Abdominal musculature segmentation and surface prediction from CT using deep learning for sarcopenia assessment.

PURPOSE: The purpose of this study was to build and train a deep convolutional neural networks (CNN) algorithm to segment muscular body mass (MBM) to predict muscular surface from a two-dimensional axial computed tomography (CT) slice through L3 vertebra. MATERIALS AND METHODS: An ensemble of 15 deep learning models with a two-dimensional U-net architecture with a 4-level depth and 18 initial filters were trained to segment MBM. The muscular surface values were computed from the predicted masks and corrected with the algorithm's estimated bias. Resulting mask prediction and surface prediction were assessed using Dice similarity coefficient (DSC) and root mean squared error (RMSE) scores respectively using ground truth masks as standards of reference. RESULTS: A total of 1025 individual CT slices were used for training and validation and 500 additional axial CT slices were used for testing. The obtained mean DSC and RMSE on the test set were 0.97 and 3.7 cm2 respectively. CONCLUSION: Deep learning methods using convolutional neural networks algorithm enable a robust and automated extraction of CT derived MBM for sarcopenia assessment, which could be implemented in a clinical workflow.

Machine learning algorithms can classify outdoor terrain types during running using accelerometry data.

BACKGROUND: Running is a popular physical activity that benefits health; however, running surface characteristics may influence loading impact and injury risk. Machine learning algorithms could automatically identify running surface from wearable motion sensors to quantify running exposures, and perhaps loading and injury risk for a runner. RESEARCH QUESTION: (1) How accurately can machine learning algorithms identify surface type from three-dimensional accelerometer sensors? (2) Does the sensor count (single or two-sensor setup) affect model accuracy? METHODS: Twenty-nine healthy adults (23.3 ±â€¯3.6 years, 1.8 ±â€¯0.1 m, and 63.6 ±â€¯8.5 kg) participated in this study. Participants ran on three different surfaces (concrete, synthetic, woodchip) while fit with two three-dimensional accelerometers (lower-back and right tibia). Summary features (n = 208) were extracted from the accelerometer signals. Feature-based Gradient Boosting (GB) and signal-based deep learning Convolutional Neural Network (CNN) models were developed. Models were trained on 90% of the data and tested on the remaining 10%. The process was repeated five times, with data randomly shuffled between train-test splits, to quantify model performance variability. RESULTS: All models and configurations achieved greater than 90% average accuracy. The highest performing models were the two-sensor GB and tibia-sensor CNN (average accuracy of 97.0 ±â€¯0.7 and 96.1 ±â€¯2.6%, respectively). SIGNIFICANCE: Machine learning algorithms trained on running data from a single- or dual-sensor accelerometer setup can accurately distinguish between surfaces types. Automatic identification of surfaces encountered during running activities could help runners and coaches better monitor training load, improve performance, and reduce injury rates.

Gait adaptations of older adults on an uneven brick surface can be predicted by age-related physiological changes in strength.

BACKGROUND: Outdoor falls in community-dwelling older adults are often triggered by uneven pedestrian walkways. It remains unclear how older adults adapt to uneven surfaces typically encountered in the outdoor built-environment and whether these adaptations are associated to age-related physiological changes. RESEARCH QUESTION: The aims of this study were to (1) compare gait parameters over uneven and flat brick walkways, (2) evaluate the differences between older and young adults for these two surfaces, and (3) assess if physiological characteristics could predict adaptations in older adults. METHODS: Balance, strength, reaction-time, full-body marker positions, and acceleration signals from a trunk-mounted inertial measurement unit were collected in seventeen older (71.5 ±â€¯4.2 years) and eighteen young (27.0 ±â€¯4.7 years) healthy adults to compute lower-limb joint kinematics, spatio-temporal parameters, dynamic stability, and accelerometry-derived metrics (symmetry, consistency, and smoothness). RESULTS: Both groups increased hip flexion at foot-strike, while decreasing ankle dorsiflexion, margin of stability, symmetry, and consistency on the uneven, compared to flat, surface. Older, compared to young, adults showed a larger increase in knee flexion at foot-strike and a larger decrease in smoothness on the uneven surface. Only young adults decreased hip abduction on the uneven surface. Strength, not balance nor reaction-time, was the main predictor of hip abduction in older adults on both surfaces. SIGNIFICANCE: While older adults may be especially vulnerable, uneven surfaces negatively impact gait, irrespective of age, and could represent a risk to all pedestrians.

