Significance of the cribriform morphology area ratio for biochemical recurrence in Gleason score 4 + 4 prostate cancer patients following robot-assisted radical prostatectomy.

BACKGROUND: In prostate cancer, histological cribriform patterns are categorized as Gleason pattern 4, and recent studies have indicated that their size and percentage are associated with the risk of biochemical recurrence (BCR). However, these studies included a mixture of cases with various Gleason scores (GSs). We therefore examined the prognostic value of the area and percentage of cribriform patterns in patients with GS 4 + 4 prostate cancer. METHODS: We investigated 108 patients with GS 4 + 4 prostate cancer who underwent robot-assisted radical prostatectomy (RARP). After digitally scanning the hematoxylin and eosin-stained slides, we measured the area of the entire cancer and cribriform patterns. Predictive factors for BCR were explored using log-rank test and Cox proportional hazard model analyses. RESULTS: Sixty-seven (62.0%) patients had a cribriform pattern in RARP specimens, and 32 (29.6%) experienced BCR. The median total cancer area, cribriform pattern area, and percentage of cribriform pattern area (% cribriform) were 427.70 mm2 (interquartile range [IQR], 171.65-688.53 mm2 ), 8.85 mm2 (IQR, 0-98.83 mm2 ), and 2.44% (IQR, 0%-33.70%), respectively. Univariate analyses showed that higher preoperative serum prostate-specific antigen (PSA) levels, positive resection margins, advanced pathological T stage, extraprostatic extension, larger total cancer area, larger cribriform morphology area, and higher % cribriform values were significantly associated with BCR. A multivariate analysis demonstrated that the PSA level (hazard ratio [HR], 1.061; 95% confidence interval [CI], 1.011-1.113; p = 0.017) and % cribriform (HR, 1.018; 95% CI, 1.005-1.031; p = 0.005) were independent predictors of BCR. CONCLUSIONS: An increased % cribriform value was associated with BCR in patients with GS 4 + 4 prostate cancer following RARP.

Genome-Wide Association Study Identifies Novel Candidate Variants Associated with Postoperative Nausea and Vomiting.

Considerable individual differences are widely observed in the incidence of postoperative nausea and vomiting (PONV). We conducted a genome-wide association study (GWAS) to identify potential candidate single-nucleotide polymorphisms (SNPs) that contribute to PONV by utilizing whole-genome genotyping arrays with more than 950,000 markers. The subjects were 806 patients who provided written informed consent and underwent elective surgery under general anesthesia with propofol or desflurane. The GWAS showed that two SNPs, rs2776262 and rs140703637, in the LOC100506403 and CNTN5 gene regions, respectively, were significantly associated with the frequency of nausea. In another GWAS conducted only on patients who received propofol, rs7212072 and rs12444143 SNPs in the SHISA6 and RBFOX1 gene regions, respectively, were significantly associated with the frequency of nausea as well as the rs2776262 SNP, and the rs45574836 and rs1752136 SNPs in the ATP8B3 and LOC105370198 gene regions, respectively, were significantly associated with vomiting. Among these SNPs, clinical and SNP data were available for the rs45574836 SNP in independent subjects who underwent laparoscopic gynecological surgery, and the association was replicated in these subjects. These results indicate that these SNPs could serve as markers that predict the vulnerability to PONV. Our findings may provide valuable information for achieving satisfactory prophylactic treatment for PONV.

Comparison of the incidence of fetal prolonged deceleration after induction of labor analgesia between dural puncture epidural and combined spinal epidural technique: a pilot study.

