Significance of KRAS mutation in patients receiving mFOLFOX6 with or without bevacizumab for metastatic colorectal cancer.

BACKGROUND/AIMS: KRAS mutation is an important prognostic factor for patients with metastatic colorectal cancer receiving anti-epidermal growth factor receptor therapy. However, the influence of KRAS mutation on the response to mFOLFOX6 ± bevacizumab remains unclear. METHODOLOGY: We retrospectively analyzed 49 patients who received modified FOLFOX6 (mFOLFOX6) ± bevacizumab as first-line therapy. Genetic analysis showed that 30 patients had wild-type (WT) KRAS and 19 patients hadKRAS mutations (MT). These two groups were compared with regard to the response rate (RR), progression-free survival (PFS), and overall survival (OS). RESULTS: The RR was not significantly different between the WT and MT groups, but PFS and OS were significantly better in the WT group than the MT group (PFS: 11.8 months vs. 8.7 months, p<0.01; OS: 37.8 months vs. 29.3 months, p<0.0385). A similar analysis of 27 patients who were treated with mFOLFOX6 + bevacizumab showed a better prognosis for WT patients. Multivariate analysis also revealed that KRAS mutation was an independent factor with a significant relation to PFS. CONCLUSIONS: These results suggest that KRAS mutation may be a useful prognostic marker for patients with metastatic colorectal cancer receiving mFOLFOX6 ± bevacizumab therapy, especially for patients treated with mFOLFOX6 + bevacizumab.

Risk factors for parastomal hernia in Japanese patients with permanent colostomy.

PURPOSE: Although the definitive risk factors for parastomal hernia development remain unclear, potential contributing factors have been reported from Western countries. The aim of this study was to identify the risk factors for parastomal hernia in Japanese patients with permanent colostomies. METHODS: All patients who received abdominoperineal resection or total pelvic exenteration at our institution between December 2004 and December 2011 were reviewed. Patient-related, operation-related and postoperative variables were evaluated, in both univariate and multivariate analyses, to identify the risk factors for parastomal hernia formation. RESULTS: Of the 80 patients who underwent colostomy, 22 (27.5 %) developed a parastomal hernia during a median follow-up period of 953 days (range 15-2792 days). Hernia development was significantly associated with increasing patient age and body mass index, a laparoscopic surgical approach and the transperitoneal route of colostomy formation. In the multivariate analysis, the body mass index (p = 0.022), the laparoscopic approach (p = 0.043) and transperitoneal stoma creation (p = 0.021) retained statistical significance. CONCLUSIONS: Our findings in Japanese ostomates match those from Western countries: a higher body mass index, the use of a laparoscopic approach and a transperitoneal colostomy are significant independent risk factors for parastomal hernia formation. The precise role of the stoma creation route remains unclear.

Balloon kyphoplasty combined with percutaneous pedicle screw (PPS) for the treatment of osteoporotic thoracolumbar fractures has minimum correction loss 2 years after surgery: compared to vertebroplasty using hydroxyapatite block combined with PPS.

BACKGROUND: Balloon kyphoplasty (BKP) is a useful treatment performed in patients with painful osteoporotic vertebral body fracture (OVF). However, in cases with large intra-vertebral clefts and cases with posterior spinal tissue damage, adjacent vertebral body fractures (AVFs), and cement migration may occur early after BKP, which may be a factor for poor results. In such cases, percutaneous vertebroplasty (PVP) combined with percutaneous pedicle screw (PPS) is useful treatment. This study compared BKP combined with PPS (BKP + PPS) compared to PVP using hydroxyapatite (HA) block combined with PPS (HAVP + PPS) for thoracolumbar OVF (TLOVF). METHODS: Twenty-eight patients who sustained painful TLOVFs without neurologic deficits underwent HAVP + PPS (group H, n=14) or BKP + PPS (group B, n=14). We evaluated time from injury to surgery, pre- and post-operative visual analogue scale (VAS) of low back pain, wedging angle of fractured vertebra, duration of operation, intraoperative blood loss, number of instrumented vertebra, and length of stay at hospital. RESULTS: Group B had significantly less surgery time and less blood loss during surgery. VAS of low back pain improved equally in both groups, but at 1 year and 2 years postoperatively, wedging angle of fractured vertebra progressed significantly in group H compared with group B. CONCLUSIONS: PPS fixation combined with percutaneous vertebral cement augmentation with BKP for OVF was suggested to be minimally invasive in the elderly patients. In addition, there is no correction loss of the fractured vertebral body after BKP + PPS, which is considered to be a useful surgical procedure.

Moment arms of the ankle throughout the range of motion in three planes.

