients underwent acute-phase rehabilitation interventions based on the early goal-directed mobilization protocol. The primary objectives were to assess the occurrence of medical accidents related to acute-phase rehabilitation and evaluate their impact on survival and mobility upon hospital discharge. Statistical techniques and machine learning algorithms were employed for data analysis. Results: Remarkably, no medical accidents occurred during the acute-phase rehabilitation among the patients. Furthermore, our findings indicated that acute-phase rehabilitation did not influence survival outcomes. However, it did have a positive impact on the mobility of patients upon hospital discharge. Conclusions: Acute-phase rehabilitation can be safely administered to patients with severe COVID-19 by following an early goal-directed mobilization protocol. This approach may also contribute to improved activities of daily living after discharge.

p-Type Conversion of WS2 and WSe2 by Position-Selective Oxidation Doping and Its Application in Top Gate Transistors.

For the complementary operation of two-dimensional (2D) material-based field-effect transistors (FETs), high-performance p-type FETs are essential. In this study, we applied surface charge-transfer doping from WOx, which has a large work function of ∼6.5 eV, selectively to the access region of WS2 and WSe2 by covering the channel region with h-BN. By reducing the Schottky barrier width at the contact and injecting holes into the valence band, the p-type conversion of intrinsically n-type trilayer WSe2 FET was successfully achieved. However, trilayer WS2 did not show clear p-type conversion because its valence band maximum is 0.66 eV lower than that of trilayer WSe2. Although inorganic WOx boasts high air stability and fabrication process compatibility due to its high thermal budget, the trap sites in WOx cause large hysteresis during back gate operation of WSe2 FETs. However, by using top gate (TG) operation with an h-BN protection layer as a TG insulator, a high-performance p-type WSe2 FET with negligible hysteresis was achieved.

[Giant Mature Cystic Teratoma Causing Loss of Consciousness before Surgery].

A 30-year-old woman who presented loss of consciousness was diagnosed as having large anterior mediastinal tumor. Computed tomography (CT) showed a 17.0×13.0×7.3 cm cystic mass with internal calcification in the anterior mediastinum that was markedly compressing the heart, great vessels, trachea and bronchi. A mature cystic teratoma was suspected, and the mediastinal tumor was resected through a median sternotomy. At the induction of anesthesia to prevent the development of the respiratory and circulatory collapse, the patient was consciously intubated under the right lateral decubitus position while preparing for percutaneous cardiopulmonary support by cardiac surgeons, and the surgery was safely performed. The tumor was pathologically diagnosed as a mature cystic teratoma, and symptoms such as loss of consciousness have disappeared.

Comparison of utility of deep learning reconstruction on 3D MRCPs obtained with three different k-space data acquisitions in patients with IPMN.

OBJECTIVE: To compare the utility of deep learning reconstruction (DLR) for improving acquisition time, image quality, and intraductal papillary mucinous neoplasm (IPMN) evaluation for 3D MRCP obtained with parallel imaging (PI), multiple k-space data acquisition for each repetition time (TR) technique (Fast 3D mode multiple: Fast 3Dm) and compressed sensing (CS) with PI. MATERIALS AND METHODS: A total of 32 IPMN patients who had undergone 3D MRCPs obtained with PI, Fast 3Dm, and CS with PI and reconstructed with and without DLR were retrospectively included in this study. Acquisition time, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR) obtained with all protocols were compared using Tukey's HSD test. Results of endoscopic ultrasound, ERCP, surgery, or pathological examination were determined as standard reference, and distribution classifications were compared among all 3D MRCP protocols by McNemar's test. RESULTS: Acquisition times of Fast 3Dm and CS with PI with and without DLR were significantly shorter than those of PI with and without DLR (p < 0.05). Each MRCP sequence with DLR showed significantly higher SNRs and CNRs than those without DLR (p < 0.05). IPMN distribution accuracy of PI with and without DLR and Fast 3Dm with DLR was significantly higher than that of Fast 3Dm without DLR and CS with PI without DLR (p < 0.05). CONCLUSION: DLR is useful for improving image quality and IPMN evaluation capability on 3D MRCP obtained with PI, Fast 3Dm, or CS with PI. Moreover, Fast 3Dm and CS with PI may play as substitution to PI for MRCP in patients with IPMN. KEY POINTS: • Mean examination times of multiple k-space data acquisitions for each TR and compressed sensing with parallel imaging were significantly shorter than that of parallel imaging (p < 0.0001). • When comparing image quality of 3D MRCPs with and without deep learning reconstruction, deep learning reconstruction significantly improved signal-to-noise ratio and contrast-to-noise ratio (p < 0.05). • IPMN distribution accuracies of parallel imaging with and without deep learning reconstruction (with vs. without: 88.0% vs. 88.0%) and multiple k-space data acquisitions for each TR with deep learning reconstruction (86.0%) were significantly higher than those of others (p < 0.05).