[Arterial and portal venous complications after HPB surgical procedures: Interdisciplinary management]. / Arterielle und portalvenöse Gefäßkomplikationen nach HBP-Eingriffen : Interdisziplinäres Management.

The surgical treatment of hepatopancreatobiliary (HPB) diseases requires complex operative procedures. Within the last decades the morbidity (36-50 %) and mortality (<5 %) of these procedures could be reduced; nonetheless, postoperative complications still occur in 41.2 % of cases. Compared with hepatobiliary procedures, pancreatic surgery shows an increased rate of complications. Postoperative bleeding has a major effect on the outcome and the incidence is 6.7 % after pancreatic surgery and 3.2 % after hepatobiliary surgery. The major causes of early postoperative hemorrhage are related to technical difficulties in surgery whereas late onset postoperative hemorrhage is linked to anastomosis insufficiency, formation of fistulae or abscesses due to vascular arrosion or formation of pseudoaneurysms. In many cases, delayed hemorrhage is preceded by a self-limiting sentinel bleeding. The treatment is dependent on the point in time, location and severity of the hemorrhage. The majority of early postoperative hemorrhages require surgical treatment. Late onset hemorrhage in hemodynamically stable patients is preferably treated by radiological interventions. After interventional hemostatic therapy 8.2 % of patients require secondary procedures. In the case of hemodynamic instability or development of sepsis, a relaparotomy is necessary. The treatment concept includes surgical or interventional remediation of the underlying cause of the hemorrhage. Other causes of postoperative morbidity and mortality are arterial and portal venous stenosis and thrombosis. Following liver resection, thrombosis of the portal vein occurs in 8.5-9.1 % and in 11.6 % following pancreatic resection with vascular involvement. Interventional surgical procedures or conservative treatment are suitable therapeutic options depending on the time of diagnosis and clinical symptoms. The risk of morbidity and mortality after HPB surgery can be reduced only in close interdisciplinary cooperation, which is particularly true for vascular complications.

[Biliary leaks after liver resection. Prevention and treatment]. / Gallenleckage nach Leberresektion. Vermeidung und Behandlung.

The surgical treatment of primary and secondary liver pathologies is nowadays standard practice. Since the first major resections performed by Langenbruch in 1888 there have been significant developments in the surgical technique. In addition to the surgical technique, the diagnostics and patient selection, perioperative care and anesthetic management as well as knowledge of liver anatomy and physiology have also shown significant developments. The proportion of complex operations, even within the framework of multimodal concepts has also increased. Despite this increasing complexity, the morbidity (< 45 %) and mortality (< 5 %) of liver surgery could be clearly reduced; however, the incidence of postoperative biliary leaks in large published series currently lies between 0 % and 30 % and has only shown a minimal reduction in recent years. The management of bile leakage requires an interdisciplinary management involving endoscopic and radiological, interventional or operative therapy. Most leakages (69-94 %) persist under conservative treatment (drainage and if necessary antibiotic therapy). For high volume fistulas and persistent biliary leakage endoscopic retrograde cholangiography (ERC) with stent placement represents the therapy of choice. Infections with biliary peritonitis and failure of interventional strategies often require revision surgery, possibly consisting of suturing if a leakage is identifiable, replacement of drainages or application of a bile duct drainage (e.g. T-drain or transhepatic external biliary drainage).

Assessment and monitoring of liver function by ¹³C-aminopyrine breath test after selective transarterial chemoembolisation of hepatocellular carcinoma.

