A case of abdominal aortic aneurysm presenting with multiple organs embolization.

BACKGROUND: Distal embolization as the first manifestation of an abdominal aortic aneurysm (AAA) is relatively rare. AAAs presenting with multiple organs embolization are rarer and serious systemic conditions. There are no reports of life-saving outcomes in patients with AAAs presenting with multiple organs embolization prior to surgery. CASE PRESENTATION: A 78-year-old man presented with right acute lower limb ischemia (ALLI) and ischemic enteritis coexisting with an 83-mm AAA with a large mural thrombus. Although the patient underwent successful revascularization with endovascular treatment for right ALLI, the manifestation of ischemia of the calf muscles and infection forced right above-knee amputation. The patient also presented with ischemic colitis that resolved with conservative treatment. After receiving appropriate medical therapy and rehabilitation, the patient was successfully treated with open aortic repair for the AAA. CONCLUSION: We successfully performed open aortic surgery for a rare case of AAA presenting with multiple organs embolization.

Skeletal Muscle Mass Index Reduction Rate as a Prognostic Indicator for Patients Undergoing Pancreatectomy for Pancreatic Cancer.

Background/Aim: There have been many studies on skeletal muscle depletion before surgery, and skeletal muscle depletion is a known risk factor for poor prognosis. However, reports on the association between changes in skeletal muscle mass and prognosis after surgery for pancreatic cancer are very few. Patients and Methods: The data of 137 patients who underwent pancreatectomy for pancreatic cancer between 2005 and 2022 were reviewed. Muscle areas were measured at the third lumbar vertebral level, and skeletal muscle mass index (SMI) reduction rates were calculated. Patients were divided into two groups using receiver operating characteristic (ROC) curve analysis based on the SMI reduction rate with a cutoff of 14% reduction rate. The clinicopathological factors, overall survival (OS), and recurrence-free survival (RFS) were compared between the two groups. Survival rates were analyzed both univariately and multivariately to clarify the factors associated with poor prognosis after pancreatectomy. Results: A total of 102 patients met the inclusion criteria. SMI reduction rate ≥14% significantly correlated with advanced age and higher incidence of postoperative complications. In the multivariate Cox regression analysis, preoperative prognostic nutritional index (PNI) <40 and SMI reduction rate ≥14% were significantly associated with poor OS. Tumor size ≥3.0 cm, preoperative neutrophile-lymphocyte ratio ≥3.0, and SMI reduction rate ≥14% were significantly associated with poor RFS. Conclusion: The rate of skeletal muscle mass reduction after pancreatic surgery is an independent prognostic factor for survival in patients with pancreatic cancer.

A case of abdominal aortic aneurysm presenting as symptomatic disseminated intravascular coagulation treated with endovascular aneurysm repair and postoperative administration of Nafamostat mesylate.

BACKGROUND: Cases of abdominal aortic aneurysm discovered as purpura on the extremities with disseminated intravascular coagulation (DIC) are rare. The number of currently established strategies for the control of DIC with aortic aneurysm is limited. CASE PRESENTATION: An 85-year-old woman was referred to the hematology department because of purpura on her shoulder and thigh. Enhanced fibrinolytic-type DIC was diagnosed by a blood test. Enhanced computed tomography (CT) revealed 60-mm abdominal aortic and 42-mm right common iliac aneurysms. We performed endovascular aneurysm repair (EVAR) and coiling of the right internal iliac artery with postoperative administration of Nafamostat mesylate. The patient promptly recovered from DIC, and the purpura gradually disappeared. CONCLUSIONS: We safely performed EVAR with postoperative administration of Nafamostat mesylate for an abdominal aortic aneurysms that presented as symptomatic DIC.

Pure Red Cell Aplasia and Chromosomal Abnormality in a Patient With Lung Adenocarcinoma Receiving Immune Checkpoint Inhibitors: A Case Report.

BACKGROUND/AIM: Immune checkpoint inhibitors can induce immune-related adverse events in various organs, thus careful observation is required. CASE REPORT: A 69-year-old man was diagnosed with advanced lung adenocarcinoma and treated with combined therapy of carboplatin plus pemetrexed plus pembrolizumab. After two cycles of treatment, anemia was noted. Myelosuppression due to cytotoxic anticancer agents was suspected and the cytotoxic agents were discontinued, followed by three courses of pembrolizumab monotherapy. However, the anemia persisted, requiring red blood cell transfusions. A bone marrow biopsy revealed erythroblast hypoplasia and chromosomal abnormalities, resulting in a diagnosis of pure red cell aplasia. These adverse events were considered immune-related because of the treatment history with an immune checkpoint inhibitor, and 60 mg/day (1 mg/kg/day) of prednisolone was initiated. Anemia improved, and it did not recur during the tapering of prednisolone. CONCLUSION: Immune-related pure red cell aplasia should be considered for patients presenting anemia during treatment with immune checkpoint inhibitors.