Hybrid repair for Kommerell's diverticulum and right aortic arch with aberrant right vertebral artery.

Kommerell's diverticulum (KD) is a rare aneurysm of the origin of an aberrant subclavian artery. Hybrid aortic arch repair for KD is being performed more often. We report hybrid arch repair for KD in a 63-year-old man with a right aortic arch and aberrant right vertebral artery, an extremely rare variant. We performed total arch replacement to completely reconstruct the five cervical arteries with elephant trunk to create an adequate landing zone, followed by second-stage endovascular stent-grafting from the ascending aorta to the proximal descending aorta.

A Bayesian approach to diffusional kurtosis imaging.

PURPOSE: Diffusional kurtosis metrics show high performance for detecting pathological changes and are therefore expected to be disease biomarkers. Kurtosis maps, however, tend to be noisy. The maps' visual quality is crucial for disease diagnosis, even when kurtosis is being used quantitatively. A Bayesian method was proposed to curtail the large statistical error inherent in kurtosis estimation while maintaining potential application to biomarkers. THEORY: Gaussian priors are determined from first-step estimations implemented using the least-square method (LSM). The likelihood-function variance is determined from the residuals of the estimation. Although the proposed approach is similar to a regularized LSM, regularization parameters do not have to be artificially adjusted. An appropriate balance between denoising and preventing false shrinkages of metric dispersions is automatically achieved. METHODS: Map qualities achieved using the conventional and proposed methods were compared. The receiver-operating characteristic analysis was performed for glioma-grade differentiation using simulated low- and high-grade glioma DWI datasets. Noninferiority of the proposed method was tested for areas under the curves (AUCs). RESULTS: The noisier the conventional maps, the better the proposed Bayesian method improved them. Noninferiority of the proposed method was confirmed by AUC tests for all kurtosis-related metrics. Superiority of the proposed method was also established for several metrics. CONCLUSIONS: The proposed approach improved noisy kurtosis maps while maintaining their performances as biomarkers without increasing data acquisition requirements or arbitrarily choosing LSM regularization parameters. This approach may enable the use of higher-order terms in diffusional kurtosis imaging (DKI) fitting functions by suppressing overfitting, thereby improving the DKI-estimation accuracy.

Urgent intraoperative endovascular stent placement to resolve acute hepatic or portal venous obstruction during liver surgery: a case series.

BACKGROUND: Acute obstruction of the hepatic vein (HV) or the portal vein (PV), particularly when it occurs during liver surgery, is potentially fatal unless repaired swiftly. As surgical interventions for this problem are technically demanding and potentially unsuccessful, other treatment options are needed. CASE PRESENTATION: We report two cases of acute, surgically uncorrectable HV or PV obstruction during liver resection or living donor liver transplantation (LDLT), which was successfully treated with urgent intraoperative placement of endovascular stents using interventional radiology (IVR). In Case 1, a patient with colonic liver metastases underwent a non-anatomic partial hepatectomy of the segments 4 and 8 with middle hepatic vein (MHV) resection. Additionally, the patient underwent an extended right posterior sectionectomy with right hepatic vein (RHV) resection for tumors involving RHV. Reconstruction of the MHV was needed to avoid HV congestion of the anterior section of the liver. The MHV was firstly reconstructed by an end-to-end anastomosis between the MHV and RHV resected stumps. However, the reconstruction failed to retain the HV outflow and the anterior section became congested. Serial trials of surgical revisions including re-anastomosis, vein graft interposition and vein graft patch-plasty on the anastomotic wall failed to recover the HV outflow. In Case 2, a pediatric patient with biliary atresia underwent an LDLT and developed an intractable PV obstruction during surgery. Re-anastomosis with vein graft interposition failed to restore the PV flow and elongated warm ischemic time became critical. In both cases, the misalignment in HV or PV reconstruction was likely to have caused flow obstruction, and various types of surgical interventions failed to recover the venous flow. In both cases, an urgent IVR-directed placement of self-expandable metallic stents (SEMS) restored the HV or PV perfusion quickly and effectively, and saved the patients from developing critical conditions. Furthermore, in Cases 1 and 2, the SEMS placed were patent for a sufficient period of time (32 and 44 months, respectively). CONCLUSIONS: The IVR-directed, urgent, intraoperative endovascular stenting is a safe and efficient treatment tool that serves to resolve the potentially fatal acute HV or PV obstruction that occurs in the middle of liver surgery.

