Evaluation of the Validity of Endoscopic Transpapillary Gallbladder Drainage for Acute Cholecystitis Based on the Tokyo Guidelines 2018.

GOALS: We evaluated the validity of endoscopic transpapillary gallbladder drainage (ETGBD) as a bridging therapy prior to elective Lap-C for the patients with acute cholecystitis (AC). BACKGROUND: The Tokyo Guidelines 2018 recommend early laparoscopic cholecystectomy (Lap-C) for patients with AC, however, some patients require the preoperative drainage because of inadequate for early Lap-C du to background and comorbidities. STUDY: We performed a retrospective cohort analysis using data from our hospital records from 2018-2021. In total, 71 cases of 61 patients with AC underwent ETGBD. RESULTS: The technical success rate was 85.9%. Patients in the failure group had more complicated branching of the cystic duct. The length of time until feeding was started and until WBC levels normalized, and the length of hospital stay were significantly shorter in the success group. The median waiting period for surgery was 39 days in the ETGBD success cases. The median operating time, amount of bleeding, and length of postoperative hospital stay were 134 min, 83.2g, and 4 days, respectively. In patients who underwent Lap-C, the waiting period for surgery and the operating time were similar between the ETGBD success and failure groups. However, the temporary discharge period after drainage and the length of postoperative hospital stay were significantly longer in the patients with ETGBD failure. CONCLUSIONS: Our study revealed that ETGBD has equivalent efficacy prior to elective Lap-C despite some challenges that lower its success rate. Preoperativ ETGBD can improve patient quality of life by eliminating the need for a drainage tube.

Clinical complete response maintained for more than 5 years after aggressive chemoradiotherapy for advanced rectal cancer with necrotizing fasciitis: a case report.

We report the case of a 65-year-old male diagnosed with advanced rectal cancer associated with necrotizing fasciitis (NF). Since radical surgery, total pelvic exenteration with sacrectomy, was rejected because of detrimental effects on quality of life, chemoradiotherapy (CRT) was chosen as anti-cancer treatment after urgent debridement. Although CRT was paused unintentionally just after delivering the total dose of radiation owing to the relapse of NF, the patient has maintained clinical complete response (cCR) without any distant metastasis for >5 years. Advanced rectal cancer is recognized as an NF risk factor. No definitive treatment strategies have been reported for NF-inducing rectal cancer; however, some reports have demonstrated curative extended surgery. Thus, CRT may be a less-invasive treatment option for NF-inducing rectal cancer, whereas severe adverse effects including re-infection after debridement should be closely monitored.

Tooth Loss as a Predictor of Postoperative Complications and Prognosis in Patients with Colorectal Cancer.

PURPOSE: We hypothesized that preoperative tooth loss could predict general health conditions, including inflammation, postoperative complications (POCs), and overall survival (OS), in patients with colorectal cancer (CRC) and other gastrointestinal cancers. METHODS: Data of patients who underwent curative surgical resection for CRC during 2017-2021 at our hospital were retrieved. The primary outcomes were POCs, whereas the secondary endpoint was OS. According to the Japanese database, patients within each age range with more than the age-adjusted average number of teeth were classified as the Oral N (normal) group, whereas those with less than the age-adjusted average number of teeth were classified as the Oral A (abnormal) group. The relationship between tooth loss and POCs was assessed using a logistic regression model. RESULTS: Overall, 146 patients were enrolled, with 68 (46.6%) and 78 (53.4%) patients in the Oral N and A groups, respectively. In the multivariate analysis, the Oral A group was an independent risk factor for POCs [hazard ratio (HR), 5.89; 95% confidence interval (CI), 1.81-19.1; p < 0.01]. Similarly, univariate analysis revealed that the Oral A group tended to be associated with OS (HR, 4.57; 95% CI, 0.99-21.2; p = 0.052), but the association was not statistically significant. CONCLUSION: In CRC patients who underwent curative resection, tooth loss was a predictor of POCs. Although further investigations are needed, our results support the use of tooth loss as a simple and essential preoperative evaluation system.