BACKGROUND: Abnormal cardiotocogram (CTG) tracing may appear after induction of neuraxial labor analgesia. Non-reassuring fetal status (NRFS) indicated by severely abnormal tracings, such as prolonged deceleration (PD) or bradycardia, can necessitate immediate operative delivery. Combined spinal epidural analgesia (CSEA) is known to result in more frequent abnormal tracings than epidural analgesia (EA); however, the corresponding data related to dural puncture epidural (DPE) are unclear. We aimed to evaluate the rates of incidence of severe abnormal CTG after induction of DPE and CSEA. METHODS: In this study of nulliparous women with full-term pregnancy, data for the DPE intervention group were prospectively collected, while those for the CSEA control group were obtained from medical records. Neuraxial analgesia was performed with cervical dilation ≤ 5 cm, administering initial epidural dosing of 15 mL of 0.125% levobupivacaine with fentanyl 2.5µg/mL for DPE, and intrathecal 0.5% bupivacaine 2.5 mg (0.5ml), fentanyl 10 µg (0.2ml), and 1.3 mL of saline for CSEA. The primary outcome was the incidence of PD, defined as a fetal heart rate reduction ≥ 15 bpm below the baseline and with a lowest value < 80 bpm, and lasting for ≥ 2 min but < 10 min (fetal heart rate < 80 bpm does not have to last for ≥ 2 min), within 90 min after induction of neuraxial labor analgesia. RESULTS: A total of 302 patients were analyzed, with 151 in each group. The incidence of PD after DPE induction was significantly lower than that after CSEA induction (4.0% vs. 14.6%, P = 0.0015, odds ratio = 0.243, 95% confidence interval = 0.095-0.617). CONCLUSION: DPE appears to be a safer method compared to CSEA for neuraxial labor analgesia in the early stages of labor for nulliparous women. TRIAL REGISTRATION: UMIN-CTR: UMIN000035153 . Date registered: 01/01/2019.

[Long-term Survival Giant Cell Carcinoma of the Lung with Chest Wall Invasion by Multidisciplinary Therapy:Report of a Case].

Giant cell carcinoma of the lung is a rare tumor with poor prognosis. A 70-year-old male was referred to our hospital because of chest pain and abnormal shadow on the chest X-ray. He had a lung tumor invading the chest wall. The tumor was surgically removed, and since the diagnosis of giant cell carcinoma with p-N2 was obtained pathologically, adjuvant chemotherapy was performed. However, the local recurrence was found at eight months after surgery and was treated with radiotherapy( total 70 Gy/28 Fr). The patient has been well for over 10 years with no clinically evident recurrence after treatment.

Formulating an anesthetic plan using a list of high-risk pregnant women on cloud-based business communication tools: a case report.

BACKGROUND: We report a case in which a list of high-risk pregnant women on cloud-based business communication tools was useful in formulating an anesthetic plan for unscheduled cesarean section. CASE PRESENTATION: A 37-year-old woman, who had been prescribed icosapentate for hypertriglyceridemia, received an antenatal anesthetic evaluation for possible cesarean delivery, and it was agreed that the anesthetic method for emergency cesarean section was general anesthesia if the surgery would take place within 7 days after the discontinuation of the drug, and regional anesthesia if it would take place any time later. Then this agreement was uploaded on the cloud-based business communication tools, and updated until she delivered her baby via unscheduled cesarean section. CONCLUSIONS: A cloud-based business communication tools was useful in formulating an anesthesia plan for a patient undergoing a cesarean delivery. However, more discussion would be needed to utilize it in security.

The value of the portable fibrinogen measuring device-a case report of severe postpartum hemorrhage with obstetric disseminated intravascular coagulation.

BACKGROUND: Fibrinogen concentration is an important indicator of the treatment for obstetric disseminated intravascular coagulation (DIC). We present how using the fibrinogen measuring device could solve problems in the treatment of postpartum hemorrhage with complicated DIC. CASE PRESENTATION: A 32-year-old woman with monochorionic diamniotic twins at 22 weeks of pregnancy was diagnosed with placental abruption and underwent emergent cesarean section. The estimated blood loss was 8375 g. She was transferred to our hospital for further treatment. Compressive uterine sutures and balloon tamponade were performed. We transfused fibrinogen and fresh frozen plasma actively during the operation to maintain plasma fibrinogen above 200 mg/dL by using a point-of-care fibrinogen measuring device. In spite of massive hemorrhage exceeding 10 L, she was extubated at the end of the operation and discharged on the 7th day after the operation. CONCLUSION: The portable fibrinogen measuring device was useful for point-of-care assessment of obstetric DIC.

