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Technique: In pancreatic transplantation, during bench surgery, the oral and anal sides of a graft duodenum are cut with linear staplers to be as short as possible in order to ascertain blood flow to the graft duodenum stumps. However, this can lead to a distended graft duodenum owing to the large amount of pancreatic juice produced after blood reperfusion during the recipient operation. Controlling bleeding after blood reperfusion and ensuring complete hemostasis are difficult due to obstructed vision caused by the distended graft duodenum. Additionally, the edematous mucosa due to the distended graft duodenum makes it difficult to anastomose the graft duodenum to the recipient's small intestine. Herein, we developed a novel technique during bench surgery to overcome these disadvantages of a distended graft duodenum, by initially leaving the anal side of the graft duodenum uncut to drain the produced pancreatic juice following blood reperfusion. After confirming the hemostasis and anastomosing the graft duodenum to the small intestine, the anal side of the graft duodenum is cut with a linear stapler at the point where sufficient blood flow is confirmed based on duodenal color. Results: This technique enables us to concentrate on the hemostasis and anastomosis without attending to the distended graft duodenum. Furthermore, stump issues due to insufficient blood flow can be avoided. Conclusion: This pancreatic juice drainage technique in pancreas transplantation can be useful to reduce postoperative complications.

Abstract. Background. We clarified the predictive factors for changes in the status of medications for lower urinary tract symptoms (LUTS) 2 years after local radiotherapy for nonmetastatic prostate cancer. Materials and methods. We retrospectively included patients who underwent local external radiotherapy for nonmetastatic prostate cancer in 8 institutions between April 2001 and March 2016. Patients were divided into the medication and no-medication group based on the use of drugs for LUTS before radiotherapy. We defined improvement of LUTS as when the patient did not require medication for LUTS at 24 months after radiotherapy in the medication group and as deterioration when medication was required in the no-medication group. Logistic regression analysis was used to evaluate predictive factors for changes in medication status. Results. Altogether, 505 patients were divided into a no-medication group (n = 352) and a medication group (n = 153). The number of patients with deterioration and improvement in LUTS was 49 (14%) and 36 (23%), respectively. In the multivariate analysis, the predictive variables for deterioration were the International Prostate Symptom Score (≥8; odds ratio [OR], 2.21; p = 0.014) and the biopsy Gleason score (≤3 + 4 = 7; OR, 2.430; p = 0.008) in the no-medication group, whereas those for improvement were age (

In ABO blood group incompatible kidney transplantation (ABO-I), potential issues on acute antibody-mediated rejection (ABMR) remain to be solved. This study aimed to assess the risk factors of acute ABMR using recipient- or donor-derived specimens. Quantitative analysis of A/B antigen expression was conducted in 104 donor kidney tissues (Kt), platelets (Plt), and red blood cells (RBC) by immunohistochemical staining or flow cytometry (FCM). ABO-I pre-transplant recipient serum samples (ABMR = 12, non-ABMR = 27) were extracted by propensity score matching. Anti-A antibody titers of IgM, IgG and IgG subclasses, and C1q binding ability (%) on antibody were measured using RBC-FCM. No association was observed between ABMR and A/B antigen expression levels in donor’s Plt, RBC, or Kt. In recipient’s sample, C1q-IgG binding ability was significantly higher in the ABMR group than in the non-ABMR group (C1q−IgG: 9.04% vs. 5.93% p = 0.049). Neither the A/B antigen expression level in donors (grafts) nor anti-blood group IgG/IgM antibodies in recipient sera before desensitization seemed to influence ABMR incidence in ABO-I. In contrast, C1q-IgG binding ability could be a potential predictor for ABMR in ABO-I.

Summary: Detecting antibodies, particularly those targeting donor human leukocyte antigens in organ transplantation and self-antigens in autoimmune diseases, is crucial for diagnosis and therapy. Radioprotective 105 (RP105), a Toll-like receptor family protein, is expressed in immune-competent cells, such as B cells. Studies in mice have shown that the anti-mouse RP105 antibody strongly activates B cells and triggers an adjuvant effect against viral infections. However, the anti-human RP105 antibody (ɑhRP105) weakly activates human B cells. This study established new culture conditions under, which human B cells are strongly activated by the ɑhRP105. When combined with CpGDNA, specific antibody production against blood group carbohydrates, ɑGal, and SARS-CoV-2 was successfully detected in human B cell cultures. Furthermore, comprehensive analysis using liquid chromatography-electrospray ionization tandem mass spectrometry, single-cell RNA sequencing, and quantitative real-time PCR revealed that ɑhRP105 triggered a different activation stimulus compared to CpGDNA. These findings could help identify antibody-producing B cells in cases of transplant rejection and autoimmune diseases.