Dosimetric comparison between three-dimensional conformal radiotherapy followed by electron beam boost and volumetric modulated arc therapy using concomitant boost for the heart and cardiac segments in patients with left-sided breast cancer at risk for radiation-induced cardiac toxicity.

PURPOSE: We aimed to compare dosimetric parameters between three-dimensional conformal radiation therapy followed by electron beam boost (3D-CRT + EB) and volumetric modulated arc therapy using simultaneous integrated boost (SIB-VMAT) in left-sided breast cancer patients. METHODS: This study included 57 patients with left-sided breast cancer who underwent SIB-VMAT. All patients had a computed tomography-based maximum heart distance of ≥ 1 cm and were prescribed a dose of 42.56 Gy/16 fractions to the planning target volume and a concomitant-boosted target dose of 53.2 Gy or 51.2 Gy. The 3D-CRT + EB plan was retrospectively created for the purpose of comparison using tangential fields with field-in-field technique followed by electron beam irradiation. RESULTS: The doses to the clinical target volume significantly improved in the SIB-VMAT plans. All dosimetric parameters for the left anterior descending coronary artery (LAD) and LAD middle position (LAD mid) in the SIB-VMAT plans were significantly lower than those for 3D-CRT + EB plans (P < 0.01), while the doses to the heart, lung, contralateral breast and non-target tissue were decreased in the 3D-CRT + EB plans compared with those in the SIB-VMAT plans (e.g., 1.9 Gy vs. 2.9 Gy; P < 0.001 for the mean dose of heart). CONCLUSIONS: SIB-VMAT significantly improved the dose to the target while reducing the doses to the LAD and LAD mid, whereas 3D-CRT + EB significantly decreased the doses to the heart and other organs at risk in patients with left-sided breast cancer at risk for radiation-induced coronary artery disease.

Dose-Based Radiomic Analysis (Dosiomics) for Intensity Modulated Radiation Therapy in Patients With Prostate Cancer: Correlation Between Planned Dose Distribution and Biochemical Failure.

PURPOSE: Although radiation therapy is one of the most significant treatment modalities for localized prostate cancer, the prognostic factors for biochemical recurrence (BCR) regarding the treatment plan are unclear. We aimed to develop a novel dosiomics-based prediction model for BCR in patients with prostate cancer and clarify the correlations between the dosimetric factors and BCR. METHODS AND MATERIALS: This study included 489 patients with localized prostate cancer (BCR: 96; no-BCR: 393) who received intensity modulated radiation therapy. A total of 2475 dosiomic features were extracted from the dose distributions on the prostate, clinical target volume (CTV), and planning target volume. A prediction model for BCR was trained on a training cohort of 342 patients. The performance of this model was validated using the concordance index (C-index) in a validation cohort of 147 patients. Another model was constructed using clinical variables, dosimetric parameters, and radiomic features for comparisons. Kaplan-Meier curves with log-rank analysis were used to assess the univariate discrimination based on the predictive dosiomic features. RESULTS: The dosiomic feature derived from the CTV was significantly associated with BCR (hazard ratio, 0.73; 95% CI, 0.57-0.93; P = .01). Although the dosiomics model outperformed the dosimetric and radiomics models, it did not outperform the clinical model. The performance significantly improved by combining the clinical variables and dosiomic features (C-index: 0.67; 95% CI, 0.65-0.68; P < .0001). The predictive dosiomic features were used to distinguish high-risk and low-risk patients (P < .05). CONCLUSIONS: The dosiomic feature extracted from the CTV was significantly correlated with BCR in patients with prostate cancer, and the dosiomics model outperformed the model with conventional dose indices. Hence, new metrics for evaluating the quality of a treatment plan are warranted. Moreover, further research should be conducted to determine whether dosiomics can be incorporated in a clinical workflow or clinical trial.