Deep learning-based and hybrid-type iterative reconstructions for CT: comparison of capability for quantitative and qualitative image quality improvements and small vessel evaluation at dynamic CE-abdominal CT with ultra-high and standard resolutions.

PURPOSE: To determine the image quality improvement including vascular structures using deep learning reconstruction (DLR) for ultra-high-resolution CT (UHR-CT) and area-detector CT (ADCT) compared to a commercially available hybrid-iterative reconstruction (IR) method. MATERIALS AND METHOD: Thirty-two patients suspected of renal cell carcinoma underwent dynamic contrast-enhanced (CE) CT using UHR-CT or ADCT systems. CT value and contrast-to-noise ratio (CNR) on each CT dataset were assessed with region of interest (ROI) measurements. For qualitative assessment of improvement for vascular structure visualization, each artery was assessed using a 5-point scale. To determine the utility of DLR, CT values and CNRs were compared among all UHR-CT data by means of ANOVA followed by Bonferroni post hoc test, and same values on ADCT data were also compared between hybrid IR and DLR methods by paired t test. RESULTS: For all arteries except the aorta, the CT value and CNR of the DLR method were significantly higher compared to those of the hybrid-type IR method in both CT systems reconstructed as 512 or 1024 matrixes (p < 0.05). CONCLUSION: DLR has a higher potential to improve the image quality resulting in a more accurate evaluation for vascular structures than hybrid IR for both UHR-CT and ADCT.

Development and proof of concept of an immersive virtual reality system to evaluate near and far space neglect in individuals after stroke: A brief report.

BACKGROUND: Unilateral spatial neglect (USN) is defined as impaired attention to sensory stimuli on one side. The symptoms can exist for near and far spaces combined or independently. Thus, it is important to evaluate both possibilities in a clinical environment. OBJECTIVE: To develop a tractable immersive virtual reality (iVR) system that can evaluate both near and far space neglect along with a proof of concept study to determine whether near and far spatial neglect could be described in an actual patient with USN. METHODS: An object-detecting task was developed in a three-dimensional virtual reality space. The examiner recorded the positional data of objects that were recognized by the patient with USN using coordinate data. RESULTS: The system could be used to detect near and far space neglects in a patient with USN. No side effects such as vertigo were seen during measurement. This patient showed that the angle for recognition was significantly larger for near space than far space, and exhibited a tendency for the angle of recognition to increase with lower height. CONCLUSIONS: Our proof of concept study indicated the possibility of applying an evaluation system that separates far and near space neglect using iVR.

[Acute Necrotizing Esophagitis Occurred after Lung Resection for Lung Cancer].

The patient was a 78-year-old man who had undergone left lung segmentectomy (S6) with lymph node dissection for lung adenocarcinoma. One year and 5 months later, lung partial resection was performed for the lung cancer recurrence and the hematemesis was noted on the next day of surgery. Upper gastrointestinal endoscopy revealed extensive black necrosis on the mucosa of the esophagus, which was diagnosed as acute necrotizing esophagitis. To treat the bleeding, the exposed esophageal vessels were clipped via endoscopy several times. The endoscopy on the 64th post-operative day showed the mucosa recovered and he could be discharged on the 85th day. The exact etiology of acute necrotizing esophagitis is unknown in most cases.

Measurement of effective renal plasma flow using model analysis of dynamic CT in the preoperative evaluation of the renal transplant donors.

OBJECTIVES: Renal scintigraphy is widely used to evaluate residual function of a transplanted kidney from the donor. Dynamic computed tomography (CT) imaging can evaluate both kidney morphology and regional renal function. The aim of this study was to develop an imaging protocol and a calculation method using dynamic CT for assessing the effective renal plasma flow (ERPF) by model analysis, and to evaluate the validity of the obtained ERPF values. METHODS: Preoperative dynamic CT examination with a low radiation dose exposure system was performed for 25 renal transplant donors, and ERPF was calculated from the obtained images (CT-ERPF). To calculate CT-ERPF, we set the region of interest (ROI) in the renal cortex using automatic ROI-setting software developed in our laboratory. We compared the processing time with automatic and manual ROI settings. To evaluate the validity of CT-ERPF, we examined the correlation of age with CT-ERPF and compared with reported ERPF values. We also compared the uptake rates of technetium-99m-dimercaptosuccinic acid and CT-ERPF in terms of the right-to-left ratio. RESULTS: There was good agreement of CT-ERPF assessed using automatic and manual ROIs. CT-ERPF was negatively correlated with age and showed values below the reference ERPF range in 21 cases. The right-to-left ratio of CT-ERPF showed a significant correlation with that of technetium-99m-dimercaptosuccinic acid. CONCLUSIONS: Using our method, CT-ERPF was a useful indicator for preoperative evaluation of donor's renal function.