Tertiary hyperparathyroidism (THPT) is characterized by elevated parathyroid hormone and serum calcium levels after kidney transplantation (KTx). To ascertain whether pre-transplant calcimimetic use and dose information would improve THPT prediction accuracy, this retrospective cohort study evaluated patients who underwent KTx between 2010 and 2022. The primary outcome was the development of clinically relevant THPT. Logistic regression analysis was used to evaluate pre-transplant calcimimetic use as a determinant of THPT development. Participants were categorized into four groups according to calcimimetic dose, developing two THPT prediction models (with or without calcimimetic information). Continuous net reclassification improvement (CNRI) and integrated discrimination improvement (IDI) were calculated to assess ability to reclassify the degree of THPT risk by adding pre-transplant calcimimetic information. Of the 554 patients, 87 (15.7%) developed THPT, whereas 139 (25.1%) received pre-transplant calcimimetic treatment. Multivariate logistic regression analysis revealed that pre-transplant calcimimetic use was significantly associated with THPT development. Pre-transplant calcimimetic information significantly improved the predicted probability accuracy of THPT (CNRI and IDI were 0.91 [p < 0.001], and 0.09 [p < 0.001], respectively). The THPT prediction model including pre-transplant calcimimetic information as a predictive factor can contribute to the prevention and early treatment of THPT in the era of calcimimetics.

With the increased use of digital devices, forensic document examiners (FDEs) encounter increasing number of dynamic or online signatures during their physical examinations. This shift expands the possibility of examinations and creates new challenges for FDEs. As such, FDEs require new examination skills using data science-based analyses with artificial intelligence and machine-learning techniques. In recent years, automated signature verification has gained significant interest in biometric research and could be useful in forensic investigations. However, the use of complex black-box systems inconveniencing FDEs in explaining the rationale behind their final assessment, especially when dealing with limited signature samples and various types of forged signatures. Therefore, a new forensic method is needed to assist FDEs’ analysis. To tackle these challenges and incorporate lessons learned from biometrics into forensics, this study proposes a novel forensic online signature analysis method. The proposed method uses a single-template strategy based on recent scientific findings in biometrics while updating the strategy for forensic use. This strategy creates a mean-template set from known signature samples that serve as a writer’s signature master pattern. Consequently, FDEs can evaluate intra-writer and inter-item variations using the mean-template set and a questioned signature. Furthermore, to take advantage of recent digital devices, we focused on both on-surface and in-air trajectories of online signatures, which could improve the discriminative power because in-air trajectories are invisible for imposters. Finally, we demonstrate the effectiveness and applicability of the proposed method in a forensic scenario using a public forensic online signature dataset.

IntroductionThe impact of the perioperative estimated glomerular filtration rate (eGFR) on graft survival in kidney transplant recipients is yet to be evaluated. In this study, we developed prediction models for the ideal perioperative eGFRs in recipients.MethodsWe evaluated the impact of perioperative predicted ideal and actual eGFRs on graft survival by including 1,174 consecutive adult patients who underwent living-donor kidney transplantation (LDKT) between January 2008 and December 2020. Prediction models for the ideal perioperative eGFR were developed for 676 recipients who were randomly assigned to the training and validation sets (ratio: 7:3). The prediction models for the ideal best eGFR within 3 weeks and those at 1, 2, and 3 weeks after LDKT in 474 recipients were developed using 10-fold validation and stepwise multiple regression model analyzes. The developed prediction models were validated in 202 recipients. Finally, the impact of perioperative predicted ideal eGFRs/actual eGFRs on graft survival was investigated using Fine–Gray regression analysis.ResultsThe correlation coefficients of the predicted ideal best eGFR within 3 weeks and the predicted ideal eGFRs at 1, 2, and 3 weeks after LDKT were 0.651, 0.600, 0.598, and 0.617, respectively. Multivariate analyzes for graft loss demonstrated significant differences in the predicted ideal best eGFR/actual best eGFR within 3 weeks and the predicted ideal eGFRs/actual eGFRs at 1, 2, and 3 weeks after LDKT.DiscussionThe predicted ideal best eGFR/actual best eGFR within 3 weeks and the predicted ideal eGFRs/actual eGFRs at 1, 2, and 3 weeks after LDKT were independent prognostic factors for graft loss. Therefore, the perioperative predicted ideal eGFR/actual eGFR may be useful for predicting graft survival after adult LDKT.