Age-specific comparisons in the rate of force development of toe pressure strength and its association with the timed up and go test.

PURPOSE: It has recently been recommended that Rate of Force Development (RFD) be evaluated in addition to maximal muscle strength. There are no studies on RFD of toe pressure strength, and its importance in older adults and the extent to which it is associated with aging needs to be clarified. This study purpose was to examine the association between the RFD of toe pressure strength and timed up and go test (TUG) in an age-specific study. METHODS: This study is a cross-sectional study. Participants in the study included 159 younger adults (26.3 ± 13.1 years, 52% male) and 88 older adults (75.0 ± 6.2 years, 26% male). The RFD of toe pressure strength was determined from the force-time curve obtained during the toe pressure strength assessment, and the ability to exert maximum muscle force in the shortest possible time was assessed. Regression analysis was performed for each group to test the association between RFD of toe pressure strength and TUG by age. RESULTS: Younger adults showed no association between TUG and RFD of toe pressure strength, and significant association between TUG and RFD of toe pressure strength was found only in the older adults (standard regression coefficient = - 0.19, p = 0.048). CONCLUSION: This study showed a significant association between TUG and RFD of toe pressure strength in older adults. These findings show that RFD is one of the functions that should be assessed, particularly in older adults. Furthermore, it was suggested that approaching RFD could improve gait, standing, and sitting movements.

Transcriptome analysis of an AKT inhibitor-resistant endometrial cancer cell line.

BACKGROUND: Drug resistance in endometrial cancer (EC) is a serious problem and a barrier to improving prognosis. The PI3K/AKT/mTOR pathway is highly activated in EC and can serve as a potential therapeutic target. Inhibitors against AKT have been developed, but resistance to these inhibitors is a concern. This study aimed to establish AKT inhibitor resistant cell lines and identify differentially expressed genes (DEGs) between parental and AKT inhibitor resistant cell lines to understand the mechanism of drug resistance to AKT inhibitors in EC. METHODS: The sensitivity of eight EC cell lines to AKT inhibitor was analyzed. One of them was used to establish a drug-resistant cell line. DEGs were examined using RNA sequencing (RNA-seq). Furthermore, DEGs were comprehensively analyzed to identify hub genes. Hub genes were evaluated using quantitative real-time polymerase chain reaction. RESULTS: RNA-seq identified 617 DEGs. Hub genes were selected using bioinformatics analysis. The top 10 hub genes were TNF, CDH1, CCND1, COL1A1, CDH2, ICAM1, CAV1, THBS1, NCAM1, and CDKN2A. Relative mRNA expression was significantly upregulated for TNF, CDH1, CCND1, THBS1, p16INK4a, and p14ARF and significantly downregulated for CDH2, ICAM1, and NCAM1 in borussertib-resistant EC cell line. CONCLUSIONS: Drug resistance to AKT inhibitors may depend on genes related to cell adhesion-mediated resistance and transforming growth factor ß signaling.

A case of difficult-to-diagnose hepatic reactive lymphoid hyperplasia finally diagnosed by using PCR analysis of IgH-gene rearrangements: a case report.

Reactive lymphoid hyperplasia (RLH) of the liver is extremely rare. Despite advancements in diagnostic imaging technology, it is still difficult to distinguish from hepatocellular carcinoma (HCC). Herein, we present a case of hepatic RLH mimicking HCC that was postoperatively diagnosed using several imaging modalities. A 78-year-old female was referred to our hospital with a positive hepatitis C virus antibody (HCV Ab) test. Ultrasonography revealed a 13 mm isoechoic lesion in segment 8 of the liver. Contrast-enhanced computed tomography (CE-CT) demonstrated arterial hyperintensity and washout during the later phase. On ethoxybenzyl magnetic resonance imaging (EOB-MRI), the lesion was hyperenhanced in the arterial phase and of low intensity in the hepatocyte phase. Although the tumor markers were all within normal limits, the pattern of contrast enhancement of the tumor on CT and MRI was consistent with that of HCC. We performed S8 segmentectomy of the liver. Histological examination of the resected specimen revealed dense lymphoid tissue of variable sizes and shapes with expanded germinal centers. Immunohistochemical examination was positive for CD3, CD10 (germinal center), and CD20, and negative for B-cell lymphoma 2 (bcl-2) (germinal center) and Epstein-Barr virus (EBV). A polymerase chain reaction (PCR) analysis of IgH-gene rearrangements revealed polyclonality. Based on these findings, hepatic RLH was diagnosed. The postoperative course was uneventful, and the patient was discharged on the 10th postoperative day. She had a good quality of life after surgery and no liver nodule recurrence was detected at the 4-month medical follow-up. Hepatic RLH is an extremely rare disease and preoperative diagnosis is difficult. This should be considered in the differential diagnosis of single small hepatic tumors. An echo-guided biopsy and careful observation of imaging may help diagnose hepatic RLH, and a PCR analysis of IgH-gene rearrangements would be necessary for the definitive diagnosis of hepatic RLH.

