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Radiology Jun 2024Background Structured radiology reports for pancreatic ductal adenocarcinoma (PDAC) improve surgical decision-making over free-text reports, but radiologist adoption is...
Background Structured radiology reports for pancreatic ductal adenocarcinoma (PDAC) improve surgical decision-making over free-text reports, but radiologist adoption is variable. Resectability criteria are applied inconsistently. Purpose To evaluate the performance of large language models (LLMs) in automatically creating PDAC synoptic reports from original reports and to explore performance in categorizing tumor resectability. Materials and Methods In this institutional review board-approved retrospective study, 180 consecutive PDAC staging CT reports on patients referred to the authors' European Society for Medical Oncology-designated cancer center from January to December 2018 were included. Reports were reviewed by two radiologists to establish the reference standard for 14 key findings and National Comprehensive Cancer Network (NCCN) resectability category. GPT-3.5 and GPT-4 (accessed September 18-29, 2023) were prompted to create synoptic reports from original reports with the same 14 features, and their performance was evaluated (recall, precision, F1 score). To categorize resectability, three prompting strategies (default knowledge, in-context knowledge, chain-of-thought) were used for both LLMs. Hepatopancreaticobiliary surgeons reviewed original and artificial intelligence (AI)-generated reports to determine resectability, with accuracy and review time compared. The McNemar test, test, Wilcoxon signed-rank test, and mixed effects logistic regression models were used where appropriate. Results GPT-4 outperformed GPT-3.5 in the creation of synoptic reports (F1 score: 0.997 vs 0.967, respectively). Compared with GPT-3.5, GPT-4 achieved equal or higher F1 scores for all 14 extracted features. GPT-4 had higher precision than GPT-3.5 for extracting superior mesenteric artery involvement (100% vs 88.8%, respectively). For categorizing resectability, GPT-4 outperformed GPT-3.5 for each prompting strategy. For GPT-4, chain-of-thought prompting was most accurate, outperforming in-context knowledge prompting (92% vs 83%, respectively; = .002), which outperformed the default knowledge strategy (83% vs 67%, < .001). Surgeons were more accurate in categorizing resectability using AI-generated reports than original reports (83% vs 76%, respectively; = .03), while spending less time on each report (58%; 95% CI: 0.53, 0.62). Conclusion GPT-4 created near-perfect PDAC synoptic reports from original reports. GPT-4 with chain-of-thought achieved high accuracy in categorizing resectability. Surgeons were more accurate and efficient using AI-generated reports. © RSNA, 2024 See also the editorial by Chang in this issue.
Topics: Humans; Pancreatic Neoplasms; Retrospective Studies; Carcinoma, Pancreatic Ductal; Female; Male; Aged; Middle Aged; Tomography, X-Ray Computed; Natural Language Processing; Artificial Intelligence; Aged, 80 and over
PubMed: 38888478
DOI: 10.1148/radiol.233117 -
Cureus May 2024Spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) is a rare condition, particularly when complicated by hemorrhagic shock. This case report...
Spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) is a rare condition, particularly when complicated by hemorrhagic shock. This case report describes the discovery of SIDSMA in an 88-year-old woman through CT angiography. The patient initially presented with acute abdominal pain, nausea, and diarrhea, which later progressed to hemorrhagic shock. After fluid resuscitation, the patient underwent successful endovascular treatment.
PubMed: 38887324
DOI: 10.7759/cureus.60543 -
Colorectal Disease : the Official... Jun 2024The aim of this work was to investigate the association between early postoperative anastomotic leakage or pelvic abscess (AL/PA) and symptomatic anastomotic stenosis...
AIM
The aim of this work was to investigate the association between early postoperative anastomotic leakage or pelvic abscess (AL/PA) and symptomatic anastomotic stenosis (SAS) in patients after surgery for left colonic diverticulitis.
METHOD
This is a retrospective study based on a national cohort of diverticulitis surgery patients carried out by the Association Française de Chirurgie. The assessment was performed using path analyses. The database included 7053 patients operated on for colonic diverticulitis, with surgery performed electively or in an emergency, by open access or laparoscopically. Patients were excluded from the study analysis where there was (i) right-sided diverticulitis (the initial database included all consecutive patients operated on for colonic diverticulitis), (ii) no anastomosis was performed during the first procedure or (iii) missing information about stenosis, postoperative abscess or anastomotic leakage.
RESULTS
Of the 4441 patients who were included in the final analysis, AL/PA occurred in 327 (4.6%) and SAS occurred in 82 (1.8%). AL/PA was a significant independent factor associated with a risk for occurrence of SAS (OR = 3.41, 95% CI = 1.75-6.66), as was the case for diverting stoma for ≥100 days (OR = 2.77, 95% CI = 1.32-5.82), while central vessel ligation proximal to the inferior mesenteric artery was associated with a reduced risk (OR = 0.41; 95% CI = 0.19-0.88). Diverting stoma created for <100 days or ≥100 days was also a factor associated with a risk for AL/PA (OR = 3.08, 95% CI = 2-4.75 and OR = 12.95, 95% CI = 9.11-18.50). Interestingly, no significant association between radiological drainage or surgical management of AL/PA and SAS could be highlighted.