IntroductionFollowing total parathyroidectomy (PTx), transcervical thymectomy, and forearm autograft for secondary hyperparathyroidism (SHPT), recurrent SHPT can occur in the autografted forearm. However, few studies have investigated the factors contributing to re-PTx due to autograft-dependent recurrent SHPT before the completion of the initial PTx.MethodsA total of 770 patients who had autografted parathyroid fragments derived from only one of the resected parathyroid glands (PTGs) and who had undergone successful initial total PTx and transcervical thymectomy—defined by serum intact parathyroid hormone level < 60 pg/mL on postoperative day 1—between January 2001 and December 2022 were included in this retrospective cohort study. Factors contributing to re-PTx due to graft-dependent recurrent SHPT before the completion of the initial PTx were investigated using multivariate Cox regression analysis. Receiver operating characteristic (ROC) curve analysis was performed to obtain the optimal maximum diameter of PTG for autograft.ResultsUnivariate analysis showed that dialysis vintage and maximum diameter and weight of the PTG for autograft were significant factors contributing to graft-dependent recurrent SHPT. However, multivariate analysis revealed that dialysis vintage (P=0.010; hazard ratio [HR], 0.995; 95% confidence interval [CI], 0.992–0.999) and the maximum diameter of the PTG for autograft (P=0.046; HR, 1.107; 95% CI, 1.002–1.224) significantly contributed to graft-dependent recurrent SHPT. ROC curve analysis showed that < 14 mm was the optimal maximum diameter of PTG for autograft (area under the curve, 0.628; 95% CI, 0.551–0.705).ConclusionsThe dialysis vintage and maximum diameter of PTG for autograft may contribute to re-PTx due to autograft-dependent recurrent SHPT, which can be prevented by using PTGs with a maximum diameter of < 14 mm for autograft.

Background Regional disparity is an imperative component of health disparity. In particular, providing emergency care that is equally available in rural areas is an essential part of reducing the urban–rural disparity. The objective of this study was to examine the worsening admission rate among Cambodian emergency patients in a rural area and determine their background characteristics that cause this decline. Methods To investigate the disparity among patients who visited Sunrise Japan Hospital (SJH), a major general private hospital in the capital, patient data from November 2016 to September 2019 were obtained from the electronic reception patient database. The primary outcome was defined as the proportion of admission patients as an indicator of illness severity. The patients’ addresses were classified into 4 areas based on distance from the capital. Results A total of 6167 patients who visited the emergency department at SJH between January 2017 and September 2019 were included in the analysis. The proportion of patients who needed to be hospitalized or transferred increased with the distance from the capital. The proportion of patients who finished consultation decreased with the distance from the capital (P < .01: Chi- square test). The results of the logistic regression analysis showed that the admission rate in rural areas was significantly higher only among males as compared to that of the capital in multivariate analyses adjusted for age, time, and season. Conclusion The admission rate of emergency patients who visited a private general hospital in Cambodia’s capital city increased with distance from the capital city. To improve regional disparity among emergency patients, further research is necessary to identify the issues among emergency patients, especially those who are vulnerable.

Abstract Background Hypercalcemic hyperparathyroidism has been associated with poor outcomes after kidney transplantation (KTx). However, the clinical implications of normocalcemic hyperparathyroidism after KTx are unclear. This retrospective cohort study attempted to identify these implications. Methods Normocalcemic recipients who underwent KTx between 2000 and 2016 without a history of parathyroidectomy were included in the study. Those who lost their graft within 1 year posttransplant were excluded. Normocalcemia was defined as total serum calcium levels of 8.5–10.5 mg/dL, while hyperparathyroidism was defined as when intact parathyroid hormone levels exceeded 80 pg/mL. The patients were divided into two groups based on the presence of hyperparathyroidism 1 year after KTx. The primary outcome was the risk of graft loss. Results Among the 892 consecutive patients, 493 did not have hyperparathyroidism (HPT-free group), and 399 had normocalcemic hyperparathyroidism (NC-HPT group). Ninety-five patients lost their grafts. Death-censored graft survival after KTx was significantly lower in the NC-HPT group than in the HPT-free group (96.7% vs. 99.6% after 5 years, respectively, P

Secondary hyperparathyroidism (SHPT) is a major problem for patients with chronic kidney disease and can cause many complications, including osteodystrophy, fractures, and cardiovascular diseases. Treatment for SHPT has changed radically with the advent of calcimimetics; however, parathyroidectomy (PTx) remains one of the most important treatments. For successful PTx, removing all parathyroid glands (PTGs) without complications is essential to prevent persistent or recurrent SHPT. Preoperative imaging studies for the localization of PTGs, such as ultrasonography, computed tomography, and 99mTc-Sestamibi scintigraphy, and intraoperative evaluation methods to confirm the removal of all PTGs, including, intraoperative intact parathyroid hormone monitoring and frozen section diagnosis, are useful. Functional and anatomical preservation of the recurrent laryngeal nerves can be confirmed via intraoperative nerve monitoring. Total or subtotal PTx with or without transcervical thymectomy and autotransplantation can also be performed. Appropriate operative methods for PTx should be selected according to the patients’ need for kidney transplantation. In the case of persistent or recurrent SHPT after the initial PTx, localization of the causative PTGs with autotransplantation is challenging as causative PTGs can exist in the neck, mediastinum, or autotransplanted areas. Additionally, the efficacy and cost-effectiveness of calcimimetics and PTx are increasingly being discussed. In this review, medical and surgical treatments for SHPT are described.

