Combining lymph node ratio to develop prognostic models for postoperative gastric neuroendocrine neoplasm patients

BACKGROUND Lymph node ratio(LNR)was demonstrated to play a crucial role in the prognosis of many tumors.However,research concerning the prognostic value of LNR in postoperative gastric neuroendocrine neoplasm(NEN)patients was limited.AIM To explore the prognostic value of LNR in postoperative gastric NEN patients and to combine LNR to develop prognostic models.METHODS A total of 286 patients from the Surveillance,Epidemiology,and End Results database were divided into the training set and validation set at a ratio of 8:2.92 patients from the First Affiliated Hospital of Soochow University in China were designated as a test set.Cox regression analysis was used to explore the relationship between LNR and disease-specific survival(DSS)of gastric NEN patients.Random survival forest(RSF)algorithm and Cox proportional hazards(CoxPH)analysis were applied to develop models to predict DSS respectively,and compared with the 8th edition American Joint Committee on Cancer(AJCC)tumornode-metastasis(TNM)staging.RESULTS Multivariate analyses indicated that LNR was an independent prognostic factor for postoperative gastric NEN patients and a higher LNR was accompanied by a higher risk of death.The RSF model exhibited the best performance in predicting DSS,with the C-index in the test set being 0.769[95%confidence interval(CI):0.691-0.846]outperforming the CoxPH model(0.744,95%CI:0.665-0.822)and the 8th edition AJCC TNM staging(0.723,95%CI:0.613-0.833).The calibration curves and decision curve analysis(DCA)demonstrated the RSF model had good calibration and clinical benefits.Furthermore,the RSF model could perform risk stratification and individual prognosis prediction effectively.CONCLUSION A higher LNR indicated a lower DSS in postoperative gastric NEN patients.The RSF model outperformed the CoxPH model and the 8th edition AJCC TNM staging in the test set,showing potential in clinical practice.

深度学习在内镜下内痔诊断及危险分级中的应用

目的建立内镜下内痔诊断及危险分级的深度学习模型,探讨人工智能辅助内镜下内痔诊疗的可行性。方法收集该院内镜中心的肛齿状线上倒镜图片,分为内痔组和正常组(A任务);根据LDRf分级标准,将内痔组进一步分为Rf0组、Rf1组和Rf2组(B任务)。选取基于卷积神经网络(CNN)框架的Xception、ResNet和EfficientNet,以及基于Transformer框架的ViT和ConvMixer等5个神经网络,建立针对A、B两项计算机视觉任务的深度学习模型。模型评价指标包括准确率、召回率、精确度、F1值和读片时间。将深度学习模型的读片表现与两位不同年资内镜医生进行比较。结果5种深度学习模型在A与B任务测试集中皆展现出较好的准确性。其中,最优模型为ConvMixer,准确性最高(0.961和0.911),其次为EfficientNet(0.956和0.901),均优于高年资内镜医生(0.952和0.881)和低年资内镜医生(0.913和0.832)。同时,所有深度学习模型在验证集中读片用时均<10 s,速度快于内镜医生(均>300 s)。此外,笔者采用梯度加权分类激活映射(Grad-CAM)方法突出图像中对模型判断较重要的区域。结论建立的内痔诊断及危险分级的深度学习模型,其表现优于内镜医生。基于深度学习的计算机视觉模型可辅助内镜医师进行内痔诊断和分级,展现出潜在的临床应用前景。

血清细胞骨架蛋白4检测对肝细胞癌的诊断价值

目的探讨检测血清细胞骨架蛋白4(CKAP4)水平对识别肝细胞癌(HCC)患者的临床价值。方法选取2013 年1 月—2017 年12 月苏州大学附属第一医院HCC 患者88 例为HCC 组,同期选取肝硬化患者91 例、慢性乙型肝炎患者87 例、门诊体检部健康体检者81 例作为3 个对照组。血清CKAP4 水平检测采用酶联免疫吸附试验(ELISA)。受试者操作特征(ROC)曲线用于评价蛋白对HCC 的识别能力。结果 HCC 患者的血清CKAP4 水平高于肝硬化患者、慢性乙肝患者及健康体检者(P <0.05)。CKAP4 的Cut-off 值为261.1 pg/ml,判断HCC 的ROC 下面积(AUC)为0.843(95% CI :0.799,0.888),敏感性为0.761,特异性为0.737。CKAP4与甲胎蛋白(AFP)比较,差异无统计学意义(P >0.05)。CKAP4 判断早期HCC 的AUC 为0.865(95% CI :0.814,0.915),敏感性为0.784,特异性为0.737,结果优于AFP(P <0.05)。结论 CKAP4 可成为HCC 诊断的血清肿瘤标志物。

Can mean platelet volume play a role in evaluating the severity of acute pancreatitis?

