Objective: The objective of the present study was to investigate the utility of placing a chimney-type (stacked subcutaneous Penrose) drain to prevent surgical site infection (SSI), and particularly superficial SSI (sSSI), following surgery performed for lower gastrointestinal perforation.

Subjects and methods: Our subjects were 93 patients who underwent emergency surgery after being diagnosed as having lower gastrointestinal perforation at our hospital from October 2009 to August 2020. All patients not meeting the inclusion criteria were excluded from the study. Subjects were divided into three groups (listed in chronological order): group C, 36 subjects with no drain inserted from 2009 to 2012; group B, 39 subjects in whom closed negative-pressure drains were placed from 2012 to 2017; and group A, 18 subjects in whom chimney-type drains were placed from 2017 to 2020. We retrospectively investigated patient factors, surgical factors, postoperative drain indwelling time, whether sSSI onset occurred and days until sSSI onset. sSSI was diagnosed based on the criteria published by the Japan Nosocomial Infection Surveillance (JANIS) program run by the Japanese Ministry of Health, Labour and Welfare.

Results: The incidence of sSSI was lower in group B than in group C, but the difference was not statistically significant. The incidence of sSSI was significantly lower in group A than in group C (5.6% vs 33.3%, p=0.04) and was also lower in group A than in group B, but not statistically significantly so (5.6% vs 20.5%, p=0.24)

Discussion: We believe that insertion of a chimney-type drain is useful for preventing sSSI in patients who have undergone surgery to treat lower gastrointestinal perforation.

Background: Systemic chronic active Epstein-Barr virus infection (sCAEBV) is a rare and fatal lymphoid neoplasm characterized by sustained systemic inflammation and clonal proliferation of EBV-infected T or NK cells. Because the mechanisms responsible for the development of the disorder have not been elucidated to date, its optimal chemotherapy has not been established, and the prognosis of sCAEBV has remained very poor. We previously found and reported that simvastatin, an inhibitor of HMG-CoA reductase, inhibits prenylation of intracellular signal-mediating molecules in adult T-cell lymphoma/leukemia cells. On the basis of these findings, we hypothesized that simvastatin could also induce apoptosis in EBV-positive T or NK cells from sCAEBV.

Methods: We examined two clinical samples of EBV-positive T-cell lines derived from sCAEBV, SNT8 and SNT15. The samples were obtained from six patients with sCAEBV. The in vitro effects of simvastatin on the cells were examined by XTT and Annexin V assay, and the in vivo effects of simvastatin on sCAEBV were examined in xenograft models of sCAEBV generated from NOD/Shi-scid/IL-2Rγ^null mice.

Results: Simvastatin suppressed proliferation and induced apoptosis in the cell lines in a dose-dependent manner. Simvastatin also suppressed proliferation and induced apoptosis of peripheral blood mononuclear cells derived from patients with sCAEBV with infected cell types of CD4 in 3 patients, CD8 in 2 patients, and CD56 in 1 patient. The presence of farnesyl pyrophosphate, one of the intermediates in the mevalonate pathway, restored the number of viable SNT8 and SNT15 cells treated with simvastatin. Furthermore, oral administration of simvastatin reduced EBV-DNA in the peripheral blood of sCAEBV xenograft models.

Conclusions: Simvastatin may be an attractive reagent for sCAEBV.

Introduction The appropriate management of postoperative pancreatic fistula (POPF) after gastrectomy is believed to decrease the incidence of subsequent complications. Previous reports have indicated a relationship between subsequent complications of POPF and drain fluid amylase levels (D-AMY), but this indicator did not offer adequate sensitivity and specificity. In this study, we searched for indicators using highly precise D-AMY levels to predict the onset of subsequent complications.

Materials and methods: We performed a retrospective study of 377 patients who underwent gastrectomy between 2014 and 2020 and whose D-AMY levels were measured. D-AMY levels were measured once a day, and we initiated treatment for pancreatitis if levels were ≥ 1500 U/L. We compared the incidence of complications and various clinical factors, including D-AMY level, and also strove to determine a clinically useful cut-off value.