Online signature verification is the process of using a dynamic signature verification system to confirm the writer’s identity. It can be used as a security system to confirm entrance applications and password substitutes, as well as a forensic tool to assist an expert’s investigation. This study proposes a novel online signature verification system based on a single-template strategy to improve performance in real-world scenarios. It employs discriminative mean signature template sets as well as fusion strategies of multiple local weighting and warping schemes, for dynamic time warping (DTW). The first step is to generate a set of user-specific mean signature templates for each feature using a recent time-series averaging method, namely, Euclidean barycenter-based DTW barycenter averaging. Then, using multiple and direct matching points between the mean signature templates and references for dependent and independent DTW, we obtain a local weighting estimate considering local stability sequences. Furthermore, we develop fusion strategies for calculating locally weighted DTW sets and concatenating them as a feature vector for each warping, followed by the construction of a support vector machine (SVM) classifier. Finally, in the verification phase, we use the single-template technique to compute a discriminative fused score using SVMs between the mean signature template sets and a query sample. The effectiveness of the proposed method is demonstrated by extensive experimental results obtained using three public online signature datasets: SVC2004 Task1/Task2 and MCYT-100.

Objectives: This study aims to clarify the financial burden of health on the elderly. Out-of-pocket payment (OOPP) in a major private general hospital in Phnom Penh was considered an indicator of financial burden. Study design: This study is a three-year cross-sectional study. Methods: To investigate the characteristics of patients who visited the Sunrise Japan Hospital (SJH), their data were obtained from the electronic reception database. Results: A total of 119,938 patients who visited SJH from January 2017 to September 2019 were included. The median age (25th, 75th centiles) was 52 years (36, 66) and 38.31% of patients were aged over 60 years. The OOPP median (25th, 75th centiles was 73.78 USD (32, 161.89). The median OOPP was the lowest in the 20s and highest in the 90s. The OOPP of an emergency patient was the highest in the consultation classifications. Conclusions: The need to raise public awareness regarding the financial burden on the elderly is becoming increasingly urgent. It is vital to establish a social system to prevent the medical catastrophes.

BackgroundTotal parathyroidectomy (PTx) is often performed to treat secondary hyperparathyroidism (SHPT). Successful PTx is essential to prevent recurrent and persistent SHPT because remnant parathyroid glands (PTGs) in the neck can be stimulated and may secrete excessive parathyroid hormone (PTH) in end-stage renal disease. However, to date, few studies have investigated factors contributing to successful PTx before the completion of surgery.Materials and methodsBetween August 2010 and February 2020, 344 patients underwent total PTx, transcervical thymectomy, and forearm autograft for SHPT at our institute. Factors contributing to successful PTx before the completion of surgery were investigated. Preoperative imaging diagnoses, including computed tomography, ultrasonography, technetium-99m methoxyisobutylisonitrile (99mTc-MIBI) scintigraphy, intraoperative intact PTH (IOIPTH) monitoring, and frozen section histologic diagnosis, were performed. Successful PTx was defined as intact PTH level < 60 pg/mL on postoperative day 1. A sufficient decrease in IOIPTH level was defined as > 70% decrease in intact PTH levels measured 10 min after total PTx and transcervical thymectomy compared to intact PTH levels measured before skin incision. Logistic regression analysis was conducted to investigate factors contributing to PTx success.ResultsUnivariate analysis showed that the number of all PTGs identified preoperatively by imaging modalities and the specimens submitted for frozen section diagnosis, which surgeon presumed to be PTGs, were not significant factors contributing to successful PTx. However, multivariate analysis revealed that the number of PTGs identified by frozen section diagnosis (P < 0.001, odds ratio [OR] 4.356, 95% confidence interval [CI] 2.499–7.592) and sufficient decrease in IOIPTH levels (P = 0.001, OR 7.847, 95% CI 2.443–25.204) significantly contributed to successful PTx.ConclusionSufficient intact PTH level decrease observed on IOIPTH monitoring and the number of PTGs identified by frozen section diagnosis contributed to successful PTx for SHPT. IOIPTH monitoring and frozen section diagnosis are essential for achieving successful PTx for SHPT.