BACKGROUND: Liver function and tumor staging are essential parameters for selection of treatment modalities in patients with hepatocellular carcinoma (HCC). Transarterial chemoembolization (TACE) is associated with a risk of deterioration of liver function. In clinical routine hepatic function in patients with liver cirrhosis is assessed by the Child-Pugh-classification. Dynamic breath tests allow the assessment of the hepatic functional mass and have the potential to give more accurate information on hepatic function periinterventionally. PATIENTS AND METHODS: A prospective clinical study was performed in 13 patients receiving a total of 18 TACE sessions. (13)C-aminopyrine breath test was performed the day before TACE, 2 days and 30 days after TACE and correlated with standard laboratory work-up of the patients. RESULTS: Fourteen TACE sessions were performed in Child A liver cirrhosis, 4 in Child B cirrhosis. All patients presented with impaired aminopyrine metabolism at baseline. No significant changes in the (13)C aminopyrine breath test following TACE were observed. Two patients treated in Child A cirrhosis decompensated to Child B, one of them recovered. No further decompensation was observed in patients treated in Child B cirrhosis. DISCUSSION AND CONCLUSION: Liver function assessment with (13)C-aminopyrine breath test and Child-Pugh-classification following TACE was discordant in a large proportion of patients. Whether a quantification of mitochondrial liver function in patients planned to undergo locoregional treatment of HCC in liver cirrhosis is helpful in the prediction of postprocedural liver decompensation needs to be addressed in larger prospective clinical trials.

TV news and concerns about - the EHEC-outbreak 2011 in Germany.

BACKGROUND AND AIM: In the beginning of May 2011 and finally terminated on July 26th 2011 an outbreak of infections with enterohaemorrhagic Escherichia (E.) coli (EHEC) strain O104:H4 occurred in Germany. The aim of this study is to analyse whether media coverage of the outbreak influenced the number of patients presenting with diarrhoea to the emergency room of a tertiary centre and to evaluate the influence of information on perception and rating of symptoms. METHODS: Prospectively collected data in a tertiary centre on the number of patients presenting to the emergency room with diarrhea during the EHEC outbreak was correlated with retrospectively collected data about the media coverage of the outbreak on TV and compared to the number of patients that had presented with diarrhea during a comparative period in 2010. RESULTS: A total of 1,625 patients presented to our emergency room during the observation period in 2011 between May 31st and June 13th, including 72 patients (4.4%) presenting with the predominant symptom of diarrhoea, of whom six patients (0.4%) reported haemorrhagic diarrhoea. In the comparative period in 2010, between May 31st and June 13th, twelve patients (1.6%) presenting the symptom of diarrhea were treated in our emergency room. The analysis of the news reports in 2011 revealed a total of 1,150 reports broadcast in the ARD and a total of 173 reports broadcast in the regional news channel MDR between May 29th and June 11th. In 2010 not a single report regarding our search terms was broadcast in the corresponding time period. CONCLUSION: Our data suggest a clear positive correlation of the frequency of TV reports dealing with the epidemic disease outbreak and the rate of outpatient consultations in emergency rooms because of diarrhoea and could make an important contribution for future discussions.

Coping trajectories in later life: a 20-year predictive study.

OBJECTIVES AND METHOD: Information about aging-related change in coping is limited mainly to results of cross-sectional studies of age differences in coping, and no research has focused on predictors of aging-related change in coping behavior. To extend research in this area, we used longitudinal multilevel modeling to describe older adults' (n = 719; baseline M = 61 years) 20-year, intraindividual approach and avoidance coping trajectories, and to determine the influence of two sets of predictors (threat appraisal and stressor characteristics; gender and baseline personal and social resources) on level and rate of change in these trajectories. RESULTS: Over the 20-year study interval, participants declined in the use of approach coping and most avoidance coping strategies, but there was significant variation in this trend. In simultaneous predictive models, female gender, more threat appraisal, stressor severity, social resources, and depressive symptoms, and fewer financial resources were independently associated with higher initial levels of coping responses. Having more social resources, and fewer financial resources, at baseline in late-middle-age predicted faster decline over time in approach coping. Having more baseline depressive symptoms, and fewer baseline financial resources, hastened decline in use of avoidance coping. Independent of other variables in these models, decline over time in approach coping and avoidance coping remained statistically significant. CONCLUSION: Overall decline in coping may be a normative pattern of coping change in later life. However, it also is modifiable by older adults' stressor appraisals, their stressors, and the personal and social resources they possess at entry to later life, in late-middle-age.

