Objective evaluation of tongue diagnosis ability using a tongue diagnosis e-learning/e-assessment system based on a standardized tongue image database.

Background: In Kampo medicine, tongue examination is used to diagnose the pathological condition "Sho," but an objective evaluation method for its diagnostic ability has not been established. We constructed a tongue diagnosis electronic learning and evaluation system based on a standardized tongue image database. Purpose: This study aims to verify the practicality of this assessment system by evaluating the tongue diagnosis ability of Kampo specialists (KSs), medical professionals, and students. Methods: In the first study, we analyzed the answer data of 15 KSs in an 80-question tongue diagnosis test that assesses eight aspects of tongue findings and evaluated the (i) test score, (ii) test difficulty and discrimination index, (iii) diagnostic consistency, and (iv) diagnostic match rate between KSs. In the second study, we administered a 20-question common Kampo test and analyzed the answer data of 107 medical professionals and 56 students that assessed the tongue color discrimination ability and evaluated the (v) correct answer rate, (vi) test difficulty, and (vii) factors related to the correct answer rate. Result: In the first study, the average test score was 62.2 ± 10.7 points. Twenty-eight questions were difficult (correct answer rate, <50%), 34 were moderate (50%-85%), and 18 were easy (≥85%). Regarding intrarater reliability, the average diagnostic match rate of five KSs involved in database construction was 0.66 ± 0.08, and as for interrater reliability, the diagnostic match rate between the 15 KSs was 0.52 (95% confidence interval, 0.38-0.65) for Gwet's agreement coefficient 1, and the degree of the match rate was moderate. In the second study, the difficulty level of questions was moderate, with a correct rate of 81.3% for medical professionals and 82.1% for students. The discrimination index was good for medical professionals (0.35) and poor for students (0.06). Among medical professionals, the correct answer group of this question had a significantly higher total score on the Kampo common test than the incorrect answer group (85.3 ± 8.4 points vs. 75.8 ± 11.8 points, p < 0.01). Conclusion: This system can objectively evaluate tongue diagnosis ability and has high practicality. Utilizing this system can be expected to contribute to improving learners' tongue diagnosis ability and standardization of tongue diagnosis.

"Kambakutaisoto" and Emotional Instability Associated With Premenstrual Syndrome.

Many women suffer from premenstrual syndrome (PMS), which can be considered a modern illness in this busy society; mental symptoms, such as irritability, often affect the surroundings and result in loss of self-confidence. The symptoms of PMS are diverse, and it is often difficult to treat psychiatric and social symptoms with low-dose estrogen progestin combination drug (LEP) alone. Selective serotonin reuptake inhibitors (SSRIs) are also effective; however, many are unable to take them owing to their side effects. "Kambakutaisoto" is a Kampo medicine consisting of "jujube," "licorice," and "wheat," which is often described as "food"; however, it is highly effective in treating emotional instability attributed to PMS in sensitive young women. There are many reports on the effects of kambakutaisoto; the molecular nutritional findings of kambakutaisoto, which has dramatic effects despite its mild composition of crude drugs, have also been reported, suggesting an association with premenstrual exacerbation of functional hypoglycemia. A narrative review of its clinical effects on PMS and the results of molecular nutrition studies was performed.

Reference urinary biopyrrin level and physiological variation in healthy young adults: relation of stress by learning.

BACKGROUND: Biopyrrins are end products of oxidation reactions of bilirubin with reactive oxygen, and urinary biopyrrin (UBP) levels might increase under oxidative stress. The authors examined the reference UBP level for healthy adults and its physiological variation in 40 healthy volunteers recruited from among students of our university (20 students each from third-year and fourth-year), and compared the results with data on 8-hydroxy-2-deoxyguanosine (8OHdG). METHODS: UBP and 8OHdG levels could be considered as oxidative stress markers. The UBP levels were measured with a competitive ELISA kit using biopyrrin antibody 24G7, according to the manufacturer's protocol. 8OHdG levels were measured with a Highly Sensitive 8-OHdG Check kit. UBP and 8OHdG measurements were performed in triplicate and means values calculated. For both parameters, creatinine (Cr) correction was performed using urinary creatinine levels measured by an enzymatic method. RESULTS: A comparison of the UBP levels between different grades revealed that the third-year students under high stress from clinical training and other course work tended to have a higher UBP level than fourth-year students. Therefore, we compared the current UBP levels in fourth-year students (samples collected in 2018) with their UBP level when they were in the third-year (samples collected in 2017) to examine the annual change. We found that the UBP level in 2017 samples was significantly higher than that in 2018 samples (P < 0.05). No difference in the 8OHdG level. Additionally, no effect of menstrual stress on the UBP level was observed. CONCLUSIONS: These results suggest that the UBP levels may be related to school-related stress and menstruation has no effects on urinalysis results.