Results There were 64 patients (17.0%) who were diagnosed as having pancreatitis by D-AMY levels ≥ 1500 U/L and required treatment. The significant risk factors were D-AMY ≥ 766 U/L on postoperative day (POD) 2 (p=0.0415, OR=32.46), and a total D-AMY of ≥ 6801 U/L from POD 0 to POD 4 (p=0.0023, OR=55.85). The area under the receiver operator characteristics curve, sensitivity and specificity were 0.84511, 78.6% and 90.9%, and 0.96834, 82.4% and 96.7% for the POD 2 and POD 0—4 cut-off values, respectively.

Conclusion The POD 2 cut-off value correlated with POPF complications after gastrectomy, but the concomitant use of the cut-off value for the period from POD 0—4 facilitated even more accurate prediction of subsequent onset of complications.

Background: Video laryngoscopy (VL) is an attractive airway management device; however, its user's motion during tracheal intubation (TI) has not been evaluated. Therefore, this study aimed to investigate the differences in head and eye movement during TI using VL, McGRATH^®, between experts and novices.

Methods: Time for TI, head movements, and gaze distribution during TI in a mannequin with McGRATH^® were recorded using motion capture and eye-tracking systems. TI was divided into three phases: A) from mouth opening to laryngoscope insertion, B) from the insertion into the mouth to enable visualization of the vocal cords, and C) from holding a constant vocal cord view to the finish of intubation. Data were compared between the experts and novices according to the phases.

Results: In the experts, total TI time was significantly shorter (17.5 vs. 20.5 sec, p＜0.001), and the duration of Phases A and C were significantly shorter (A: 5.0 vs. 6.4 sec, p＜0.001; C: 8.1 vs. 9.2 sec, p=0.031). The intra-group comparison showed the head height in both groups significantly decreased until the Phase B and significantly increased in Phase C. Inter-group comparison showed the head heights in the Phases B and C were significantly lower in the novices (B: 152.2 vs. 142.6 cm, p＜0.001; C: 157.4 vs. 145.9 cm, p＜0.001). The height differences between the occipital and temporal regions indicated both groups turned their faces down from Phase A to B and upward in Phase C. The extent of head tilting in each phase was significantly larger in the novices. Gaze analysis indicated that while the experts continued looking down and further throughout TI, the novices looked up during Phases B and C.

Conclusion: Posture and gaze distribution during TI using McGRATH^® were different between the novices and experts. These results should be considered in instructing and learning TI.

Background: The hair cycle is key to understanding the onset of alopecia. We investigated the effects of culturing human hair follicle-derived keratinocytes (HFK) and human follicle dermal papilla cells (HFDPC) under specific conditions to determine the effects of products secreted by the former on hair-related gene expression in the latter to clarify intercellular signal transduction between the tissues that make up the hair root.

Methods: We measured HFDPC gene expression after addition of cultured HFK supernatant and after co-culture with HFK. We also performed experiments using cultured HFK supernatant from which the exosomes had been removed.

Results: A significant increase in the expression of Wnt gene family member 5A (WNT5A), fibroblast growth factor 2 (FGF2) and vascular endothelial growth factor (VEGF) was observed in the HFDPC cultures to which cultured HFK supernatant was added. Meanwhile, co-culture of HFK and HFDPC revealed a less intense increase in WNT5A and FGF2 expression but a more significant increase in VEGF expression. When we removed the exosomes from the cultured HFK supernatant, we observed decreased expression of WNT5A and FGF2, with increased expression of bone morphogenetic protein-2 (BMP2) and VEGF.

Conclusion: These results suggest that the HFDPC hair cycle-related genes are affected by multiple HFK-derived factors. One of these factors may be the exosomes themselves, which increase expression of genes that promote hair loss. Going forward, it may be possible to develop new therapies for alopecia if we can identify these signal transduction factors and verify their presence and function in animals.