[Invention and Evaluation of a Novel Air Leak Check System for Vacuum-type Patient Immobilization Device].

PURPOSE: We developed a novel system to measure air leakage in vacuum cushions, which are used in high-precision radiation therapy. The purpose of this study was to verify the usefulness of this system by evaluating the accuracy and the capability for detecting air leakage. METHODS AND RESULTS: The novel system was used to measure pressure in the cushion using a manometer. The advantage of this system was that we can measure the pressure without deformation of the cushion and check the pressure immediately. We confirmed that the pressure measured using this system is proportional to the reading in the reference manometer by the coefficient of 1.0. This system had a higher capability in the leak detection than the capability by checking softness in our sense of touch. We checked the leakage using this system against 18 cushions without air leakage (NL group) and 7 cushions that had problems regarding usage in patients due to the leakage (CW group). Average pressure variations in the NL group and the CW group were 22 kPa and 46 kPa, respectively. This was a significant difference in both groups. We could decide the criteria of pressure in the cushions that may cause troubles in the future use. CONCLUSION: We concluded that this system can detect air leakage in the cushions with a higher detectivity than our tactile sense.

Cost-effectiveness analysis of initial nonoperative management versus emergency laparoscopic appendectomy for acute complicated appendicitis.

BACKGROUND: The evidence regarding the safety and efficacy of nonoperative management is growing. However, the best treatment strategy for acute complicated appendicitis remains controversial. We aimed to evaluate the cost-effectiveness of treatment strategies for complicated appendicitis patients. This study sought to determine the most cost-effective strategy from the health care-payer's perspective. METHODS: The primary outcome was an incremental cost effectiveness ratio (ICER) using nonoperative management with or without interval laparoscopic appendectomy (ILA) as the intervention compared with operative management with emergency laparoscopic appendectomy (ELA) alone as the control. Model variables were abstracted from a literature review, and from data obtained from the hospital records of Tochigi Medical Center. Cost-effectiveness was evaluated using an ICER. We constructed a Markov model to compare treatment strategies for complicated appendicitis in otherwise-healthy adults, over a time horizon of a single year. Uncertainty surrounding model parameters was assessed via one-way- and probabilistic-sensitivity analyses. Threshold analysis was performed using the willingness-to-pay threshold set at the World Health Organization's criterion of $107,690. RESULTS: Three meta-analysis were included in our analysis. Operative management cost $6075 per patient. Nonoperative management with interval laparoscopic appendectomy (ILA) cost $984 more than operative management and produced only 0.005 more QALYs, resulting in an ICER of $182,587. Nonoperative management without ILA cost $235 more than operative management, and also yielded only 0.005 additional QALYs resulting in an ICER of $45,123 per QALY. Probabilistic sensitivity analysis with 1000 draws resulted in average ICER of $172,992 in nonoperative management with ILA and $462,843 in Nonoperative management without ILA. The threshold analysis demonstrated that regardless of willingness-to-pay, nonoperative management without ILA would not be most cost-effective strategy. CONCLUSIONS: Nonoperative management with ILA and Nonoperative management without ILA were not cost-effective strategies compared with operative management to treat complicated appendicitis. Based on our findings, operative management remains the standard of care and nonoperative management would be reconsidered as a treatment option in complicated appendicitis from economic perspective.

Spontaneous Biloma Resulting from Intrahepatic Bile Duct Perforation Coexisting with Intrahepatic Cholelithiasis and Cholangiocarcinoma: A Case Report and Literature Review.