Diagnostic Immunocytostaining with Peroxisome Proliferator-Activated Receptor-Gamma in Urine Cytology Samples.

INTRODUCTION: Urine cytology is a common method for detection of urothelial carcinoma (UC), however, is not high sensitivity. Improvement of the accuracy of cytodiagnosis using immunocytostaining as an auxiliary method is needed. This study aimed to determine the cytodiagnostic usefulness of peroxisome proliferator-activated receptor-gamma (PPAR-γ) immunocytostaining in urine cytology for the detection of UCs, particularly low-grade urothelial carcinomas (LGUC). METHODS: PPAR-γ immunocytostaining was performed for 37 UC cases and 26 benign cases. Among the UC cases, 22 cases were of the papillary proliferation type, not including the mixed type comprising both papillary and flat growth. Fifteen LGUC cases of all papillary proliferation types were included. For comparison, the same samples were also immunocytostained for p53 and Ki-67. RESULTS: Of the UC cases, 25 of 37 were positive for PPAR-γ, while 24 of the 26 benign cases were PPAR-γ-negative. Regardless of histological grading, 13 of the 22 UC cases with papillary proliferation were PPAR-γ-positive. In particular, PPAR-γ immunocytostaining showed higher sensitivity for LGUC cases than that of the other biomarkers. Regarding LGUC specifically, 4 of 10 cases not identified by primary cytology were detected by PPAR-γ immunocytostaining. CONCLUSION: PPAR-γ immunocytostaining enhances the accuracy of urine cytodiagnosis. Furthermore, PPAR-γ is a more useful immunobiomarker in urine cytology than p53 and Ki-67, the commonly used immunobiomarkers for malignant cell detection.

Glucocorticoid treatment and clinical outcomes in patients with polymyalgia rheumatica: A cohort study using routinely collected health data.

OBJECTIVE: We aimed to describe the following in patients with polymyalgia rheumatica (PMR): (1) real-world glucocorticoid (GC) therapy, (2) improvement in inflammatory parameters associated with disease activity (C-reactive protein [CRP] level and erythrocyte sedimentation rate [ESR]), and (3) incidence of GC-related adverse events (AEs). METHODS: A cohort study was conducted using a Japanese electronic medical records database. We included newly diagnosed PMR patients aged≥50years with baseline CRP levels≥10mg/L and/or ESR>30mm/h and an initial GC dose of≥5mg/day. The outcomes were GC dose, inflammatory parameters, and GC-related AEs. RESULTS: A total of 373 PMR patients (mean age, 77.3 years) were analyzed. The median initial GC dose was 15.0mg/day, which gradually decreased to 3.5mg/day by week 52. The median cumulative GC dose at week 52 was 2455.0mg. The median CRP level on day 0 was 64.3mg/L, which decreased during weeks 4-52 (1.4-3.2mg/L). At week 52, 39.0% of patients had a CRP level>3.0mg/L. The cumulative incidence of GC-related AEs at week 52 was 49.0% for osteoporosis, 30.2% for diabetes, 14.9% for hypertension, 12.2% for peptic ulcer, 11.3% for dyslipidemia, 2.9% for glaucoma, and 4.3% for serious infection. The incidence of osteoporosis and diabetes increased with the GC dose. CONCLUSION: The incidence of GC-related AEs was associated with the GC dose in PMR patients. Further research is required to identify treatment strategies that can effectively control PMR disease activity while minimizing GC use.

Differences in Improvement of Physical Function in Older Adults with Long-Term Care Insurance with and without Falls: A Retrospective Cohort Study.