Effects of rs958804 and rs7858836 single-nucleotide polymorphisms of the ASTN2 gene on pain-related phenotypes in patients who underwent laparoscopic colectomy and mandibular sagittal split ramus osteotomy.

BACKGROUND: Opioids are widely used as effective analgesics, but opioid sensitivity varies widely among individuals. The underlying genetic and nongenetic factors are not fully understood. Based on the results of our previous genome-wide association study, we investigated the effects of single nucleotide polymorphisms (SNPs) of the astrotactin 2 (ASTN2) gene on pain-related phenotypes in surgical patients. METHODS: We investigated the effects of two SNPs, rs958804 T/C and rs7858836 C/T, of the ASTN2 gene on eight and seven pain-related phenotypes in 350 patients who underwent laparoscopic colectomy (LAC) and 358 patients who underwent mandibular sagittal split ramus osteotomy (SSRO), respectively. In both surgical groups, intravenous fentanyl patient-controlled analgesia (PCA) was used for postoperative analgesia, and 24-hour postoperative PCA fentanyl use was the primary endpoint. RESULTS: The association analyses among the two SNPs and pain-related traits showed that 24-hour fentanyl use was significantly associated with the two SNP genotypes in both surgical groups. The Mann-Whitney test showed that 24-hour fentanyl use was lower in patients with the C allele than in patients with the TT genotype of the rs958804 T/C SNP (P = .0019 and .0200 in LAC and SSRO patients, respectively), and it was lower in patients with the T allele than in patients with the CC genotype of the rs7858836 C/T SNP (P = .0017 and .0098 in LAC and SSRO patients, respectively). CONCLUSION: The two SNPs of the ASTN2 gene were consistently associated with fentanyl requirements after two different types of surgery. These findings may contribute to personalized pain control.

Comparison of real-ear insertion gains in Japanese-speaking individuals wearing hearing aids with DSLv5 and NAL-NL2.

OBJECTIVE: We used real-ear insertion gain (REIG), with the international speech test signal (ISTS), to evaluate the amplifying characteristics of hearing aids, set for patients who have been wearing such aids for a long time in a stable manner. We further compared this to the target values of the DSLv5 and NAL-NL2 methods. METHODS: The subjects were adults with moderate sensorineural hearing loss. We examined 40 ears in 25 individuals (15 people wearing hearing aids in both ears and ten people wearing aid in only one ear). Fit assessments were performed based on the speech performance-intensity functions and tolerance of environmental noise, and the ears studied were categorized as either ears with sufficient benefit or ears with insufficient benefit. Additionally, we evaluated the REIG for international speech test signals at 65-dB and 80-dB sound pressure level (SPL). We compared the REIG and target values for voice input at 65-dB and 80-dB SPL, calculated from the DSLv5 and NAL-NL2 methods. RESULTS: Among the 40 ears, 34 received sufficient benefit and six received an insufficient benefit from hearing aids. The REIG for ISTS at 65-dB in the sufficient benefit ears, at frequencies of 1,000 Hz and 2,000 Hz, were similar to the target values of NAL-NL2 and DSLv5 but were significantly lower at 250 Hz, 500 Hz, and 4,000 Hz frequencies. The compression ratio of REIG for sufficient benefit ears was similar to that of DSLv5. The REIG for ISTS at 65-dB in the insufficient benefit ears was smaller than that in the sufficient benefit ears at frequencies of 2,000 Hz and 4,000 Hz. CONCLUSION: This study suggested that the target values of NAL-NL2 and DSLv5 are appropriate, even for Japanese-speaking individuals, at mid-pitch sounds. Although it is necessary to investigate the necessity for low-pitch and high-pitch gains further in the future, this study provides meaningful data regarding the amplifying characteristics in Japanese-speaking individuals who have been wearing hearing aids in a stable manner.