BACKGROUND Spontaneous biloma is a rare non-traumatic disease in which an extrahepatic or intrahepatic bile duct perforates spontaneously with no discernable cause. We present the details of a patient with spontaneous biloma resulting from intrahepatic bile duct perforation with concurrent intrahepatic cholelithiasis and cholangiocarcinoma. CASE REPORT A 74-year-old woman was admitted to our hospital with symptoms of abrupt epigastralgia, nausea, and fever. Physical examination revealed epigastric tenderness, guarding, and rebound tenderness. Laboratory test results were normal, except for elevated leukocytes, and C-reactive protein, total bilirubin, and blood urea nitrogen concentrations. Carcinoembryonic antigen and carbohydrate antigen 19-9 concentrations were also elevated. Abdominal computed tomography revealed perihepatic fluid and ascites, with common bile duct dilatation and localized cholangiectasia of B2 with areas of slight high density, which indicated an intraabdominal abscess and intrahepatic cholelithiasis. Spontaneous intrahepatic bile duct perforation was subsequently diagnosed by cholangiography via endoscopic nasobiliary drainage. Left hepatic lobectomy was performed to treat the intrahepatic cholelithiasis and spontaneous biloma. Intraoperatively, a perforation was identified at the edge of the lateral segment of the left triangular ligament, through which bile had been leaking. Histopathology revealed intraductal cholangiocellular carcinoma with intrahepatic cholangiolithiasis. The patient's postoperative course was excellent, and she was discharged on postoperative day 16. However, cancer dissemination to the peritoneum was identified 8 months after surgery. CONCLUSIONS Treatment for patients with intrahepatic cholelithiasis should involve aggressive surgery because of the associated carcinogenicity. This approach reduces the risk of dissemination secondary to intrahepatic bile duct perforation.

Overall judgment of loudness of time-varying sounds.

Listeners can judge the overall loudness of time-varying sounds quite easily, i.e., assign a single value that represents the loudness of the entire sound. This holds even if the duration is long and the judgment includes memory effects. Different metrics for calculating overall loudness have been developed. They agree that overall loudness is higher than the mean of loudness over time. Percentiles like the N5, the loudness being exceeded 5% of the time, are adopted by ISO 532-1. In the present study the concept of an energy mean known from level measurements (ISO 1996-1) was applied to the loudness domain. This equivalent continuous loudness level, LLP, was compared to the N5 using a set of real-world sounds that was orthogonal between the two metrics over a wide dynamic range of 30 phon. Cross-modality matching with line length was used in three experiments with a focus on either the overall judgment of loudness, continuous judgment while a sound was played, or both. The LLP showed considerably higher correlations with overall judgments than N5. Comparing continuous instantaneous judgment with calculated instantaneous loudness suggests that the participants might have focused on the sounds' prominent portions.

Spectral loudness summation: shortcomings of current standards.

There are two competing national standards for the calculation of loudness of steady sounds, DIN 45631 and ANSI S3.4. Their different concepts of critical bands lead to different predictions for broadband sounds. As that discrepancy is neither constant nor linear but highly frequency-dependent, the present study investigates spectral loudness summation in three frequency regions, at various levels, and using two different methods. The results show that both algorithms overestimate loudness; however, DIN 45631 comes closer to the subjective evaluations and often falls within their interquartile range. The overestimation by the standards is particularly large in the frequency range from 2 to 5 kHz.

[Impact of dynamic parameters on dose delivery accuracy in volumetric modulated arc therapy].

Volumetric modulated arc therapy (VMAT) is an irradiation method in which the multi-leaf collimator (MLC) shape, gantry speed and dose-rate is continuously varied. Gantry speed and dose-rate are treated as specific dynamic parameters (DPs) in VMAT, so there is a need to confirm the influence of DPs on dose distribution. The purpose of this study was to verify the impact of DPs on the accuracy of dose delivery in VMAT. We adopted an irradiation scenario in which DPs were modified from the original plan without making any changes in the dose distribution. We carried out irradiation and measured the dose distributions using a Delta4 diode array phantom, during which we acquired log files that enabled us to calculate DPs. The results showed that dose errors exceeding 1% or geometric errors greater than 1 mm were not produced by modifying the DPs. We were therefore able to verify the impact of DPs on dose delivery accuracy in VMAT.