Background Hand-assisted laparoscopic donor nephrectomy (HALDN) is widely performed to minimize burden on living kidney donors. However, hand port-site infections after HALDN may occur. This study aimed to assess the impact of donor characteristics including preoperative comorbidities and operative factors on hand port-site infection after HALDN. Methods In this single-center, retrospective cohort study, 1,260 consecutive HALDNs for living-donor kidney transplantation performed between January 2008 and December 2021 were evaluated. All living donors met the living kidney donor guidelines in Japan. Hand port-site infections were identified in 88 HALDN cases (7.0%). To investigate risk factors for hand port-site infection, donor characteristics including preoperative comorbidities such as hypertension, glucose intolerance, dyslipidemia, obesity, and operative factors such as operative duration, blood loss, preoperative antibiotic prophylaxis, and prophylactic subcutaneous suction drain placement at the hand port-site were analyzed using logistic regression analysis. Results In the multivariate analysis, significant differences were identified regarding sex (P = 0.021; odds ratio [OR], 1.971; 95% confidence interval [CI], 1.108–3.507), preoperative antibiotic prophylaxis (P

Abstract Background To best employ radium‐223 dichloride (Ra‐223) for patients with castration‐resistant prostate cancer (CRPC) and bone metastasis, we investigated the bone‐predominant status in patients treated with Ra‐223. Methods We retrospectively evaluated 127 CRPC patients who underwent treatment with Ra‐223. The patients were divided into three groups based on the types of dynamic changes of bone metastasis between diagnosis and just before Ra‐223: (a) only known lesions; (b) de novo lesions; (c) new progressive lesions. We developed the risk assessment using predictive factors based on progression‐free survival (PFS). Results During the median follow‐up period of 10.4 months, the median PFS in the only known lesions group was 11.3 months compared to 8.1 months in the de novo lesions group and 5.1 months in the new progressive lesions group (P 1 (HR 1.74, 95% CI 1.04‐2.89, P = .034), PSA value of >100 ng/mL (HR 1.59, 95% CI 1.02‐2.50, P = .043), and PSA doubling time (PSADT) of

Making medical tourism a more valuable healthcare system is a significant public health issue. However, little discussion has been conducted on what lessons can be learned from the impact of COVID-19 on medical tourism. This study aimed to discuss the issues and barriers faced by patients unable to seek medical tourism, and the medical care experience at private general hospital in capital, Cambodia. First, when patients seeking medical tourism were unable to go abroad due to the pandemic or other reasons, some of them could not easily visit domestic health care facilities. Second, even if patients received medical care in the home country's hospitals due to the interruption of medical tourism, sharing the patient's medical information between domestic and overseas medical institutions was difficult. The third problem in medical tourism is that dependence on overseas medical resources might hinder the development of medical professionals, facilities, and other environments in the country of origin. This experience revealed the need to encourage patients who were unable to undertake medical tourism to visit domestic medical facilities, make efforts to share patient information across countries, and to invest in developing each department in domestic hospitals. Support for patients who are unable to undertake medical tourism is urgently needed.

Introduction: Recent reports have described an increased risk of renal disease in living kidney donors compared with the general population. However, these reports do not detail the outcomes of medically complex living donors (MCLDs) with preoperative comorbidities (PCs), such as hypertension, dyslipidemia, glucose intolerance, and obesity. Analysis of living donors with end-stage renal disease (ESRD) has shown that these PCs may contribute significantly to the development of ESRD. We aimed to evaluate the effect of PCs on postoperative renal function and mortality in MCLDs. Methods: Between January 2008 and December 2016, 807 living-donor kidney transplants were performed in our unit. Of these, 802 donors completed postoperative follow-up of >5 months. Donors were stratified into 4 groups based on the number of PCs present: healthy living donors (HLDs) with no PCs (n = 214) or MCLDs with 1 PC (n = 302), 2 PCs (n = 196), or 3 PCs (n = 90) (denoted MCLD [PC 1], MCLD [PC 2], or MCLD [PC 3], respectively). We compared pathology observation data from baseline biopsy, postoperative estimated glomerular filtration rate (eGFR), postoperative urinary protein concentration, and mortality between HLD and MCLD groups. Results: Interstitial fibrosis, tubular atrophy, glomerulosclerosis, and arteriolosclerosis were more frequent in MCLDs (PC 3) than in HLDs. No significant differences were identified between HLDs and MCLDs in terms of postoperative eGFR and short-term mortality. Overt proteinuria and ESRD were not observed. Conclusions: Appropriate postdonation management of MCLDs with PCs may result in similar outcomes as for HLDs. Keywords: baseline biopsy, estimated glomerular filtration rate, kidney transplantation, medically complex living donor, preoperative comorbidities, proteinuria