BACKGROUND: The moment, a force applied at a distance, is responsible for movement and balance. A key component of the moment is the moment arm. The moment arms of nine muscles surrounding the ankle complex during motion in three planes, were studied. MATERIALS AND METHODS: Five cadaveric feet were mounted in a testing device that created moments in the sagittal, coronal and transverse planes. Axial and tendon loads were applied as the foot was passively moved in these planes. Tendon excursions and bone kinematics were monitored. The moment arm was calculated using the tendon excursion method and averaged across all specimens. RESULTS: The largest average moment arm during plantarflexion/dorsiflexion, was the Achilles (mean, 53.1; SD, 5.1 mm). During internal/external rotation the largest moment arm was the peroneus brevis (mean, 20.5; SD, 6.4 mm). During inversion/eversion, the largest moment arm was the peroneus longus (31 mm; SD, 2.3 mm). CONCLUSION: This study quantified the functional moment arms of nine tendons of the ankle/foot. The involvement of multiple tendons in multiple planes of motion should be considered in computational models and when deciding treatments. CLINICAL RELEVANCE: The correlation between moment arms and muscle function has significant effects on treatment efficacy. Information on the balance of moments around the ankle will assist in achieving optimal biomechanical behavior following operative treatments.

[Hepatic arterial infusion chemotherapy with oxaliplatin in unresectable liver metastases from colorectal cancer after systemic chemotherapy failure].

UNLABELLED: We report 5 cases of colorectal liver metastases (CRLM) with hepatic arterial infusion (HAI) oxaliplatin after systemic infusion chemotherapy failure. Patients with unresectable CRLM and history of systemic chemotherapy failure were treated with HAI oxaliplatin (L-OHP 100 mg/body, 2 hours) combined with intravenous (iv) levofolinate calcium (175 mg/body, 2 hours) and iv bolus 5-FU (500 mg/body) every 2 weeks. RESULT: An average age was 58 years. All patients had previously received FOLFOX. Lung metastases had already existence before HAI oxaliplatin in 4 patients. A median of 10 treatments were administered (range 5-14). Serum level of CEA was decreased in 4 cases. In 2 patients, lung metastasis developed while a PR was obtained in the liver metastasis. Progress disease (PD) was confirmed in other 3 patients. No major toxicity was presented. The median time to progression free survival was 3.0 months and the median overall survival was 7.1 months. CONCLUSION: HAI oxaliplatin might be beneficial as a salvage therapy for CRLM without extrahepatic metastasis, which demonstrated an acceptable tolerability and maintenance of QOL.

Usefulness of Machine Learning-Based Gut Microbiome Analysis for Identifying Patients with Irritable Bowels Syndrome.

Irritable bowel syndrome (IBS) is diagnosed by subjective clinical symptoms. We aimed to establish an objective IBS prediction model based on gut microbiome analyses employing machine learning. We collected fecal samples and clinical data from 85 adult patients who met the Rome III criteria for IBS, as well as from 26 healthy controls. The fecal gut microbiome profiles were analyzed by 16S ribosomal RNA sequencing, and the determination of short-chain fatty acids was performed by gas chromatography-mass spectrometry. The IBS prediction model based on gut microbiome data after machine learning was validated for its consistency for clinical diagnosis. The fecal microbiome alpha-diversity indices were significantly smaller in the IBS group than in the healthy controls. The amount of propionic acid and the difference between butyric acid and valerate were significantly higher in the IBS group than in the healthy controls (p < 0.05). Using LASSO logistic regression, we extracted a featured group of bacteria to distinguish IBS patients from healthy controls. Using the data for these featured bacteria, we established a prediction model for identifying IBS patients by machine learning (sensitivity >80%; specificity >90%). Gut microbiome analysis using machine learning is useful for identifying patients with IBS.

Safety and Efficacy of Percutaneous Pedicle Screw Placement Using a Power Tool.

INTRODUCTION: This study compared traditional manual methods and power tool use with regard to the speed and accuracy of percutaneous pedicle screw (PPS) placement and determined the advantages associated with the use of power tools. Although the indication of PPS placement in minimally invasive spine stabilization (MISt) procedures has been recently expanded, there are no reports on PPS insertion using a power tool. METHODS: We evaluated 35 patients who underwent PPS insertion using a power tool during MISt procedures. On one side, PPS insertion was performed using the manual (M) method, whereas on the contralateral side, insertion was performed using the power tool (P) method. We assessed the number of implanted PPSs, time taken to implant PPSs after guidewire insertion, and accuracy of PPS placement as ranked postoperatively using computed tomography images. RESULTS: A total of 294 PPSs were inserted (147 using the M method and 147 using the P method). The mean PPS insertion time was 10.5 s using the P method and 27.4 s using the M method. The time required for inserting a screw using the P method remained consistent in the range of 10-15 s, whereas the time using the M method tended to increase from the second screw onward, with a range of 25-30 s. With regard to PPS insertion accuracy, a 2 mm or more pedicle breach was noted in 2 (1.4%) case after the P method and in 2 (1.4%) case after the M method. CONCLUSIONS: PPS placement using power tools has the potential to save the surgical time during MISt procedures.