Small bowel obstruction caused by endometriosis in a postmenopausal woman.

We report a rare case of small bowel obstruction (SBO) caused by endometriosis in a postmenopausal woman. A 54-year-old postmenopausal woman presented with severe abdominal pain and vomiting. Before menopause, she sometimes had abdominal pain associated with menses. Axial multi-dimensional CT images revealed a SBO with small nodules near the terminal ileum. The obstruction was diagnosed as being caused by small bowel endometriosis. Curved planar reconstruction images showed a complicated obstruction of the small intestine 15 cm from the terminal ileum. Based on the stenotic lesion, a SILS procedure was performed. The patient's SBO diagnosis was histologically confirmed as being caused by small bowel endometriosis. SILS was deemed to be a safe, feasible procedure for treating this bowel obstruction. Curved planar reconstruction images were useful in preoperative imaging and diagnosis of SBO, especially as they were able to highlight the constricting legion.

Ultrasound for evaluation of adnexal malignancy: from 2D to 3D ultrasound.

Conventional two-dimensional (2D) ultrasound has been widely used for the evaluation of adnexal malignancy in gynecologic fields. This 2D ultrasound evaluation includes a morphological assessment, color/power and pulsed Doppler sonographic assessment, scoring system, and contrast agent assessment of adnexal masses. The introduction of three-dimensional (3D) ultrasound would facilitate the novel assessment of adnexal masses. With the recent advance in 3D power Doppler (3DPD) ultrasound as well as quantitative 3DPD histogram analysis, quantitative and qualitative assessments of the vascularization and blood flow of adnexal masses have become feasible. These novel techniques may assist in the evaluation of adnexal malignancy, and offer potential advantages relative to conventional 2D sonographic assessments. 3D ultrasound may be an important modality in future gynecologic oncology research and in the evaluation of adnexal malignancy in clinical practice, although some limitations regarding the assessment of adnexal malignancy employing 3D ultrasound remain unresolved.

Uterine cervical carcinosarcoma with heterologous mesenchymal component: a case report and review of the literature.

INTRODUCTION: Carcinosarcomas of the uterine cervix are very rare. Most of them have a homologous mesenchymal component, and cervical carcinosarcomas with a heterologous mesenchymal component are limited to nine cases. CASE REPORT: A 61-year-old Japanese woman was admitted to the hospital for treatment of a ureteral stone. Imaging studies detected an indistinct cervical mass. A histopathological diagnosis of the cervical biopsy was a carcinosarcoma. A total abdominal hysterectomy with bilateral salpingo-oophorectomy and pelvic lymphadenectomy was carried out upon a diagnosis of stage Ib1 cervical carcinosarcoma. Microscopically, the cervical mass revealed a carcinosarcoma consisting of endometrioid adenocarcinoma and chondrosarcoma. Immunohistochemically, p53 was positive in the epithelial and mesenchymal components. Postoperatively, the patient underwent radiation and chemotherapy. She is alive with no evidence of recurrence 5 years and 10 months after the operation. CONCLUSION: We suppose that the similar proportion of p53 overexpression in both the epithelial and mesenchymal components may be one of the findings explaining the histogenesis of this tumor by combination theory.

Positron emission tomography with the glucose analog [F]-fluoro-2-deoxy-D-glucose for evaluating pelvic lymph node metastasis in uterine corpus cancer: comparison with CT and MRI findings.