Characterization of beta-lactam antibiotic-induced vancomycin-resistant MRSA (BIVR) in a patient with septicemia during long-term vancomycin administration.

It was reported that some methicillin-resistant Staphylococcus aureus (MRSA) show resistance to vancomycin (VCM) and beta-lactam antibiotics; thus, they are termed beta-lactam antibiotic-induced VCM-resistant MRSA (BIVR). The VCM resistance of MRSA is induced by the administration of beta-lactam antibiotics, but this phenomenon can be difficult to detect in the clinical laboratory. We detected the BIVR strain in a 64-year-old man who had had a ventilator tube inserted directly into the windpipe during long-term VCM therapy. The patient was diagnosed with MRSA pneumonia and septicemia on July 5, 2007, and sulbactam/ampicillin (SBT/ABPC) was administered for 5 days. However, the fever recurred, and administration of VCM was resumed for 7 days from July 19. Fever developed again, and VCM was administered again for 14 days from September 30. BIVR and VCM-low-sensitive MRSA were isolated from blood on October 18 and 22, although the VCM trough concentration was 10.2 microg/ml. On October 27, we changed to a combination of fosfomycin (FOM) and arbekacin (ABK), and thereafter the fever quickly decreased and the clinical symptoms abated. We isolated five MRSA strains from the blood of the patient, three strains of VCM-sensitive MRSA, one strain of BIVR, and one strain of a VCM-low-sensitive MRSA. The DNA band patterns determined by pulsed-field gel electrophoresis were completely identical except for the VCM-low-sensitive MRSA, which was missing one band. Furthermore, the VCM-low-sensitive MRSA became sensitive to beta-lactam antibiotics. Our results indicate the possibility that long-term VCM therapy is one of the factors that allow BIVR or VCM-low-sensitive MRSA to emerge, and this allows VCM therapy for MRSA to fail.

Automatic detection system for cough sounds as a symptom of abnormal health condition.

The problem of attending to the health of the aged who live alone has became an important issue in developed countries. One way of solving the problem is to check their health condition by a remote-monitoring technique and support them with well-timed treatment. The purpose of this study is to develop an automatic system that can monitor a health condition in real time using acoustical information and detect an abnormal symptom. In this study, cough sound was chosen as a representative acoustical symptom of abnormal health conditions. For the development of the system distinguishing a cough sound from other environmental sounds, a hybrid model was proposed that consists of an artificial neural network (ANN) model and a hidden Markov model (HMM). The ANN model used energy cepstral coefficients obtained by filter banks based on human auditory characteristics as input parameters representing a spectral feature of a sound signal. Subsequently, an output of this ANN model and a filtered envelope of the signal were used for making an input sequence for the HMM that deals with the temporal variation of the sound signal. Compared with the conventional HMM using Mel-frequency cepstral coefficients, the proposed hybrid model improved recognition rates on low SNR from 5 dB down to -10 dB. Finally, a preliminary prototype of the automatic detection system was simply illustrated.

[Examination of formula for enhanced dynamic wedge factors in symmetric and asymmetric fields].

We proposed a formula for the enhanced dynamic wedge (EDW) factor in the half-field (HF) that combined the formula proposed by Liu et al. in 1998 and their formula in 2003. When the EDW was used for irradiation to the tangent line of the HF breast, the values calculated by our formula and the measured values were consistent within 0.5%. We showed that our proposed formula was useful, easy to use, and more accurate than the conventional formula. The purpose of this study was to examine the available range of the wedge factor of symmetrical and asymmetric EDW calculated by our formula. As a result of the examination, the values calculated by our formula and the measured values were consistent within 2% except for highly asymmetric EDW. We created a spreadsheet to calculate the wedge factor easily and accurately. We will examine the reason why the calculated and measured values were greater than 2%, and improve our formula so that it can be used in a wider range.