Objective To investigate the factors associated with adherence of an enlarged parathyroid gland to the recurrent laryngeal nerve (RLN) and the effectiveness of intraoperative neural monitoring (IONM). Methods This single-center retrospective study involved samples from 197 consecutive patients (394 RLNs; 733 parathyroid glands) who underwent parathyroidectomy and transcervical thymectomy between September 2010 and December 2014. The presence of parathyroid gland adhesion to the RLN and the clinical characteristics of patients with and without nerve adhesion were recorded. All patients underwent intraoperative monitoring of the electromyographic responses of the vocal cords using the endotracheal NIM-Response 3.0 system. The patients’ postoperative clinical outcomes were recorded. Results Parathyroid gland adhesion to the RLN was significantly associated with maximum gland diameter (>15 mm), weight (>500 mg), and the presence of nodular hyperplasia. IONM demonstrated a sensitivity of 97.8%, specificity of 43.5%, and accuracy of 94.7% for detecting nerve damage. Parathyroid gland adhesion to 17 RLNs occurred in 3 cases (17.6%) of vocal cord paralysis, whereas the 377 glands without nerve adhesion resulted in vocal cord paralysis in 20 cases (5.3%). Conclusion Our findings demonstrated the effectiveness of IONM using endotracheal electromyography in patients who underwent parathyroidectomy for secondary hyperparathyroidism.

In pre-sensitizing events, immunological memory is mainly created via indirect allorecognition where CD4+ T cells recognize foreign peptides in the context of self-HLA class II (pHLA) presented on antigen-presenting cells. This recognition makes it possible for naive CD4+ T-helper cells to differentiate into memory cells, resulting in the creation of further antibody memory. These responses contribute to effective secretion of donor-specific anti-HLA antibodies (DSA) after second encounters with the same peptide. Preformed donor-reactive CD4+ memory T cells may induce early immune responses after transplantation; however, the tools to evaluate them are limited. This study evaluated shared T cell epitopes (TEs) between the pre-sensitizing and donor HLA using an in silico assay, an alternative to estimate donor-reactive CD4+ memory T cells before transplantation. In 578 living donor kidney transplants without preformed DSA, 69 patients had anti-HLA antibodies before transplantation. Of them, 40 had shared TEs and were estimated to have donor-reactive CD4+ memory T cells. De novo DSA formation in the early phase was significantly higher in the shared TE-positive group than in the anti-HLA antibody- and shared TE-negative groups (p=0.001 and p=0.02, respectively). In conclusion, evaluation of shared TEs for estimating preformed donor-reactive CD4+ memory T cells may help predict the risk of early de novo DSA formation after kidney transplantation.

Persistent or recurrent renal hyperparathyroidism may occur after total parathyroidectomy and transcervical thymectomy with forearm autograft under continuous stimulation due to uremia. Parathyroid hormone (PTH) levels may reflect persistent or recurrent renal hyperparathyroidism because of the enlarged autografted parathyroid glands in the forearm or remnant parathyroid glands in the neck or mediastinum. Detailed imaging requires predictive localization of causative parathyroid glands. Casanova and simplified Casanova tests may be convenient. However, these methods require avascularization of the autografted forearm for >10 min with a tourniquet or Esmarch. The heavy pressure during avascularization can be incredibly painful and result in nerve damage. An easier method that minimizes the burden on patients in addition to predicting the localization of causative parathyroid glands was developed in this study. Ninety patients who underwent successful re-parathyroidectomy for persistent or recurrent renal hyperparathyroidism after parathyroidectomy between January 2000 and July 2019 were classified according to the localization of causative parathyroid glands (63 and 27 patients in the autografted forearm and the neck or mediastinum groups, respectively). Preoperatively, intact PTH levels were measured from bilateral forearm blood samples following a 5-min avascularization of the autografted forearm. Cutoff values of the intact PTH ratio (intact PTH level obtained from the non-autografted forearm before re-parathyroidectomy/intact PTH level obtained from the autografted forearm before re-parathyroidectomy) were investigated with receiver operating characteristic curves to localize the causative parathyroid glands. Intact PTH ratios of 0.859 with an AUC 0.744 (95% CI: 0.587-0.901; P = 0.013) could predict causative parathyroid glands in the autografted forearm and the neck or mediastinum with diagnostic accuracies of 81.1% and 83.3%, respectively. Therefore, we propose that the intact PTH ratio is useful for predicting the localization of causative parathyroid glands for re-parathyroidectomy.