OBJECTIVE: The aims of this study were to investigate the ability of positron emission tomography (PET) with the glucose analog [(18)F]-fluoro-2-deoxy-D-glucose (FDG) to detect pelvic lymph node metastasis of uterine corpus cancer and to perform a retrospective comparison with computed tomography (CT) and magnetic resonance imaging (MRI) findings. METHODS: Forty-six patients with uterine corpus cancer scheduled for surgery, including bilateral pelvic and/or para-aortic lymphadenectomy, were eligible for this study. CT and MRI of the pelvis and abdomen were performed in all patients within 2 weeks preceding whole-body FDG-PET. FDG-PET images were analyzed visually for objective assessment of regional tracer uptake. The sensitivity and specificity of each imaging modality for detecting pelvic lymph node metastasis were determined, respectively. RESULTS: Eleven (7 with myometrial invasion less than 1/2, 4 with myometrial invasion over 1/2) of the 46 patients (23.9%) were revealed to have pelvic lymph node metastasis. The sensitivity and specificity for detecting pelvic lymph node metastasis in patients with uterine corpus cancer by FDG-PET were 31.3% and 96.1% by lymph node region, respectively, and 36.4% and 91.4% by patient, respectively. No significant difference was noted among each imaging modality with sensitivity or specificity. Moreover, the sensitivity and specificity for detecting pelvic lymph node metastasis in 29 patients with endometrioid adenocarcinomas by FDG-PET were 28.6% and 96.1% by lymph node region, respectively, and 50% and 92% by patient, respectively. No significant difference was noted among each imaging modality in terms of sensitivity or specificity. Among 11 patients with pathologically positive pelvic lymph node metastasis, three out of four patients with myometrial invasion over 1/2 were diagnosed as pelvic lymph node metastasis positive by all diagnostic modalities, however, only one of seven patients with myometrial invasion less than 1/2 was diagnosed as pelvic lymph node metastasis positive by PDF-PET and CT. MRI could not detect pelvic lymph node metastasis in patients with myometrial invasion less than 1/2. CONCLUSIONS: We suggest that current imaging modalities including FDG-PET cannot change medical management of patients with uterine corpus cancer before surgery.

Does three-dimensional power Doppler ultrasound improve the diagnostic accuracy for the prediction of adnexal malignancy?

OBJECTIVE: The aim of the present study was to investigate the diagnostic accuracy of three-dimensional power Doppler ultrasound (3DPD) in the differentiation between benign and malignant adnexal masses and evaluate 3DPD for assessing malignancy in comparison with two-dimensional transvaginal gray-scale sonography (2DTVS), magnetic resonance imaging (MRI) and positron emission tomography (PET). SUBJECTS AND METHODS: Thirty-six patients with suspicious adnexal masses were included in this study. 2DTVS and 3DPD were performed preoperatively. MRI and PET examinations were also carried on within two weeks of initial sonography. All the results of diagnostic imaging techniques were evaluated separately. Final diagnosis was confirmed by the postoperative histopathology. The mature cystic teratomas and endometriomas with typical gray-scale sonographic appearance were excluded from the study. RESULTS: Of the 36 patients, 25 had a malignancy, 5 had a borderline tumor, and 6 had a benign mass. Sensitivity of 2DTVS, 3DPD, MRI and PET were 96.7%, 76.7%, 96.7% and 83.3%, respectively. The sensitivity of 2DTVS was as high as that of MRI, and both of them were significantly higher than those of 3DPD and PET, respectively. There were no significant differences both in specificity and accuracy among these 4 techniques. CONCLUSION: 3DPD did not improve the diagnostic accuracy for the prediction of malignancy in adnexal masses. 2DTVS may still remain an important modality for the prediction of adnexal malignancy.

Three-dimensional sonographic features of a fetus with Wolf-Hirschhorn syndrome.

We present a case of fetal Wolf-Hirschhorn syndrome diagnosed by conventional two-dimensional and three-dimensional ultrasonography. Conventional two-dimensional ultrasonography revealed a diaphragmatic hernia, nuchal edema, and suspected hypospadias. Three-dimensional ultrasonography clearly showed a flattening of the face, a high forehead, a broad nasal bridge continuing to the forehead, exophthalmos, and micrognathia (resembling the appearance of a Greek warrior helmet), but conventional two-dimensional ultrasonography did not depict these findings. Prenatal chromosomal analysis confirmed the diagnosis of Wolf-Hirschhorn syndrome [46XY, del(4)(p15.2)]. Here we demonstrate how three-dimensional ultrasonography provided a novel visual depiction of the facial dysmorphism, which helped substantially in prenatal counseling.