The effect of flatfoot deformity and tendon loading on the work of friction measured in the posterior tibial tendon.

BACKGROUND: There is limited information regarding the mechanical factors contributing to the progression of posterior tibial tendon dysfunction. Therefore, an investigation of the mechanical forces on the posterior tibial tendon may improve our understanding of this pathology. METHODS: The gliding resistance and excursion of the posterior tibial tendon in the retromalleolar region was measured in seven cadaveric lower limbs in the coronal, transverse, and sagittal planes. These data were used to calculate the work of friction and to characterize the effect of different tendon loading levels (0.5, 1.0, and 2.0 kg) in the intact and flatfoot conditions. FINDINGS: Flatfoot deformity significantly increased the excursion of the posterior tibial tendon (P<0.05), increased forefoot and hindfoot range of motion in the coronal and transverse planes (P<0.05) and the work of friction in the coronal and transverse planes (P<0.05), but not in the sagittal plane. There was a significant increase in the work of friction between 0.5 and 2 kg (P<0.05) in all three planes of motion. INTERPRETATION: The motions in the coronal and transverse planes have a greater effect on the work of friction of the posterior tibial tendon than sagittal plane motion in the flatfoot condition. This study suggests that aggressive treatment of early stage PTT dysfunction with bracing designed to limit coronal and transverse motions, while permitting sagittal motion should be investigated further. Such bracing may decrease the potential of progressive deformity while allowing for more normal ambulation.

Chemoradiation therapy with S-1 for primary squamous cell carcinoma of the rectum: report of three cases.

PURPOSE: Although successful treatment of squamous cell carcinoma (SCC) of the rectum using chemoradiation therapy (CRT) has been reported, a standard protocol has yet to be established. The aim is to ascertain the effectiveness of CRT with S-1 for three patients with SCC of the rectum. CASE PRESENTATION: We treated three female patients complaining of rectal bleeding. The patients were diagnosed as having primary SCC of the rectum by means of routine examinations; one of them was a very rare case because of the presence of two lesions in the lower rectum. We treated the patients using CRT with S1 at a radiation dose of 1.8 Gy/fraction given five times weekly (Monday to Friday) to a median dose of 59.4 (45 to 59.4) Gy; S-1 (80 mg/m(2)/day) was administered orally during radiation therapy. One of three patients had an adverse event involving massive hemorrhage from the tumor. All patients exhibited an excellent response to CRT with S-1; two patients had a complete response, and one patient had a partial response and underwent a posterior pelvic exenteration with advancement flap reconstruction as a salvage treatment. Pathological examination of the resected specimen and lymph nodes revealed no tumor cells indicating a pathological complete response. In this series, the response rate was 100%. CONCLUSIONS: We suggest that CRT with S-1 be chosen as the first-line therapy for SCC of the rectum. However, a large study will be required to establish a safe and effective regimen.

Breath hydrogen and methane levels in a patient with volvulus of the sigmoid colon.

Volvulus of the large bowel is the third most common cause of colonic obstruction. A patient with colonic obstruction or delayed small intestinal transit may frequently have bacterial overgrowth and increased breath hydrogen (H(2)) and/or methane (CH(4)) excretion because the bacterium can contact with food residues for a longer time. A 39 year old woman attended our hospital with complaints of abdominal pain and distension. This patient's abdominal radiograph showed an inverted U-shaped shadow. The fasting breath CH(4) level was 26 ppm. An endoscopic procedure was immediately carried out with suspected sigmoid colon volvulus, and detorsion was achieved. There was resolution of the sigmoid volvulus after colonoscopy, and breath CH(4) concentration in the next morning decreased to 10 ppm. A liquid meal was supplied at noon on the second hospital day. The breath CH(4) concentration increased markedly to 38 ppm at 18:00 although she had no abdominal symptoms. This value peaked at 42 ppm at 18:00 on the third hospital day and was gradually reduced to 20 ppm the next day. The breath H(2) concentration value kept a low level during fasting and increased markedly to 51 ppm the next day after a liquid meal was supplied. The next morning, fasting breath H(2) concentration rapidly decreased to 6 ppm. This suggests that changes in breath H(2) levels may reflect transient malabsorption after a liquid test meal is supplied. In conclusion, breath H(2) and CH(4) analysis may be another tool for evaluating the intestinal circumstances.