Online signature verification has been widely applied in biometrics and forensics. Due to the recent demand on high-speed systems in this era of big data, to simultaneously improve its performance and calculation complexity, this study focuses on a single-template strategy that uses dynamic time warping (DTW) with dependent warping for online signature verification, and attempts to construct a novel time-series averaging method called Euclidean barycenter-based DTW barycenter averaging (EB-DBA). Specifically, this study proposes a single-template strategy using a mean template created by the EB-DBA to achieve higher performance at lower calculation complexity for online signature verification. The method’s discriminative power is enhanced upon the exploration of two DTW warping types, where it is found that the DTW with dependent warping exhibits better performance. The popular MCYT-100 dataset is utilized in the experiments, which confirms the effectiveness of the proposed method in simultaneously achieving lower error rate and lower calculation complexity, for online signature verification.

Purpose: We compared laparoscopic redo fundoplications performed for failed laparoscopic Toupet fundoplication (LTF) and failed laparoscopic Nissen fundoplications (LNFs). Methods: Redo LTF (R-LTF; n = 4) and redo LNF (R-LNF; n = 6) performed between 2007 and 2014 were assessed retrospectively for severity of intraperitoneal adhesions on a scale of 0–3, identification/preservation of the anterior/posterior/hepatic branches of the vagus nerve (VN), complications, and outcome. Results: Redos were performed after a mean of 34 months in R-LTF and 32 months in R-LNF (P = ns) indicated for sliding hernia (n = 3; 2 with partial wrap dehiscence) and partial wrap dehiscence (n = 1) in R-LTF and sliding hernia (n = 6; 4 with partial wrap dehiscence) in R-LNF. The mean adhesion severity score was 1.5 in R-LTF and 2.5 in R-LNF (P < 0.05). The mean number of VN branches identified/preserved was 2.0 in R-LTF and 0.8 in R-LNF (P < 0.05). Mean operative times and mean blood loss were similar. Intraoperative complications were accidental local trauma (n = 1 in R-LTF and n = 3 in R-LNF, one requiring conversion to open repair) (P = ns). Gastric outlet obstruction developed in two R-LNF cases; both were managed conservatively. There have been no further recurrences to date. Conclusion: Although our series is small, adhesions were less, and identification/preservation of VN was easier during R-LTF.

There is a risk for high-output congestive heart failure to be associated with an extra-lobar pulmonary sequestration (ELS) when there is left-to-left shunting caused by a large systemic arterial supply to a sequestration and venous drainage via the pulmonary veins into the left atrium. We present a 2-year-old boy who underwent thoracoscopic resection of an unusually hypervascular right ELS with a high output left-to-left shunt between the aorta and the left atrium via a pulmonary vein. This case is of particular interest because computed tomographic angiography identified a hypervascular nidus with indistinct borders between arterial and venous vessels suggestive of an arteriovenous malformation.

A 16-month-old boy was referred to our hospital for the management of suspected lithium button battery (LBB) ingestion. He had been previously well, but became febrile with a persistent cough resistant to oral antibiotics and dysphagia for 5 days. Radiography identified an LBB lodged in the upper esophagus. The LBB was retrieved under direct visualization with rigid laryngoscopy. He was sedated for 5 days and enteral feeding was commenced through a nasojejunal tube on the next day after procedure. On day 8 after retrieval, endoscopy and fluoroscopy identified a tracheoesophageal fistula (TEF), 6 mm in diameter. Conservative management was conducted with periodic follow-up endoscopies, which showed signs of healing in the esophagus. Following continuous antibiotics and proactive nutritional support, the TEF was found to have closed spontaneously by day 28 after the LBB removal. We present our experience of the successful nonsurgical management of acquired TEF secondary to LBB ingestion and aim to establish a protocol for managing it conservatively by reviewing the relevant literature.

Objective: We evaluated who would need further evaluations such as retrograde pyelography (RP) and/or ureteroscopy to diagnose upper urinary tract urothelial cancers (UUTUCs) when abnormal findings for the upper urinary tract (UUT) were detected by enhanced computed tomography (CT). Methods: We retrospectively analyzed 125 patients who underwent enhanced CT for various reasons and had abnormal findings for the UUT. Patients whose tumors were suspected to be of extraureteral origin were excluded. All patients received RP and/or ureteroscopy to evaluate the UUTUCs. Results: The median age of the 125 patients was 70 years and gross hematuria (26.4%) was the most frequently observed symptoms. RP, ureteroscopy and both were performed for 121, 59 and 55 patients, respectively. CT revealed tumor-like lesions in 58 patients and the other patients had non-tumor-like lesions. UUTUCs were found in 43 (34.4%) of the 125 patients. All of them had tumor-like lesions on CT. In 58 patients who had tumor-like lesions on CT, univariate and multivariate analyses revealed that tumor diameter and tumor enhancement were significant predictive factors for UUTUCs. ROC curve analysis of enhanced CT to diagnose UUTUCs revealed that a tumor diameter of 18 mm was the best cutoff point. The sensitivity, specificity and accuracy were 90.0%, 98.8% and 92.7% for RP and 95.5%, 100% and 97.1% for ureteroscopy, respectively. Both of them had high sensitivity, specificity and accuracy. Conclusion: We should decide to evaluate the UUT according to the tumor diameter on enhanced CT. When we evaluate the UUT in patients with tumor diameters of less than 20 mm, ureteroscopy is recommended.