Deep inferior epigastric perforator (DIEP) flap for vulvar reconstruction after radical vulvectomy: a less invasive and simple procedure utilizing an abdominal incision wound.

For vulvar reconstruction following radical vulvectomy in a 71-year-old woman with a large vulvar cancer, we applied the deep inferior epigastric perforator flap (DIEP flap), a typical perforator flap, which could be performed by utilizing an abdominal incision wound without producing another surgical scar and had less donor site morbidity because of a minimal sacrifice of muscles. The surgical procedures were less invasive and simple, and morphologically and functionally satisfactory results were obtained: no recurrence of cancer, a well-preserved vulvar morphology with less donor site scarring, and no functional disturbance such as dysuria and abdominal hernia. We consider that the DIEP flap is the first choice for vulvar reconstruction following radical vulvectomy. Even in radical vulvectomy without an abdominal incision wound, the DIEP flap with an anatomically reliable vascular pedicle can be an effective option.

Laparoscopy-assisted intrapelvic sonography with a high-frequency, real-time miniature transducer to assess the ovary: a preliminary report.

OBJECTIVE: Our purpose was to evaluate the normal and pathologic internal textures of the ovary using laparoscopy-assisted intrapelvic sonography (LAIPS) with a specially developed 20-MHz flexible catheter-based high-resolution real-time miniature (2.4 mm in outer diameter) ultrasound transducer in patients with gynecologic disorders and infertile women. METHODS: 30 women (19 patients with gynecologic disorders and normal menstrual cycles (2 adenomyoses, 1 cervical cancer, 5 fibromyomas, 5 simple ovarian cysts, 1 endometriosis, 3 benign cystic teratomas, and 2 endometriomas), and 11 patients with infertility including 4 with polycystic ovarian syndrome, PCOS) were studied by intrapelvic sonography using a high-frequency real-time miniature transducer with pelvic saline effusion and laparoscopy. RESULTS: In the normal ovary in the mid-follicular phase, follicles were depicted more distinctly than with transvaginal sonography (TVS). In the late-follicular phase, cumulus oophorus formations were visualized in 6 of 9 patients (54.5%), but were not clear using TVS. In the luteal phase, the corpus luteum was noted in 9 of 12 patients (75%) by both TVS and LAIPS. In patients with PCOS, the thickened capsule of the ovary was distinguished clearly especially in the peripheral type, in which numerous small cysts were aligned in the subcapsular region of the ovary, whereas it could not be detected by TVS. In all 4 cases with PCOS (8 ovaries), the ovarian capsular thickness could be measured by means of LAIPS. In subjects with benign cystic teratoma, minimal high echoic lesions were depicted. In subjects with endometrioma, a diffuse coarse-granular internal texture was visualized. However, depiction of internal structures in large pathologic ovarian lesions was markedly limited because of the shallow scanning range of the high-frequency transducer. CONCLUSION: LAIPS with a high-frequency real-time miniature transducer might be a useful diagnostic modality to evaluate the normal physiologic textures of the ovary, as well as those with PCOS.

Nuchal translucency thickness and fetal cardiac flow velocity in normal fetuses at 11-13 weeks of gestation.

OBJECTIVE: To investigate the relationship between nuchal translucency thickness and cardiac flow velocity in normal fetuses at 11-13 weeks of gestation. SUBJECTS AND METHODS: Eighteen normal pregnancies were prospectively studied with transvaginal sonography and pulsed and color Doppler ultrasound. Flow velocities at the fetal atrioventricular valves (mitral and tricuspid valve) and outflow tract levels (ascending aorta and pulmonary artery), and at the descending aorta were recorded. Nuchal translucency thickness was also measured. RESULTS: Mitral peak velocity during early diastolic filling correlated with gestational age. Mitral peak velocities during early diastolic filling and atrial contraction, tricuspid peak velocity during early diastolic filling, ascending aorta peak velocity, and pulmonary artery peak velocity correlated well with nuchal translucency thickness. There was an inverse correlation between umbilical artery pulsatility index and gestational age. CONCLUSIONS: These results suggest that the increase of nuchal translucency thickness in normal fetuses at 11-13 weeks of gestation may be the consequence of changes in fetal cardiac functions.