[Acute abdomen in a patient with ANCA-associated vasculitis]. / Akutes Abdomen bei ANCA-Assoziierter Vaskulitis.

HISTORY AND FINDINGS: A 49-year-old man complained of increasing pain in the lower left abdomen. Three weeks previously joint pain had developed, and in the last 7 days the patient had noted a cutaneous rash at the lower legs. Within three days after admission a paralytic ileus developed, progressed and culminated in a small bowel perforation. In the 60 cm ileum specimen as well as in the skin lesions there was marked intra- und perivascular infiltration with neutrophil granulocytes and focal necrosis, but no granuloma. DIAGNOSIS, TREATMENT AND COURSE: As the proteinase 3 subtype of antineutrophil cytoplasmic antibodies (ANCA) was positive ANCA-associated vasculitis with gastrointestinal, cutaneous and kidney involvement was diagnosed. After initiation of cytostatic treatment with methylprednisolone boli und cyclophosphamide the patient's condition improved. The post-operative course was uneventful. CONCLUSION: ANCA-associated vasculitis rarely presents with severe gastrointestinal complications. The disease represents an interdisciplinary challenge because of its variable clinical presentation and the possibly lethal outcome if not adequately treated.

[Palliative treatment in gastroenterology at the border to (abdominal) surgery]. / Palliativtherapie im Grenzgebiet zwischen Gastroenterologie und (Viszeral-)Chirurgie.

BACKGROUND: In the management of gastrointestinal tumour lesions, palliative treatment has attained an increasing role. As also in curative treatment, an interdisciplinary cooperation between gastroenterologists and surgeons has to be aimed for. AIM: The aim of this study is to illustrate the diagnostic and therapeutic management of frequently occurring diseases in palliative medicine from a gastroenterological point of view. METHODS: Complementary short overviews on clinical experience and selectively searched references from the current scientific literature were evaluated. RESULTS: The symptomatic complex is very heterogeneous and requires an adequate approach taking into account the differential diagnosis. The palliative gastroenterological approach is characterised by the competent care on ascites, management of "malignant intestinal obstruction and obstipation" (MIO) as well as appropriate nutrition and analgetic therapy. The surgical approach is indicated after sequential exhaustion of medical, interventional endoscopic and (eventually) image-guided radiological measures; it comprises creation of a peritoneovenous shunt (ascites), bypass procedures (gastroenteral, biliodigestive, enteroenteral) as well as, in extraordinary cases, resection in addition to the implantation of an i. v. port-a-cath or surgical revision of a PEG / stent complication; in particular, in case of recurrent and massive haemorrhage and perforation (absolute indication), surgery becomes necessary. DISCUSSION: A lack of appropriate studies, absence of adequate study results including the difficult initiation of medical studies with palliative intention aggravate a competent evidence-based approach. Therefore, the management is considerably affected by clinical experience. CONCLUSION: Efficacious care in palliative visceral medicine requires relevant clinical expertise and interdisciplinary action because of the occurrence of clinical cases in gastroenterology at the border to surgery.

Causes and mechanisms in acute pancreatitis.

Acute pancreatitis (AP) presents clinically with either mild or severe clinical course. There are no effective specific drugs for treatment of AP today. Basic knowledge about pathophysiological processes is the key for the development of novel therapeutic principles. This article provides a review on the pathophysiological mechanisms involved in the early phase of AP.

[Exceptional bilocular inflammatory myofibroblastic pseudotumour (IMT) characterized by recurrent thoracic tumour growth and a rare (adult) second manifestation within the mesenteric tissue of the small intestine]. / Ungewöhnlicher bilokulärer inflammatorischer myofibroblastärer Pseudotumor (IMT), charakterisiert durch thorakales Rezidiv und seltene, da adulte, Zweitmanifestation im Dünndarmmesenterium.