A boy with myelomeningocele who had sigmoidocolocystoplasty and ureteric reimplantation when 2-years old and normal annual cystoscopies, developed hematuria and abdominal pain with liver dysfunction 14 years postoperatively. Computed tomography showed a tumor on the left side of the augmented bladder, a large lymph node, and large multiple probable metastases in the liver. Cystoscopy 3 months earlier had been normal, but when repeated showed a tumor originating from the augmented sigmoid colon. Biopsy showed undifferentiated sarcoma. Despite chemotherapy, he died 3 months later. The diagnosis at autopsy was undifferentiated sarcoma originating from the sigmoid colon. We report the first case of undifferentiated sarcoma developing 14 years after sigmoidocolocystoplasty for meningomyelocele, and also review the 55 cases of post-bladder augmentation malignancy in the literature.

The ultrasonically assisted machining is suitable to achieve sub-millimeter drilling on difficult-to-cut materials such as ceramics, hardened steel, glass and heat-resistant steel. However, it is difficult to observe the high-frequency and micron-scale phenomenon of ultrasonic cutting. In this report, high speed camera based on photoelastic analysis realized the visualization of stress distribution on drilling process. For the conventional drilling, the stress distribution diagram showed the intensive stress occurred under the chisel because the chisel edge of drill produces large plastic deformation. On the other hand, the ultrasonic drilling produced spread stress distribution and stress boundary far away from the chisel. Furthermore, chipping or cracking of inner wall of silica glass was influenced considerably by cutting fluid.

Bone mineral density (BMD) was measured to establish the optimal timing for pectus bar (PB) removal after the Nuss procedure (NP). Twenty-three patients who had PB removal after NP were assessed according to: age at PB insertion/removal, duration of insertion, clinical outcome and BMD. BMD was measured just prior to insertion (in-BMD) and just prior to removal (out-BMD) and %BMD was determined by dividing subject BMD by BMD for age-matched controls. Age at insertion ranged from 4.3–2.7 years and age at removal ranged from 6.3–14.1 years. Duration of insertion ranged from 1.4–3.9 years. There were two cases of recurrence after NP. In these cases, PB insertion occurred at 5 and 4 years, and removal was at 6 and 8 years respectively and both BMD and %BMD were below normal. In the nine cases with no recurrence, PB removal occurred between 6–8 years old; BMD was normal, and %BMD was higher than in the two cases with recurrence. BMD and %BMD would appear to be valuable markers for the timing of PB removal.

Recently, wheel separation accidents in such vehicles as trucks, buses and passenger cars have drawn a social concern. Explications of their causes and adequate practices of countermeasures for them have been urgently required. In relation to this issue, the authors have taken notice of subjects which are concerned in bolted joints at wheels and are especially trying to study the pressure distribution at the bearing surface of nuts. This report deals with the subject of a nut with a cone-form bearing surface. Considerations are based on numerical results derived from finite-element-analysis. Feature of the pressure distribution by this profile and influences from geometrical deviations of the form are mainly discussed, and some other information concerning this issue is presented.

The outbreak of Pneumocystis jirovecii pneumonia (PJP) among kidney transplant recipients is emerging worldwide. It is important to control nosocomial PJP infection. A delay in diagnosis and treatment increases the number of reservoir patients and the number of cases of respiratory failure and death. Owing to the large number of kidney transplant recipients compared to other types of organ transplantation, there are greater opportunities for them to share the same time and space. Although the use of trimethoprim-sulfamethoxazole (TMP-SMX) as first choice in PJP prophylaxis is valuable for PJP that develops from infections by trophic forms, it cannot prevent or clear colonization, in which cysts are dominant. Colonization of P. jirovecii is cleared by macrophages. While recent immunosuppressive therapies have decreased the rate of rejection, over-suppressed macrophages caused by the higher levels of immunosuppression may decrease the eradication rate of colonization. Once a PJP cluster enters these populations, which are gathered in one place and uniformly undergoing immunosuppressive therapy for kidney transplantation, an outbreak can occur easily. Quick actions for PJP patients, other recipients, and medical staff of transplant centers are required. In future, lifelong prophylaxis may be required even in kidney transplant recipients.