Management of pregnancy and delivery in women with Kawasaki disease and residual coronary artery lesion with detailed analysis of labor analgesia: combined experience of 13 cases in two institutions.

INTRODUCTION: Approximately half of Kawasaki disease patients are expected to have transitioned to adulthood, and an increasing number of patients with cardiovascular sequelae have gotten pregnant. Management of women with Kawasaki disease who have residual coronary artery disease is poorly established. Thus, we conducted detailed analysis of these cases. METHODS: We reviewed 19 pregnancies in 13 such women in two tertiary perinatal facilities, Saitama Medical Center and National Cardiovascular Center. The medical records were reviewed in all women with Kawasaki disease and coronary artery lesion between 1998 and 2015, with regard to age of diagnosis, types of coronary artery lesion, location, previous treatment, pregnancy course and medical management for coronary lesion, cardiac function, and planned mode of delivery. RESULTS: Fourteen parturients attempted vaginal delivery, and all but one received neuraxial analgesia, providing stable hemodynamics. Four elective and two emergency cesarean deliveries were performed due to obstetric indications, while one woman required cesarean delivery at preterm due to maternal cardiac indication. Among 14 attempted vaginal deliveries, instrumental vaginal delivery was performed in 50%. Cardiac events were noted in four women, all in post-partum period, such as non-sustained ventricular tachycardia or chest discomfort without ECG changes. Antithrombotic medication was exclusively low dose aspirin in 11 of 19 pregnancies (58%), and none received anticoagulation during pregnancy or delivery. CONCLUSION: Our case series support the practice of preferred vaginal delivery, with neuraxial labor analgesia in indicated patients, while highlighting the need for vigilance in the post-partum period.

[Persistent malnutrition caused by Nihonkaiense diphyllobothriasis diagnosed during treatment of malignant lymphoma].

A 72-year-old man with ileocecal lymphadenopathy was found to have Epstein-Barr virus-positive diffuse large B-cell lymphoma using open biopsy, and an ileostoma was created. R-CHOP-like chemotherapy was initiated, but his malnutrition did not improve. After 3 cycles of chemotherapy, a 2-m-long Cestoda was removed from the stoma and was identified as Diphyllobothrium nihonkaiense using mitochondria cytochrome c oxidase subunit 1 targeted polymerase chain reaction analysis. Although D. nihonkaiense infections are asymptomatic, the ileostomy was thought to have exacerbated the malabsorption in this patient. Parasitic infections are rare; however, they should be added to the differential diagnosis of malnutrition of unknown cause during chemotherapy for hematological malignancies.

The significance of micro-lymphatic invasion and pathological Gleason score in prostate cancer patients with pathologically organ-confined disease and negative surgical margins after robot-assisted radical prostatectomy.

BACKGROUND: The development process of recurrence in prostate cancer patients with pathologically organ-confined (pT2) disease and negative surgical margins is unclear. The aim of the present study was to determine factors associated with the development of biochemical recurrence following robot-assisted radical prostatectomy among those prostate cancer patients. METHODS: We retrospectively reviewed the data of patients who underwent robot-assisted radical prostatectomy without neoadjuvant endocrine therapy. We evaluated prognostic factors in 1096 prostate cancer patients with pT2 disease and negative surgical margins. Univariate and multivariate Cox proportional hazards regression analyses were used to identify independent predictors for biochemical recurrence. RESULTS: Of the 1096 patients, 55 experienced biochemical recurrence during the follow-up period. The 5-year biochemical recurrence-free survival rate for patients with pT2 and negative surgical margins was 91.8%. On univariate analysis, clinical stage, biopsy Gleason score, percent of positive core, pathological Gleason score, and the presence of micro-lymphatic invasion were significantly associated with biochemical recurrence. On a multivariate analysis, the presence of micro-lymphatic invasion and a pathological Gleason score ≥ 4 + 3 were significant prognostic factors for biochemical recurrence. Based on these factors, we developed a risk stratification model. The biochemical recurrence-free survival rate differed significantly among the risk groups. CONCLUSIONS: The prognosis of prostate cancer patients with pT2 disease and negative surgical margins is favorable. However, patients with the presence of micro-lymphatic invasion and a pathological Gleason score ≥ 4 + 3 tend to experience biochemical recurrence more often after surgery. Therefore, careful follow-up might be necessary for those patients.