Recently, numerous attempts have been devoted to applying deep-learning-based super resolution to medical images. However, discussions on its usefulness have been limited to the use of indices such as peak signal-to-noise ratio (PSNR) and structural similarity (SSIM), and the significance of its application has not been widely discussed. This study aimed to compare several deep learning (DL) —based super-resolution methods using publicly available brain magnetic resonance imaging datasets. The impact of training the segmentation models on super-resolved images was also investigated. The results demonstrated the superiority of the DL-based model over traditional image interpolation methods and the limitations of its application in medical imaging. Additionally, the results indicated that PSNR and SSIM might not always be suitable as evaluation indices.

Introduction: There is a difficulty to predict the success rate in endoscopic combined intrarenal surgery (ECIRS). This study aimed to create a prediction model for successful ECIRS using machine learning from medical record information and diagnostic imaging data, and verify its area under the curve (AUC).

Methods: Patients who underwent ECIRS for urinary tract stones at Meirikai Tokyo Yamato Hospital were recruited. Patients were excluded if the surgical position was other than the modified Valdivia position, if the patient had been treated multiple times, or if the urinary tract stone had never been evaluated by computed tomography. Collected data included clinical information, blood biochemical findings, urinary findings, and imaging findings of the patients. To assess the performance of our model, we used 10-fold cross-validation where 90% of the data were used for training and 10% for validation. All possible input variables were used to train the model and validate its AUC and accuracy.

Results: A total of 441 patients who underwent ECIRS were included. Logistic regression, which had the highest AUC, was used as the machine-learning model. The learning accuracy was adjusted by calculating the importance of the features and selecting 18 items. LDH, stone shape, TP, age, 3rd largest stone exist distal ureter, double renal pelvis or ureter, height, 1st largest stone exists mid-ureter, length diameter of the 1st largest stone and the 2nd largest stone, WBC count of 30-49/HPF and ≥100/HPF in urine sediment, MCHC, horseshoe kidney, presence of stones or the number of stones in the renal calyx, and short diameter of the 2nd largest stone were predictors of high success in ECIRS. AUC, accuracy, sensitivity, and specificity were 0.71, 71.9, 77.7, and 54.5, respectively.

Conclusion: The machine-learning model obtained using medical record information accurately predicted the success of the ECIRS.

Purpose: Although the detailed pathogenesis of interstitial lung disease (ILD) is unknown, the involvement of apoptosis has been suggested. We investigated whether the apoptosis marker of epithelial cells in serum can be a marker of disease activity, to examine the involvement of apoptosis in the pathology of ILD associated with connective tissue disease (CTD).

Methods: We analyzed serum levels of caspase-cleaved cytokeratin-18 (M30) in 87 patients, consisting of 52 patients with rheumatoid arthritis (RA) and 35 with polymyositis or dermatomyositis (PM/DM), using enzyme-linked immunosorbent assays. Of the 87 patients, 39 (17 with RA and 22 with PM/DM) had ILD.

Results: The median (interquartile range) serum level of M30 was 283.2 (153.9-340.6) U/L in the patients with ILD associated with RA and PM/DM (RA-ILD, and PM/DM-ILD), and 143.4 (108.5-176.2) U/L in the patient without ILD. Serum level of M30 was significantly higher in patients with RA-ILD than those with RA without ILD (P＜0.001). Furthermore, serum level of M30 was significantly higher in patients with PM/DM-ILD than those with PM/DM without ILD (P＜0.001). Serum M30 levels were negatively correlated with percent-predicted forced vital capacity (r_s=-0.37). The cutoff value of serum M30 to detect CTD-ILD, revealed by receiver-operating characteristic curve analysis, was 211.7 U/L, with a sensitivity of 85.4% and specificity of 66.7%.

Conclusion: Lung apoptosis is suggested to be involved in the fibrosis of CTD-ILD. The serum M30 level can be useful as a detection and activity marker for CTD-ILD.