[Metastatic Lung Tumor from Papillary Thyroid Carcinoma Suspected of Primary Lung Cancer;Report of Two Cases].

Radiological finding of pulmonary metastasis of thyroid cancer is generally known to be multiple small nodular shadow. We experienced 2 cases of lung solitary tumor, which were suspected of primary lung cancer as differential diagnosis. Patient 1:A 67-year-old man;the tumor obstructed subsegmental bronchus (B10) of the right lobe, and pathological diagnosis by transbronchial biopsy was adeno-squamous carcinoma. Fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) showed abnormal uptake in the tumor and also in the left lobe of his thyroid gland, but no malignant findings were found by the fine-needle aspiration cytology from the thyroid gland. Patient 2:A 51-year-old woman;she had a lobulated nodule in the left lower lobe, which was diagnosed as adenocarcinoma. She had undergone an operation for thyroid cancer about 30 years earlier, but after the operation, there has been no recurrence. In both cases, primary lung cancer were suspected and the tumors were resected surgically. By immunohistochemistry, both tumors were diagnosed as pulmonary metastases from papillary thyroid carcinoma.

An Adult Case of Pulmonary Artery Sling Accompanied by Tracheobronchomalacia.

Pulmonary artery (PA) sling is a congenital disease in which the left PA abnormally arises from the right PA and is usually diagnosed during the infantile period. We present an adult case of PA sling accompanied by tracheobronchomalacia found in a 49-year-old woman with a history of recurrent pneumonia. Computed tomography of the chest showed that the left lung was nourished by two aberrant PAs. Bronchoscopy demonstrated achondroplasia of the trachea and the right bronchus, which we speculate to have resulted in their stenosis. The recurrent pneumonia was attributable to these tracheobronchial structural abnormalities; we therefore stress the importance of focusing on the anatomic abnormalities in such cases.

SWALLOWING COMPUTED TOMOGRAPHY: DOSE ESTIMATION IN A PHANTOM STUDY CONDUCTED AT VARIOUS PATIENT RECLINING ANGLES.

Swallowing computed tomography (SCT) is a relatively new technique for the morphological and kinematic analyses of swallowing. However, no optimal scan protocols are available till date. We conducted the present SCT study to estimate the patient dose at various patient reclining positions. A RANDO phantom with a thermoluminescent dosemeter was placed on a hard Table board in a semi-reclining position at the centre and off-centre. According to predetermined scan protocols, irradiation was performed to acquire scanograms at reclining angles of 55° and 65°. The effective dose was the lowest at the centre 45° (3.8 mSv) reclining angle. Comparison between the off-centre (4.6 mSv at 55°, 6.8 mSv at 65°) and centre (4.5 mSv, 5.8 mSv) values suggested that the off-centre position is undesirable with regard to the patient dose. Accordingly, we believe that SCT methods must be revised on the basis of these factors.

Thoracoscopic surgery versus open surgery for lung metastases of colorectal cancer: a multi-institutional retrospective analysis using propensity score adjustment†.

OBJECTIVES: Thoracoscopic surgery for lung metastasectomy remains controversial. The study aimed at determining the efficacy of thoracoscopic surgery for lung metastasectomy. METHODS: This was a multi-institutional, retrospective study that included 1047 patients who underwent lung metastasectomy for colorectal cancer between 1999 and 2014. Prognostic factors of overall survival were compared between the thoracoscopic and open thoracotomy groups using the multivariate Cox proportional hazard model. The propensity score, calculated using the preoperative covariates, included the era of lung surgery as a covariate. A stepwise backward elimination method, with a probability level of 0.15, was used to select the most powerful sets of outcome predictors. The difference between the radiological tumour number and the resected tumour number (delta_num) was also evaluated. RESULTS: The c -statistics and the P -value of the Hosmer-Lemeshow Chi-square of the propensity score model were 0.7149 and 0.1579, respectively. After adjusting for the propensity score, the thoracoscopy group had a better survival rate than the open group (stratified log-rank test: P = 0.0353). After adjusting for the propensity score, the most powerful predictive model for overall survival was that which combined thoracoscopy [hazard ratio (HR): 0.468, 95% CI: 0.262-0.838, P = 0.011] and anatomical resection (HR: 1.49, 95% CI: 1.134-1.953, P = 0.004). Before adjusting for the propensity score, the delta_num was significantly greater in the open group than in the thoracoscopy group (thoracoscopy: 0.06, open: 0.33, P = 0.001); however, after adjustment, there was no difference in the delta_num (thoracoscopy: 0.04, open: 0.19, P = 0.114). CONCLUSIONS: Thoracoscopic metastasectomy showed better overall survival than the open approach in this analysis. The thoracoscopic approach may be an acceptable option for resection of pulmonary metastases in terms of tumour identification and survival outcome in the current era.