(1) Background: This study examined the differences in changes in physical function with and without falls after daycare use among frail older adults with long-term care insurance (LTCI). (2) Methods: In this retrospective cohort study, 82 of 96 consecutive daycare center users met the inclusion criteria. The participants were divided into two groups based on the presence or absence of falls 6-12 months after use. Participant characteristics in the fall and non-fall groups and physical function at baseline and six months in each group were compared. Using analysis of covariance, we analyzed physical function and its changes between the two groups, and cut-off values were calculated using receiver operating characteristic curves. (3) Results: Gait speed, timed up-and-go test, and 30 s chair stand test (CS30) improved significantly over six months in the no-fall group (n = 70) and all participants (n = 82) (p < 0.01). Gait speed in the fall group (n = 12) improved significantly over six months (p = 0.04). The fall group had significantly lower adjusted ΔCS30 scores than the no-fall group (p = 0.03), with a cutoff value of 2 (p = 0.024). (4) Conclusions: In older adults with LTCI, physical function with and without falls after daycare use differed by ΔCS30, with a cutoff value of 2.

Association between Toe Pressure Strength in the Standing Position and Maximum Walking Speed in Older Adults.

BACKGROUND: Considering concerns about conventional toe grip strength, we devised a method to measure toe pressure strength in the standing position, which is close to the actual motion. This study examined the association between toe pressure strength in the standing position and walking speed among older adults. METHODS: This cross-sectional study included 150 community-dwelling older adults (81±8 years, 73% female) who participated in the physical fitness test. We analyzed the correlation between the participants' maximum walking speed and physical function. Furthermore, we performed regression analysis with the maximum walking speed as the dependent variable to examine the association with toe pressure strength in the standing position. We also examined the association between maximum walking speed and toe pressure strength in the standing position by introducing a covariate. RESULTS: Correlation analysis revealed a significant positive correlation between maximum walking speed and toe pressure strength in the standing position, with a moderate effect size (r=0.48, p<0.001). Moreover, multiple regression analysis with covariates showed an association between maximum walking speed and toe pressure strength in the standing position (standardization factor=0.13, p<0.026). CONCLUSION: Toe pressure strength in the standing position was associated with maximum walking speed. This finding clarifies the significance of assessing toe pressure strength in the standing position and suggests that enhanced toe pressure strength in the standing position may increase maximum walking speed.

Heterologous expression and characterization of salt-tolerant ß-glucosidase from xerophilic Aspergillus chevalieri for hydrolysis of marine biomass.

A salt-tolerant exo-ß-1,3-glucosidase (BGL_MK86) was cloned from the xerophilic mold Aspergillus chevalieri MK86 and heterologously expressed in A. oryzae. Phylogenetic analysis suggests that BGL_MK86 belongs to glycoside hydrolase family 5 (aryl-phospho-ß-D-glucosidase, BglC), and exhibits D-glucose tolerance. Recombinant BGL_MK86 (rBGL_MK86) exhibited 100-fold higher expression than native BGL_MK86. rBGL_MK86 was active over a wide range of NaCl concentrations [0%-18% (w/v)] and showed increased substrate affinity for p-nitrophenyl-ß-D-glucopyranoside (pNPBG) and turnover number (kcat) in the presence of NaCl. The enzyme was stable over a broad pH range (5.5-9.5). The optimum reaction pH and temperature for hydrolysis of pNPBG were 5.5 and 45 °C, respectively. rBGL_MK86 acted on the ß-1,3-linked glucose dimer laminaribiose, but not ß-1,4-linked or ß-1,6-linked glucose dimers (cellobiose or gentiobiose). It showed tenfold higher activity toward laminarin (a linear polymer of ß-1,3 glucan) from Laminaria digitata than laminarin (ß-1,3/ß-1,6 glucan) from Eisenia bicyclis, likely due to its inability to act on ß-1,6-linked glucose residues. The ß-glucosidase retained hydrolytic activity toward crude laminarin preparations from marine biomass in moderately high salt concentrations. These properties indicate wide potential applications of this enzyme in saccharification of salt-bearing marine biomass.

First-onset type 1 diabetes in an elderly woman with multiple islet-associated autoantibodies, and a literature review.