BACKGROUND: Despite its rare occurrence, inflammatory myofibroblastic pseudotumour (IMT) is relevant in the differential diagnosis of intestinal lesions. By the mean of an extraordinary case report, tumour site and specific characteristics, finding of the correct diagnosis, therapeutic management, and outcome of extrapulmonary IMT is decribed based also on relevant references from the literature. CASE REPORT: A 39-year old man experienced a multifocal thoracic recurrence and abdominal metastasis of IMT 12 years after successful primary resection of pulmonary IMT. The intra-abdominal lesion localised in the jejunal mesenteric tissue was removed surgically (resection status, R 0) by segmental resection of the mid-jejunum (length: 80 cm) followed by jejunojejunostomy. Histology evaluation confirmed IMT. Thoracic surgeons advised against a surgical approach to the pulmonary and thoracic lesions because of their number and proximity to the superior vena cava as well as mediastinal infiltration. Despite receiving repeated advice from his physicians, the patient has not agreed to combined immunosuppressive treatment with cyclophosphamide and steroids, because of his desire for children. He underwent 5 months of systemic steroid treatment, starting in the third postoperative month, which he then chose to stop because of Cushing symptomatology. He agreed to a computed tomography (CT) scan follow-up 12 months after surgery, which revealed slight local progression of the remaining pulmonary lesion. Administration of a second steroid medication was initiated at a lower dose. No further CT scans were obtained. At present, he is consulting with an alternative medicine practitioner. CONCLUSION: This report documents a rarely described case of IMT at a jejunal mesenteric tumour site, interpreted as an uncommon late and extraordinary, metastatic, multifocal recurrence found 12 years (!) after surgical resection of the primary pulmonary tumour.

[First experiences with intravenous port systems authorized for high pressure injection of contrast agent in multiphasic computed tomography]. / Erste Erfahrungen mit intravenösen Portsystemen mit der Zulassung zur Hochdruckinjektion von Kontrastmittel in der Computertomografie.

PURPOSE: The aim of this prospective study was to examine two port systems for intravenous chemotherapy, authorized for high pressure injection, with respect to implantation, complications, implementation, and patency. MATERIALS AND METHODS: 40 high pressure port systems of the two available models (20 x Power Port [Bard], 20 x T-Port-Contrast [PFM]) and 20 standard port systems (X-Port [BARD]) as the control group were implanted. Both high pressure systems are authorized for injection with a maximum pressure of 300 PSI. The patient population was comprised of patients with different malignomas and liver metastases. At regular intervals following the protocol of the chemotherapy, multiphasic CT for tumor staging was carried out. RESULTS: The intravenous port systems were implanted without complications under sonographic guidance with transjugular access. The mean implantation time was 30 min (range: 22 - 40 min). After a median follow-up time of 6 months, the port patency was 100%. No port infections and no complications during high pressure injection of contrast agent occurred during this period. The level of contrast measured in the aorta was equivalent to the level of contrast in the vessels when contrast agent is administered over a large peripheral intravenous access. CONCLUSION: The intravenous high pressure port systems are equivalent to standard systems with regard to implantation and implementation. Intravenous chemotherapy can be performed as usual. The advantage is the possibility of multiphasic CT with authorized flow rates of up to 5 ml/sec.

[Nutritional support in patients with acute pancreatitis].

A causal therapy for acute pancreatitis is not available, so treatment has to focus on best supportive care. As nutrition is a cornerstone in the treatment of the disease, recent clinical research has focused on this question. The concept of enteral nutrition is aiming at the maintenance of a normal mucosal barrriere function which has been discovered to be important in mild and severe acute pancreatitis. This review offers an overview about current concepts of nutritional support and gives recommendations for clinical care as well.

The isolated chicken eye test as a suitable in vitro method for determining the eye irritation potential of household cleaning products.