Characteristics of labor-onset hypertension persist after neuraxial labor analgesia.

AIM: This study aimed to investigate the rate of labor-onset hypertension (LOH) under neuraxial labor analgesia and the effect of neuraxial labor analgesia on LOH. METHODS: A retrospective study was conducted in a tertiary university hospital from 2015 to 2016. Patients who were admitted to the hospital for vaginal delivery under combined spinal and epidural anesthesia were selected. LOH was defined as the elevation of systolic blood pressure (BP) to ≥140 mmHg or diastolic BP to ≥90 mmHg for the first time after the onset of labor. Cases of LOH that persisted after neuraxial labor analgesia (prolonged LOH) were further analyzed to determine the hypertension severity and therapeutic intervention rate. RESULTS: Among 775 patients, 213 (28.4%) developed LOH. Prolonged LOH was observed in 30 patients (3.9%). LOH severity and the likelihood of prolonged LOH were positively correlated. Therapeutic intervention was administered only to the patients with prolonged LOH, that is, to 100% of those with emergent hypertension, to 21.1% of those with severe hypertension during labor, and to 36.8% of those with severe hypertension, to 55.6% of those with mild hypertension in the post-partum period. CONCLUSION: The rate of LOH was reduced significantly after neuraxial labor analgesia. Patients with prolonged LOH should be carefully followed up during labor and in the post-partum period because such patients often require antihypertensive therapy.

Prognostic significance of the presence of tertiary Gleason grade 5 in robot-assisted radical prostatectomy specimens in Japanese patients with clinically localized prostate cancer.

BACKGROUND: The aim of this study was to study the prognostic significance of tertiary Gleason grade (TGG) 5 in patients with clinically localized prostate cancer treated with robot-assisted radical prostatectomy (RARP). METHODS: A total of 600 Japanese patients who underwent RARP for clinical stage T1-3N0M0 prostate cancer were evaluated. TGG5 was evaluated according to the International Society of Urological Pathology criterion. Cox hazard regression was used to evaluate the prognostic significance of prostate-specific antigen and pathological features in RARP specimens. RESULTS: Of the 600 RARP specimens, 92 (15%) had TGG5. TGG5 component was found in 30 (10%) of 287 cases with Gleason score (GS) 3 + 4, 55 (37%) of 149 cases with GS 4 + 3 and 7 (17%) of 40 cases with GS 4 + 4. There were no significant differences in pathological stage and surgical margin status between GS 3 + 4 with and without TGG5, as well as between GS 4 + 4 with and without TGG5. Of the 600 patients, 92 (15%) patients had biochemical recurrence (BCR) after surgery, with a median follow-up period of 42 (3-104) months. There were no differences in 5-year BCR-free survival rates between patients with GS 3 + 4 with and without TGG5 (92 vs. 100%, P = 0.16), as well as between patients with GS 4 + 3 with and without TGG5 (79 vs. 71%, P = 0.30). Similarly, there were no differences in 3-year BCRFS rates between patients with GS 4 + 4 with and without TGG5 (80 vs. 71%, P = 0.38). CONCLUSIONS: In our population, the presence of TGG5 in RARP specimens had no strong impact on pathological and prognostic outcomes.

Postoperative renal function in parturients with severe preeclampsia who underwent cesarean delivery: a retrospective observational study.