Dose Estimating Application Software Modification: Additional Function of a Size-Specific Effective Dose Calculator and Auto Exposure Control.

Adequate dose management during computed tomography is important. In the present study, the dosimetric application software ImPACT was added to a functional calculator of the size-specific dose estimate and was part of the scan settings for the auto exposure control (AEC) technique. This study aimed to assess the practicality and accuracy of the modified ImPACT software for dose estimation. We compared the conversion factors identified by the software with the values reported by the American Association of Physicists in Medicine Task Group 204, and we noted similar results. Moreover, doses were calculated with the AEC technique and a fixed-tube current of 200 mA for the chest-pelvis region. The modified ImPACT software could estimate each organ dose, which was based on the modulated tube current. The ability to perform beneficial modifications indicates the flexibility of the ImPACT software. The ImPACT software can be further modified for estimation of other doses.

Hemodynamic-based Mapping of Neural Activity in Medetomidine-sedated Rats using a 1.5T Compact Magnetic Resonance Imaging System: A Preliminary Study.

The use of compact magnetic resonance (MR) systems for the neuroimaging of small animals is spreading. We investigated the potential of such systems in functional MR imaging (fMRI) of somatosensory cortex activity elicited by forepaw stimulation in medetomidine-sedated rats. Using a 1.5-tesla compact imager, we detected maximum activity with an electrophysiologically optimized frequency of 9 Hz in 3 appropriately sedated rats. With this compact system, we successfully mapped neural activity by combining optimum stimulation for a large hemodynamic response with appropriate anesthesia, thus demonstrating the utility of such systems in hemodynamic-based fMRI in preclinical and translational research.

Intratumoral gene expression of 5-fluorouracil pharmacokinetics-related enzymes in stage I and II non-small cell lung cancer patients treated with uracil-tegafur after surgery: a prospective multi-institutional study in Japan.

OBJECTIVES: This investigation was conducted to assess the use of the intratumoral mRNA expression levels of nucleic acid-metabolizing enzymes as biomarkers of adjuvant chemotherapy for non-small cell lung cancer (NSCLC) using uracil-tegafur in a multi-institutional prospective study. MATERIALS AND METHODS: 236 patients with a completely resected NSCLC (adenocarcinoma and squamous cell carcinoma) of pathological stage IA (maximum tumor diameter of 2 cm or greater), IB, and II tumors were given a dose of 250 mg of uracil-tegafur per square meter of body surface area per day orally for two years after surgery. Intratumoral mRNA levels of thymidylate synthase (TS), dihydropyrimidine dehydrogenase (DPD), orotate phosphoribosyltransferase (OPRT), and thymidine phosphorylase (TP) genes relative to an internal standard, ß-actin, were determined using laser-capture microdissection and fluorescence-based real time PCR detection systems. RESULTS AND CONCLUSION: Among 5-FU target enzymes, TS was the only one that showed a significant difference in the level of gene expression between the high and low gene expression groups, for both disease-free survival (DFS) and overall survival (OS), when patients were divided according to median values; 5-year DFS rates in high/low TS gene expression were 60.4% and 72.6%, respectively (p=0.050), 5-year OS rates were 78.1% and 88.6%, respectively (p=0.011). Cox's proportional hazard model indicated that the pathological stage and TS gene expression level were independent values for predicting DFS. The TS gene expression level was shown to be an independent predictive factor for DFS in stage I and II NSCLC patients who were treated with uracil-tegafur following surgery.

T-tube insertion for sclerotic subglottic stenosis.

T-tube insertion is effective treatment for subglottic stenosis, but it is generally difficult due to bending of the T-tube. In a 52-year-old woman with relapsing polychondritis, a T-tube was inserted after predilatation using Hegar dilators. We describe the details of our T-tube insertion methods for sclerotic subglottic stenosis.