AIM To investigate serum mean platelet volume(MPV) levels in acute pancreatitis(AP) patients and assess whether MPV effectively predicts the disease severity of AP.METHODS We included 117 consecutive patients with AP as the AP group and 34 consecutive patients with colorectal polyps(before endoscopic treatment) as the control group. Complete blood counts, liver function, platelet indices(MPV), coagulation parameters, lactate dehydrogenase(LDH) and C-reactive protein(CRP) were measured on days 1, 2, 3 and 7 after admission. Receiver operating characteristic curves were used to compare the sensitivity and specificity of MPV, white blood cell(WBC), LDH and CRP in predicting AP severity. The Modified Glasgow Prognostic Score(m GPS) and the 2012 revised Atlanta criteria were used to evaluate disease severity in AP.RESULTS MPV levels were significantly lower in the AP group than in the control group on day 1(P = 0.000), day 2(P = 0.029) and day 3(P = 0.001) after admission.In addition, MPV values were lower on day 1 after admission than on day 2(P = 0.012), day 3(P = 0.000) and day 7(P = 0.002) in all AP patients. Based on the m GPS, 78 patients(66.7%) were diagnosed with mild and 39 patients(33.3%) with severe AP. There was no significant difference in mean MPV levels between patients diagnosed with mild and severe AP based on the m GPS(P = 0.424). According to the 2012 revised Atlanta criteria, there were 98 patients(83.8%) without persistent organ failure(OF) [non-severe acute pancreatitis(non-SAP) group] and 19 patients(16.2%) with persistent OF(SAP group). MPV levels were significantly lower in the SAP group than in the non-SAP group on day 1 after admission(P = 0.002). On day 1 after admission using a cut-off value of 6.65 f L, the overall accuracy of MPV for predicting SAP according to the 2012 revised Atlanta criteria(AUC = 0.716) had a sensitivity of 91.8% and a specificity of 47.4% and was superior to the accuracy of the traditional markers WBC(AUC = 0.700) and LDH(AUC = 0.697).CONCLUSION MPV can be used at no additional cost as a useful, noninvasive biomarker that distinguishes AP with persistent OF from AP without persistent OF on day 1 of hospital admission.

Minor endoscopic sphincterotomy followed by large balloon dilation for large choledocholith treatment

AIM To evaluate early and late outcomes of endoscopic papillary large balloon dilation(EPLBD) with minor endoscopic sphincterotomy(m EST) for stone removal.METHODS A total of 149 consecutive patients with difficult common bile duct(CBD) stones(diameter ≥ 10 mm or ≥ 3 stones) underwent conventional endoscopic sphincterotomy(EST) or m EST plus EPLBD from May 2012 to April 2016. Their demographic, laboratory and procedural data were collected, and pancreaticobiliary complications were recorded.RESULTS Sixty-nine(94.5%) of the patients in the EPLBD + m EST group and 64(84.2%) in the conventional EST group achieved stone clearance following the first session(P = 0.0421). The procedure time for EPLBD + m EST was shorter than for EST alone(42.1 ± 13.6 min vs 47.3 ± 11.8 min, P = 0.0128). The overall rate of early complications in the EPLBD + m EST group(11%) was lower than in the EST group(21.1%); however, the difference was not significant(P = 0.0938). The cumulative recurrence rate of cholangitis and CBD stones between the two groups was also similar. The procedure time was independently associated with post-endoscopic retrograde cholangiopancreatography pancreatitis(OR = 6.374, 95%CI: 1.193-22.624, P = 0.023), CBD stone diameter ≥ 16 mm(OR = 7.463, 95%CI: 2.705-21.246, P = 0.0452) and use of mechanical lithotripsy(OR = 9.913, 95%CI: 3.446-23.154, P = 0.0133) were independent risk factors for stone recurrence. CONCLUSION EPLBD with m EST is more effective than EST alone for difficult CBD stone removal, with shorter procedure time and fewer early complications.