Reciprocal effects of tamoxifen on hormonal cytology in postmenopausal women.

OBJECTIVE: To evaluate the estrogenic effect of tamoxifen (TAM) therapy in postmenopausal women. STUDY DESIGN: The subjects were 26 postmenopausal women. The maturation index (MI), maturation value (MV) and karyopyknotic index (KPI) were evaluated based on hormonal cytology. Endometrial cytologic examinations and transvaginal ultrasonography were also performed. RESULTS: Of the 26 patients, 16 had low estrogenic activity from the viewpoint of hormonal cytology before TAM administration. During administration, their mean MV rose significantly, from 25.8 +/- 17.7 to 68.8 +/- 13.2, (mean +/- SD) and their mean KPI rose from 9.0 +/- 8.3 to 47.1 +/- 23.1. In contrast, among the 10 patients with high estrogenic activity, mean MV and KPI decreased from 62.9 +/- 8.4 and 27.2 +/- 16.9 to 58.4 +/- 7.7 and 17.7 +/- 16.1, respectively, with TAM administration. Mean endometrial thickness increased more significantly with TAM administration in the low estrogenic activity group than in the high estrogenic activity group. CONCLUSION: TAM had a reciprocal effect; no additional estrogenic effect was seen in patients with high estrogenic activity. Conversely, an estrogenic effect was seen in those with low estrogenic activity. An individualized gynecologic evaluation based on hormonal cytology is useful in selecting patients who will be more susceptible to TAM-induced endometrial abnormality.

Three-dimensional sonographic features of nuchal edema.

OBJECTIVE: To describe the three-dimensional (3D) sonographic features of nuchal edema in the early second trimester of pregnancy. METHODS: From 16 to 22 weeks of gestation 5 cases with nuchal edema were studied using transabdominal 3D sonography. RESULTS: Nuchal edema could be easily imaged with both two-dimensional and 3D sonography; however, visualization of the continuity and curvature of structures was more easily accomplished with 3D sonography. Before 20 weeks of gestation, the skin has a transparent structure, so the bony structures are clearly identified. 3D sonography allowed visualization of nuchal edema in all three dimensions at the same time, providing an improved overview and a more clearly defined demonstration of the adjusted anatomical planes. CONCLUSION: These results suggest that 3D sonography provides a novel means of visualizing nuchal edema in utero.

Adrenomedullin concentrations in early 2nd-trimester amniotic fluid: relation to preterm delivery and fetal growth at birth.

OBJECTIVE: The purpose of this study was to evaluate whether adrenomedullin concentrations in the early 2nd-trimester amniotic fluid predict preterm delivery or fetal growth at birth. METHODS: The adrenomedullin concentrations in early 2nd-trimester amniotic fluid were measured in 70 pregnancies with term delivery and in 3 pregnancies with preterm delivery. Total and free adrenomedullin concentrations were measured from early 2nd-trimester amniotic fluid samples using an immunoradiometric assay. RESULTS: The amniotic fluid total adrenomedullin concentrations in women with preterm delivery were significantly higher (129.7 +/- 19.6 fmol/ml) than those in women with term delivery (92.5 +/- 28.2 fmol/ml; p < 0.05). There were no significant differences for amniotic fluid free adrenomedullin concentrations and free/total adrenomedullin ratios between the two groups. Total or free adrenomedullin concentrations in the early 2nd-trimester amniotic fluid showed an inverse correlation both with birth weight (r = 0.27, p < 0.05, and r = 0.21, p < 0.05) and height (r = 0.30, p < 0.05, and r = 0.28, p < 0.05). There were no correlations between placental weight and total or free adrenomedullin concentrations in the early 2nd-trimester amniotic fluid. CONCLUSIONS: These results suggest that adrenomedullin concentrations in the early 2nd-trimester amniotic fluid might be related to further in utero fetal growth and that high levels of adrenomedullin in the early 2nd-trimester amniotic fluid may be involved in the occurrence of preterm delivery.