Although postoperative renal dysfunction is relatively rare after cesarean delivery, preeclampsia is considered as the high-risk population. On the other hand, hydroxyethyl starch (HES) administration for preventing maternal hypotension induced by spinal anesthesia for cesarean delivery is a common practice. However, the effect of HES administration during cesarean delivery on postoperative kidney function in parturients with severe preeclampsia is not well investigated. We retrospectively reviewed both medical and anesthesia records of patients with severe preeclampsia who underwent cesarean delivery from January 2011 to December 2013. Preoperative blood examinations were compared with postoperative values. All parturients received 6% HES 70/0.5 for preventing anesthesia-induced hypotension or for volume resuscitation during cesarean delivery. A total of 87 severe preeclampsia parturients were underwent cesarean section during the period. The amounts of HES administration were 859 ± 206 mL. There was significant reduction in serum creatinine, from 0.70 ± 0.29 mg/dL preoperatively to 0.62 ± 0.17 mg/dL in 3-7 days after the cesarean. Only one patient had postoperatively elevated serum creatinine up to clinically significant level (from 0.64 mg/dL to 1.35 mg/kg).

Successful management of obstetric disseminated intravascular coagulation using a portable fibrinogen-measuring device.

The importance of fibrinogen replacement therapy in obstetric disseminated intravascular coagulation is well recognized. However, fibrinogen measurement in conventional laboratories has been a time-consuming task. Recently, a Japanese manufacturer developed a portable device that enables immediate fibrinogen measurement at the point of care. This report describes a case in which this device was used for the successful management of obstetric disseminated intravascular coagulation.

Sonographic classification of testicular tumors by tissue harmonic imaging: experience of 58 cases.

PURPOSE: To evaluate the relationship between our proposed sonographic classification of testicular tumors by tissue harmonic imaging and histological type. METHODS: We retrospectively analyzed 58 testicular tumors and tumor-like lesions [seminomatous germ cell tumor (SGCT): 28; non-seminomatous germ cell tumor (NSGCT): 16; lymphoid and hematopoietic tumor (LHT): 7; Leydig cell tumor: 1; epidermal cyst: 2; and tumor of paratesticular structure (TPS): 4]. We divided a sonographic image into six types for morphological criteria and three types for color Doppler criteria. We examined the relationship between the sonographic classification and histological type. RESULTS: For morphological criteria, there were 21 cases of Type I (36%), 15 Type II (26%), 9 Type III (15%), five Type IV (9%), five Type V (9%), and three Type VI (5%). For color Doppler criteria, there were 47 cases classified as hypervascular (81%), eight as hypovascular (14%), and three as avascular (5%). Most of the SGCTs were divided into types I and II; the NSGCTs into types III, IV, and V; the LHTs into only type II; and the TPSs into type VI. CONCLUSION: We established a sonographic classification of testicular tumors with various histological types. This sonographic classification is potentially useful for estimating the histological type of testicular tumors.

Clinical effect of a positive surgical margin without extraprostatic extension after robot-assisted radical prostatectomy.

OBJECTIVES: The aim of this study was to investigate the effect of positive surgical margin (PSM) without extraprostatic extension after robot-assisted radical prostatectomy (RARP). MATERIALS AND METHODS: We retrospectively reviewed 837 patients who underwent RARP for clinically localized prostate cancer without neoadjuvant endocrine therapy. The pT2+category lesions were defined according to World Health Organization classification. The actuarial probabilities of biochemical recurrence-free survival (BCR-FS) were determined using Kaplan-Meier analysis. Univariate and multivariate Cox proportional hazards regression analyses were also used to identify independent predictors for BCR. RESULTS: Of the 837 patients, 102 (12.2%) experienced BCR during the follow-up period. The BCR-FS rate was significantly higher in patients with pT2+category tumors than in those with pT3a category tumors, and significantly lower in patients with pT2+category tumors than that in those with pT2 category tumors without PSM. The BCR-FS rate of patients with pT2+category tumors was significantly higher than that with pT3a category tumors with PSM but not significantly different from that with pT3a category tumors without PSM. In a multivariate analysis, the pathological T category considering pT2+category was one of independent predictive factors for BCR. CONCLUSIONS: This study support the hypothesis that the pT2+category disease is associated with a significantly increased risk of BCR in patients with organ-confined prostate cancer after RARP. As PSM can be avoided in some cases, urologists should continually seek to improve their operative skills and to reduce the rate of PSM, especially in patients with organ-confined prostate cancer.