An 80-year-old Japanese woman had shown no indication of diabetes but regularly saw a primary-care physician for health management. Six months before her referral to our hospital, her HbA1c was 6.0%. She was referred to us for diabetic ketosis because she was urine ketone body-positive with a blood glucose level of 397 mg/dL and HbA1c of 14.6%. She was diagnosed with type 1 diabetes mellitus (T1DM) with glutamic acid decarboxylase (GAD) antibodies >2,000 U/mL (by ELISA) and IA-2 antibodies >30 U/mL. Insulin injections were introduced, and she was discharged. Laboratory tests during her hospitalization were negative for thyroid antibodies (TgAb, TPOAb). Elderly individuals with first-onset T1DM who are positive for IA-2 antibody are rare, and multiple-positive cases of pancreatic islet-associated autoantibodies are particularly rare. IA-2 antibodies have an approx. 60% positive rate in acute-onset T1DM, but they are more likely to be positive in children and adolescents and are known to turn negative earlier than anti-GAD antibodies. Although a large amount of insulin is needed in general in such cases, our patient was successfully treated with a small amount of insulin. IA-2 antibody has been reported to be positive even in GAD antibody-negative individuals. In some cases, IA-2 antibody and other antibodies are positive even in elderly-onset diabetes, and this contributes to the diagnosis of T1DM.

The significance of information and communication technology education via tablets in college of physical therapy.

[Purpose] This study aimed to clarify whether collaborative learning could be promoted via information and communication technology education using tablets at college of physical therapy. [Participants and Methods] An online survey was conducted to evaluate collaborative learning among 81 first-year students at the Department of Physical Therapy actively using tablets in classes (six specific categories). [Results] The Friedman test had significant results, and a significant primary effect was observed between each questionnaire item. Following this, the Bonferroni test was performed for multiple comparisons, with significant differences were observed among certain items. [Conclusion] We reported employing tablets in the classroom positively impacted collaborative learning. Here, among the evaluations of collaborative learning, the items with the best results corresponded mainly to communication activation between students.

Comparison of toe pressure strength in the standing position and toe grip strength in association with the presence of assistance in standing up: a cross-sectional study in community-dwelling older adults.

PURPOSE: We believe that toe pressure strength in the standing position, which is closer to the actual movement, is more associated with standing up in the older adults than the conventional toe grip strength. Therefore, the purpose of this study is to examine the association between toe pressure strength in the standing position and the presence of assistance in standing up in the older adults. METHODS: Ninety-five community-dwelling older adults (82 ± 8 years old, 72% female) were included in this study. The patients were evaluated based on their need for assistance in standing up. Physical functions, including toe pressure strength in the standing position, toe grip strength, hand grip strength, knee extension strength, one-leg standing time with eyes open, and maximal walking speed, were measured. RESULTS: When compared with and without assistance to stand up, the group requiring assistance had weaker toe pressure strength in the standing position than the group without assistance (p = 0.015, ES = 0.53). After adjusting for confounding factors, the final model revealed that toe pressure strength in the standing position was associated with the use of assistance in standing up (odds ratio 0.94 [0.88-0.99, p = 0.025]). CONCLUSION: Toe pressure strength in the standing position was associated with the use of assistance in standing up in older adults. Improving toe pressure strength in the standing position may facilitate the ability of older adults to stand up.

Improvement in salt-tolerance of Aspergillus oryzae γ-glutamyl transpeptidase via protein chimerization with Aspergillus sydowii homolog.

γ-Glutamyl transpeptidase is one of the key enzymes involved in glutamate production during high-salt fermentation of soy sauce and miso by koji mold, Aspergillus oryzae. However, the activity of γ-glutamyl transpeptidase from A. oryzae (AOggtA) is markedly reduced in the presence of NaCl, thus classifying it as a non-salt-tolerant enzyme. In contrast, the homologous protein from the xerophilic mold, A. sydowii (ASggtA) maintains its activity under high-salt conditions. Therefore, in this study, a chimeric enzyme, ASAOggtA, was designed and engineered to improve salt-tolerance in AOggtA by swapping the N-terminal region, based on sequence and structure comparisons between salt-tolerant ASggtA and non-salt-tolerant AOggtA. The parental AOggtA and ASggtA and their chimera, ASAOggtA, were heterologously expressed in A. oryzae and purified. The chimeric enzyme inherited the superior activity and stability from each of the two parent enzymes. ASAOggtA showed > 2-fold greater tolerance than AOggtA in the presence of 18% NaCl. In addition, the chimera showed a broader range of pH stability and greater thermostability than ASggtA. AOggtA and ASAOggtA were sy over the range pH 3.0 to pH 10.5. Thermal stability was found to be in the order AOggtA (57.5 °C, t1/2 = 32.5 min) > ASAOggtA (55 °C, t1/2 = 20.5 min) > ASggtA (50 °C, t1/2 = 12.5 min). The catalytic and structural characteristics indicated that non-salt-tolerant AOggtA would not undergo irreversible structural changes in the presence of NaCl, but rather a temporary conformational change, which might result in reducing the substrate binding and catalytic activity, on the basis of kinetic properties. In addition, the chimeric enzyme showed hydrolytic activity toward L-glutamine that was as high as that of AOggtA. The newly-designed chimeric ASAOggtA might have potential applications in high-salt fermentation, such as miso and shoyu, to increase the content of the umami-flavor amino acid, L-glutamate.