Eye irritation is an important endpoint in the safety evaluation of consumer products and their ingredients. Several in vitro methods have been developed and are used by different industry sectors to assess eye irritation. One such in vitro method in use for some time already is the isolated chicken eye test (ICE). This investigation focuses on assessing the ICE as a method to determine the eye irritation potential of household cleaning products, both for product safety assurance prior to marketing and for classification and labeling decisions. The ICE involves a single application of test substances onto the cornea of isolated chicken eyes. Endpoints are corneal swelling, corneal opacity and fluorescein retention. The ICE results were compared to historic LVET data in this study due to availability of such in vivo data and the ability to correlate LVET to human experience data on the outcome of accidental exposures to household cleaning products in general. The results of this study indicate that the ICE test is a useful in vitro method for evaluating the eye irritation/corrosion potential and establishing classification and labeling for household cleaning products. For new product formulations, it is best used as part of a weight-of-evidence approach and benchmarked against data from comparable formulations with known eye irritation/corrosion profiles and market experience.

Smoking--a trigger for chronic inflammation and cancer development in the pancreas.

Tobacco smoke, with its complexity of constituents, damages the pancreatic organ in multiple ways. Smoke not only affects pancreatic secretion patterns via its nicotine content but induces inflammatory reactions and exerts carcinogenic effects by several other constituents. Smoke enhances ethanol-induced pancreatic injury and accelerates the development and progression of chronic pancreatitis independent of etiology. Through the process of inflammation, smoking contributes to pancreatic carcinogenesis. The experiment of Wittel and colleagues published in this issue of the American Journal of Gastroenterology sheds further light on this topic by reporting in great detail two different kinds of pancreatic damage in rats exposed to high doses of smoke.

Older adults' health and changes in late-life drinking patterns.

This study focused on the prospective associations between older adults' health-related problems and their late-life alcohol consumption and drinking problems. A sample of 1,291 late-middle-aged community residents (55-65 years old at baseline) participated in a survey of health and alcohol consumption, and was followed one year, four years, and 10 years later. Health-related problems increased and alcohol consumption and drinking problems declined over the 10-year interval. Medical conditions, physical symptoms, medication use, and acute health events predicted a higher likelihood of abstinence and less frequent and lower alcohol consumption. However, overall health burden predicted more subsequent drinking problems, even after controlling for alcohol consumption and a history of heavy drinking and increased drinking in response to stressors. Among older adults, increased health problems predict reduced alcohol consumption but more drinking problems. Older adults with several health problems who consume more alcohol are at elevated risk for drinking problems and should be targeted for brief interventions to help them curtail their drinking.

A ten-year follow-up of older former problem drinkers: risk of relapse and implications of successfully sustained remission.

OBJECTIVE: This study examines the risk, predictors of relapse and the effects of successfully sustained remission on the drinking behavior, functioning, life context, coping and help seeking of older adults who were problem drinkers earlier in life. METHOD: Older former problem drinkers (n = 447) were prospectively followed for 10 years and compared to lifetime nonproblem drinkers. RESULTS: Of former problem drinkers, 31% (n = 141) died over the 10-year interval, a rate 1.6 times higher than that of lifetime nonproblem drinkers. Among surviving former problem drinkers, although relapse was relatively uncommon (11%), a less severe drinking history, heavier baseline alcohol consumption, and lower baseline income were associated with relapse. The majority (63%) of former problem drinkers who successfully achieved sustained remission continued to drink alcohol, though at levels below those consumed by older lifetime nonproblem drinkers (n = 339). Stably remitted problem drinkers who were abstinent (SRAs) generally reported more severe drinking histories, greater functioning and life context deficits and more help seeking than did stably remitted problem drinkers who were nonabstinent (SRNs). Although SRAs and SRNs both experienced improvements in functioning over the 10-year interval, they continued to experience financial, health-related and life context deficits relative to older lifetime nonproblem drinkers. CONCLUSIONS: Results suggest there are long-term costs associated with earlier drinking problems, even when remission is maintained. Both current drinking behavior and drinking history are worth considering when making recommendations regarding older adults' alcohol consumption.