Prediction of non-biochemical recurrence rate after radical prostatectomy in a Japanese cohort: development of a postoperative nomogram.

OBJECTIVE: To develop a nomogram based on postoperative factors and prostate-specific antigen levels to predict the non-biochemical recurrence rate after radical prostatectomy ina Japanese cohort. METHODS: A total of 606 Japanese patients with T1-3N0M0 prostate cancer who underwent radical prostatectomy and pelvic lymph node dissection at Tokyo Medical University hospital from 2000 to 2010 were studied. A nomogram was constructed based on Cox hazard regression analysis evaluating the prognostic significance of serum prostate-specific antigen and pathological factors in the radical prostatectomy specimens. The discriminating ability of the nomogram was assessed by the concordance index (C-index), and the predicted and actual outcomes were compared with a bootstrapped calibration plot. RESULTS: With a mean follow up of 60.0 months, a total of 187 patients (30.9%) experienced biochemical recurrence, with a 5-year non-biochemical recurrence rate of 72.3%. Based on a Cox hazard regression model, a nomogram was constructed to predict non-biochemical recurrence using serum prostate-specific antigen level and pathological features in radical prostatectomy specimens. The concordance index was 0.77, and the calibration plots appeared to be accurate. CONCLUSIONS: The postoperative nomogram described here can provide valuable information regarding the need for adjuvant/salvage radiation or hormonal therapy in patients after radical prostatectomy.

Prognostic implication of infiltrative growth pattern and establishment of novel risk stratification model for survival in patients with upper urinary tract urothelial carcinoma.

PURPOSE: To investigate the prognostic significance of infiltrative growth pattern (INF) and to develop a novel risk stratification model for disease-specific survival (DSS) in patients with upper urinary tract urothelial carcinoma (UTUC). METHODS: This study included 113 patients with UTUC treated with radical nephroureterectomy. Pathological features, including INF, were compared with DSS. INF was classified into 3 patterns (INFa, INFb, and INFc). The prognostic factors of DSS were evaluated with univariate and multivariate Cox proportional hazard model analyses. A risk stratification model based on the relative risks of DSS was then established. RESULT: Univariate analysis revealed that patients with high-grade tumor, pathological T stage ≥T3, a non-expanding infiltration pattern (INF ≥b), sessile-type carcinoma, the presence of lymphovascular invasion and positive lymph node involvement showed significantly lower survival rates than their respective counterparts. In the multivariate analysis, high grade tumor, positive lymph node involvement and INF ≥b were independent predictors for DSS (p < 0.05). The patients were stratified into 3 risk groups. The 5-year DSS rates were 94.4 % in the low-risk group, 67.5 % in the intermediate-risk group and 20.5 % in the high-risk group. CONCLUSION: In addition to lymph node involvement and pathological tumor grade, INF is a novel independent prognostic factor in patients with UTUC treated with radical nephroureterectomy. Our risk stratification model developed using these 3 factors may help clinicians identify patients with a poor prognosis who might be good candidates for clinical trials of innovative therapies.

Development of electronic progress tables for multidisciplinary medical education in a university.

In the education of medical professionals, imitation medical records and associated documents were developed as electronic teaching materials for students in order to teach collaboration among medical professionals such as nurses, therapists and medical social workers. The roles of each medical professional and the flow of clinical practice were taught using progress tables, including medical treatment, clinical examination, and the contents of care, so that the contents of medical examination were understood based on a time series. Students' understanding of the flow of medical practice was evaluated based on the amount of description in the table before and after explanation of the important points of the clinical process concerning each medical professional. The comments of students who received the lessons suggested that this approach was useful for understanding actual clinical practice and how to utilize a progress table and to prepare information.