Clinical features of polymyalgia rheumatica patients in Japan: Analysis of real-world data from 2015 to 2020.

OBJECTIVES: To assess clinical features in patients with polymyalgia rheumatica (PMR) in Japan by the International Classification of Disease (ICD)-10 code assignment. METHODS: Demographics, treatment patterns, and concomitant diseases (identified using ICD-10 code only) in patients who were assigned the PMR ICD-10 code M35.3 at least once between 1 January 2015 and 31 December 2020 were aggregated from a nationwide medical information database owned by the Health, Clinic, and Education Information Evaluation Institute. RESULTS: The cumulative number of patients with PMR was 6325 (mean [standard deviation] age, 74.3 [11.4] years; male:female, 1:1.3). Most patients were >50 years (96.5%) with >33% between 70 and 79 years. Glucocorticoids were prescribed in ∼54% of patients within 30 days of PMR code assignment. All other drug types were prescribed in <5% of patients. Hypertension, diabetes mellitus, rheumatoid arthritis, and osteoporosis were noted in >25% and giant cell arteritis in 1% of patients. During the study period, 4075 patients were newly assigned the PMR code and 62% were prescribed glucocorticoids within 30 days. CONCLUSIONS: This is the first retrospective real-world data analysis describing the clinical features of PMR in a large patient population from Japan. Further studies of prevalence, incidence, and clinical features are warranted in patients with PMR.

A ruptured sarcomatoid hepatocellular carcinoma treated with combined immunotherapy.

Sarcomatoid hepatocellular carcinoma (sHCC) is a rare phenotype of HCC with extremely poor prognosis and no established pharmacological treatment. Interventional therapies such as radiofrequency ablation (RFA) or transcatheter arterial embolization (TAE) have been shown to limit the development of sHCC through mechanisms involving hypoxia-induced epithelial-mesenchymal transition. This report describes an 83-year-old man who developed sHCC 2 years after RFA treatment for HCC and experienced sHCC rupture. Following TAE-induced hematostasis, he was administered lenvatinib for tumor control. Although his physical status had improved, due to loss of fever and attenuation of arterial enhancement in the tumor, for 1 month after lenvatinib administration, tumor re-growth was observed 2 months after lenvatinib treatment. His general condition was preserved, and he was treated with 10 courses of atezolizumab plus bevacizumab (Atez+Bev), resulting in tumor shrinkage that was maintained for 3-8 months after Atez+Bev. Findings in this patient showed that combined immunotherapy was effective for sHCC. Further investigation in additional patients is required to maximize prognosis in patients with sHCC.

The inclusion of nuclear area improves the Paris system for reporting urinary cytology.

OBJECTIVE: The Paris System for Reporting Urinary Cytology (TPS) is a well-known urinary diagnostic model; however, occasional false-positives are a problem. To address this issue, we developed an improved algorithm (IA), based on additional cytological features, for TPS diagnosis. METHODS: Cytological features were evaluated in 29 hard-to-classify cases, including 22 malignant cases and seven benign cases, using image analysis. The optimal IA was determined using the area under the receiver operating characteristic curve as an index. Re-evaluation was performed by applying measured values to the TPS and IA algorithms. RESULTS: Using TPS, 12 of the 22 malignant cases were reassigned to a more appropriate category, and the remaining 10 malignant cases remained hard-to-classify. Two of the seven benign cases were classified as suspicious for high-grade urothelial carcinoma, and the remaining five benign cases remained in the original category. The IA, which included nuclear area as a parameter, showed the same diagnostic sensitivity as TPS, and three of the seven benign cases were reassessed as negative. Thus, the positive and negative predictive values of the IA were higher than those of TPS (84.6% and 100% vs 75.9% and 0%). CONCLUSIONS: The newly developed IA is a practical algorithm with which to address the limitations of TPS and thus may contribute to improved diagnostic accuracy.