We examined the usefulness of heart rate variability spectral analysis as a predictor of covert paroxysmal atrial fibrillation (PAF), an essential risk factor for embolic stroke. Between July 2021 and January 2022, 77 patients (mean age, 76.3 ± 10.9 years) hospitalized with cryptogenic stroke within 3 days of symptom onset were monitored by telemetry electrocardiogram (ECG) transmitter Duranta^®. Autonomic nervous activity up to maximum 30 days after monitoring by Duranta^® was analyzed and PAF was detected in 8 patients. During 24-hour post-monitoring, 8 patients with PAF had significantly higher levels of low-frequency components (LF), high-frequency components (HF), and HF normalization units and significantly lower levels of LF/HF ratio than those without PAF. Conversely, the results showed the trend of LF/HF ratio to increase and the HF values to decrease preceding the onset of PAF. These findings suggest that parasympathetic activity is predominant in the acute phase of ischemic stroke patients with PAF, but sympathetic activity become predominant towards the PAF occurrence.

For patients with estrogen-sensitive tumors, there is a concern that the high estrogen state induced by controlled ovarian stimulation (COS) for oocyte retrieval may stimulate the growth of cancer cells. Protocols using aromatase inhibitors (AIs) have been developed to suppress the elevated estrogen levels during ovarian stimulation. However, studies have shown that COS with AI may induce apoptosis in cumulus and granulosa cells due to an increase in the androgen/estrogen ratio, which is associated with decreased oocyte quality. In the present study, we examined the hormonal dynamics in follicular fluid collected from patients with breast cancers who underwent COS with AI for fertility preservation (n = 11). In addition, we examined the relative gene expressions of several oocyte quality predictor genes in the cumulus and granulosa cells. The control samples were collected from patients with general infertility who underwent COS without AI (n = 17).

Methods: The study population included patients with breast cancer who underwent COS with AI for oocyte retrieval for fertility preservation (n = 11, AI group) and patients with general infertility who underwent COS without AI for oocyte retrieval for in vitro fertilization (IVF) (n = 17, control group). The follicular fluid was collected at the time of oocyte retrieval. Estradiol (E2), progesterone, testosterone, and anti- Müllerian hormone (AMH) levels in the follicular fluid were measured by enzyme-linked immunosorbent assay (ELISA), and relative gene expressions of bone morphogenetic protein 3 (BMP3), prostaglandin-endoperoxide synthase 2 (PTGS2) and hyaluronan synthase 2 (HAS2) were analyzed by quantitative real-time polymerase chain reaction (qRT-PCR).

Results: Compared to the control group, the levels of E2 were significantly suppressed while the testosterone and AMH levels increased in the AI group. No significant differences were observed in the progesterone levels. The relative gene expressions of BMP3, PTGS2 and HAS2 in cumulus and granulosa cells showed no significant differences between the two groups.

Conclusion: We confirmed that COS with AI suppressed the E2 levels in the follicular fluid of patients with breast cancer. The elevated testosterone level in follicular fluid did not alter the BMP3, PTGS2 and HAS2 gene expressions in cumulus and granulosa cells nor affect the number of oocytes retrieved.

The patient was a 32-year-old woman who had a 20-year history of intestinal Behçet's disease without ocular involvement. At the age of 12, she developed oral aphthosis, genital ulcers, erythema nodosum on the lower limbs, and soon developed lower abdominal pain. Colonoscopic examination revealed a round punched-out ulceration in the ileocecal region. Human leukocyte antigen (HLA)-B51 (B5) antigen was negative. Drug therapies with salazosufapyridine and prednisolone was started. When prednisolone was reduced to 15 mg/d, the ileocecal lesion recurred and in addition, diabetes mellitus developed. The patient had been suffered corticosteroid dependence with severe side effects. Since the induction of thalidomide at the age of 14, partial remission that allowed for outpatient visits was maintained for more than 10 years, but negative C-reactive protein (CRP) and endoscopically mucosal healing of the ileocecal ulcer on colonoscopy were not achieved.

Switch from thalidomide to adalimumab (ADA) was introduced at the age of 26 because of reproductive concern. Since introduction of ADA, no recurrence of genital ulcer or skin lesions had been observed. Negative inflammatory reaction was maintained. Colonoscopy performed after the switch to ADA revealed sustained endoscopic mucosal healing in ileocecal ulcer. ADA may have a more specific anti-inflammatory effect on intestinal BD than thalidomide.