Effect of dietary fiber on constipation:A meta analysis

AIM:To investigate the effect of dietary fiber intake on constipation by a meta-analysis of randomized controlled trials(RCTs).METHODS:We searched Ovid MEDLINE(from 1946 to October 2011),Cochrane Library(2011),PubMed for articles on dietary fiber intake and constipation using the terms:constipation,fiber,cellulose,plant extracts,cereals,bran,psyllium,or plantago.References of important articles were searched manually for relevant studies.Articles were eligible for the meta-analysis if they were high-quality RCTs and reported data on stool frequency,stool consistency,treatment success,laxative use and gastrointestinal symptoms.The data were extracted independently by two researchers(Yang J and Wang HP) according to the described selection criteria.Review manager version 5 software was used for analysis and test.Weighted mean difference with 95%CI was used for quantitative data,odds ratio(OR)with 95%CI was used for dichotomous data.Both I2 statistic with a cut-off of ≥ 50% and the χ2 test with a P value < 0.10 were used to define a significant degree of heterogeneity.RESULTS:We searched 1322 potential relevant articles,19 of which were retrieved for further assessment,14 studies were excluded for various reasons,five studies were included in the analysis.Dietary fiber showed significant advantage over placebo in stool frequency(OR = 1.19;95%CI:0.58-1.80,P < 0.05).There was no significant difference in stool consistency,treatment success,laxative use and painful defecation between the two groups.Stool frequency were reported by five RCTs,all results showed either a trend or a significant difference in favor of the treatment group,number of stools per week increased in treatment group than in placebo group(OR = 1.19;95%CI:0.58-1.80,P < 0.05),with no significant heterogeneity among studies(I2= 0,P = 0.77).Four studies evaluated stool consistency,one of them presented outcome in terms of percentage of hard stool,which was different from others,so we included the other three studies for analysis.Two studies reported treatment success.There was significant heterogeneity between the studies(P < 0.1,I2 > 50%).Three studies reported laxative use,quantitative data was shown in one study,and the pooled analysis of the other two studies showed no significant difference between treatment and placebo groups in laxative use(OR = 1.07;95%CI 0.51-2.25),and no heterogeneity was found(P = 0.84,I2= 0).Three studies evaluated painful defecation:one study presented both quantitative and dichotomous data,the other two studies reported quantitative and dichotomous data separately.We used dichotomous data for analysis.CONCLUSION:Dietary fiber intake can obviously increase stool frequency in patients with constipation.It does not obviously improve stool consistency,treatment success,laxative use and painful defecation.

Acquired double pylorus:Clinical and endoscopiccharacteristics and four-year follow-up observations

Double pylorus(DP), or duplication of the pylorus, is an uncommon condition that can be either congenital or acquired. Acquired DP(ADP) occurs when a peptic ulcer erodes and creates a fistula between the duodenal bulb and the distal stomach. The clinical features and endoscopic characteristics of four patients with ADP were reviewed and compared with previously reported cases. An accessory channel connects the lesser curvature of the prepyloric antrum with the duodenal bulb, and in all cases, a peptic ulcer was located in or immediately adjacent to the accessory channel. In one of the patients, the bridge between the double-channel pylorus disappeared, resulting in a single large opening and duodenal kissing ulcer after two years and three months. Finally, nonsteroidal anti-inflammatory drugs, Helicobacter pylori and other risk factors associated with ADP are assessed.

Pancreatic cancer incidence and mortality patterns in 2006-2015 and prediction of the epidemiological trend to 2025 in China

BACKGROUND Due to dietary patterns,the aging population,and other high-risk factors,the occurrence of pancreatic cancer(PC)has been rapidly increasing in China.AIM To present the epidemiological trends of PC in China over the past decade and the estimated trend in 2025 and to compare the international differences in PC morbidity and mortality.METHODS This study used a series of nationally representative data from the National Central Cancer Registry of China(NCCR),the International Agency for Research on Cancer and the Institute for Health Metrics and Evaluation databases.Agestandardized data of the PC incidence and mortality from 2006 to 2015 in China were extracted from the NCCR database.Linear regression models were used to estimate the incidence and mortality rates of PC in 2025.RESULTS The age-standardized rates of PC in China increased from 3.65 per 100000 in 2006 to 4.31 per 100000 in 2015 and were estimated to reach up to 5.52 per 100000 in 2025.The mortality went from 3.35 per 100000 in 2006 to 3.78 per 100000 in 2015,estimated to reach up to 4.6 per 100000 in 2025.The number of new cases and deaths was low before 45 years and the peak age of onset was 85-89 years.The incidence and mortality rates in men were higher than those in women regardless of the region in China.In addition,the incidence and mortality rates in China were higher than the average level around the world.Likewise,disabilityadjusted life years attributed to PC in China were 197.22 years per 100000,above the average level around the world.CONCLUSION This study presented an increasing trend of PC in China and differences in morbidity,mortality and disability-adjusted life years between Chinese and global populations.Efforts need to be made to decrease the PC incidence and improve patient outcomes.

Encapsulating peritoneal sclerosis in an AMA-M2 positive patient:A case report

BACKGROUND Encapsulating peritoneal sclerosis(EPS)is hard to diagnose because of nonspecific symptoms and signs.It is a general consensus that EPS is classified as primary and secondary.There have been several studies discovering some highrisk factors such as liver cirrhosis,of which AMA-M2 is a biomarker,and intraabdominal surgery such as laparoscopic surgery.Imaging studies help to diagnose EPS and exploratory laparotomy might be an alternative if imaging fails.Nowadays,laparotomy plays a key role in treating EPS,especially when medical treatments do not work and medical therapy fails to ease patients’symptoms.CASE SUMMARY A 58-year-old man complained of unexplained vomiting and abdominal distension 2 mo after laparoscopic cholecystectomy.Increased alkaline phosphatase and liver enzymes were discovered.An autoimmune liver disease test showed that AMA-M2 was positive.A gastroscopy revealed bile reflux gastritis.A magnetic resonance imaging scan showed a slight dilatation of the intrahepatic bile duct.A colonoscopy showed that there was a mucosal eminence lesion in the sigmoid colon(24 cm away from the anus),with a size of 3 cm×3 cm and erosive surface.At last,the small intestine and the stomach were found to be encased in a cocoon-like membrane during the surgery.The membrane was dissected and adhesiolysis was done to release the trapped organs.The patient recovered and was discharged 44 d after the operation,and there was no recurrence during a follow-up period of 3 mo.CONCLUSION AMA-M2 is a marker of primary biliary sclerosis and may help to make a preoperative diagnosis of EPS.

Mifepristone (RU486) Inducing Abortion in a Mouse Model by Regulating Innate and Adaptive Immune Responses

Objective:Mifepristone(RU486),one of the most common medications for artificial abortion,attenuates the immunoregulatory effects of progesterone.However,the specific immune regulatory mechanism of RU486 in abortion remains unknown.We intended to investigate the immunomodulatory effects of RU486 on abortion.Methods:Sixty female mice were divided into the control group(0 mg RU486)and RU486 group(2 mg/kg RU486).The uterus,peripheral blood,and spleen were obtained for isolation of specific cell types.The population and phenotype of immune cells in the decidua,peripheral blood,and spleen were analyzed using flow cytometry.Statistical differences between groups were determined using two-tailed t-test.For all statistical tests,P<0.05 was considered statistically significant.Results:RU486 effectively induced abortion in pregnant mice,with a significantly higher number of decidual macrophages(dMφ)(control group=25.55%±2.467%,RU486 group=19.41%±1.423%;P<0.05),especially the major histocompatibility complex II high subset.No difference in Mφnumber was observed in the spleen or peripheral blood.Moreover,the dMφfrom mice with RU486-induced abortion displayed a remarkable activated phenotype,with increased expressions of inducible nitric oxide synthase,tumor necrosis factor-α,and interleukin(IL)-12 but decreased expressions of arginase-1 and IL-10.We also found elevated levels of decidual CD4+T-cells in the RU486 group that exhibited a higher level of the proinflammatory cytokine interferon-γand a lower level of the anti-inflammatory cytokines,IL-4 and IL-10.Conclusions:We report a new mechanism of RU486-induced abortion via the regulation of innate cell Mφactivation and the adaptive response of CD4+T-cells present in the decidua but not the periphery.