CONCLUSION
AL/PA was an independent factor associated with the risk for SAS. The treatment of AL/PA was not associated with the occurrence of anastomotic stenosis. Diverting stoma was associated with an increased risk of both AL/PA and SAS, especially if it was left for ≥100 days. Physicians must be aware of this information in order to decide on the best course of action when creating a stoma during elective or emergency surgery.
PubMed: 38886887
DOI: 10.1111/codi.17076 -
EJVES Vascular Forum 2024Diagnosing non-occlusive mesenteric ischaemia (NOMI) in patients is complicated, due to poor signs and symptoms and non-specific laboratory tests, leading to a high...
INTRODUCTION
Diagnosing non-occlusive mesenteric ischaemia (NOMI) in patients is complicated, due to poor signs and symptoms and non-specific laboratory tests, leading to a high mortality rate. This case study presents the rare case of a patient who developed mesenteric ischaemia after an emergency thoracic endovascular aneurysm repair (TEVAR) for a type B aortic dissection (TBAD) and peri-operative cardiogenic shock. Study outcomes revealed that intestinal fatty acid binding protein (I-FABP) identified early mucosal damage two days before the clinical presentation.
REPORT
A 43 year old male patient was admitted to the emergency department with an acute TBAD and a dissection of the superior mesenteric artery (SMA), for which TEVAR was performed with additional stent placement in the SMA. Peri-operatively, the patient went into cardiogenic shock with a sustained period of hypotension. Post-operatively, the plasma I-FABP levels were measured prospectively, revealing an initial increase on post-operative day five (551.1 pg/mL), which continued beyond day six (610.3 pg/mL). On post-operative day seven, the patient developed a fever and demonstrated signs of peritonitis and bowel perforation. He underwent an emergency laparotomy, followed by an ileocaecal resection (<100 cm) with a transverse ileostomy. Pathological analysis confirmed the diagnosis of mesenteric ischaemia.
DISCUSSION
The diagnosis of NOMI in critically ill patients is often complicated, and the currently available diagnostic markers lack the specificity and sensitivity to detect early intestinal injury. This case report highlights that elevated I-FABP in plasma levels may indicate the presence of early mesenteric injury. Further research needs to be conducted before I-FABP can be applied in daily practice.
PubMed: 38884076
DOI: 10.1016/j.ejvsvf.2024.04.004 -
Molecular and Cellular Biochemistry Jun 2024Acute myocardial infarction is mainly caused by a lack of blood flood in the coronary artery. Angiopoietin-like protein 2 (ANGPTL2) induces platelet activation and...
Acute myocardial infarction is mainly caused by a lack of blood flood in the coronary artery. Angiopoietin-like protein 2 (ANGPTL2) induces platelet activation and thrombus formation in vitro through binding with immunoglobulin-like receptor B, an immunoglobulin superfamily receptor. However, the mechanism by which it regulates platelet function in vivo remains unclear. In this study, we investigated the role of ANGPTL2 during thrombosis in relationship with ST-segment elevation myocardial infarction (STEMI) with spontaneous recanalization (SR). In a cohort of 276 male and female patients, we measured plasma ANGPTL2 protein levels. Using male Angptl2-knockout and wild-type mice, we examined the inhibitory effect of Angptl2 on thrombosis and platelet activation both in vivo and ex vivo. We found that plasma and platelet ANGPTL2 levels were elevated in patients with STEMI with SR compared to those in non-SR (NSR) patients, and was an independent predictor of SR. Angptl2 deficiency accelerated mesenteric artery thrombosis induced by FeCl in Angptl2 compared to WT animals, promoted platelet granule secretion and aggregation induced by thrombin and collogen while purified ANGPTL2 protein supplementation reversed collagen-induced platelet aggregation. Angptl2 deficiency also increased platelet spreading on immobilized fibrinogen and clot contraction. In collagen-stimulated Angptl2 platelets, Src homology region 2 domain-containing phosphatase (Shp)1-Y564 and Shp2-Y580 phosphorylation were attenuated while Src, Syk, and Phospholipase Cγ2 (PLCγ2) phosphorylation increased. Our results demonstrate that ANGPTL2 negatively regulated thrombus formation by activating ITIM which can suppress ITAM signaling pathway. This new knowledge provides a new perspective for designing future antiplatelet aggregation therapies.
PubMed: 38880861
DOI: 10.1007/s11010-024-05034-9 -
Journal of the American Heart... Jun 2024Acute mesenteric ischemia is rare, and few large-scale trials have evaluated endovascular therapy (EVT) and open surgical revascularization (OS). This study aimed to... (Comparative Study)
Comparative Study
Comparison of Endovascular Therapy and Open Surgical Revascularization in Patients With Acute Superior Mesenteric Artery Occlusion: A Large-Scale Analysis Based on the JROAD-DPC Database.
BACKGROUND
Acute mesenteric ischemia is rare, and few large-scale trials have evaluated endovascular therapy (EVT) and open surgical revascularization (OS). This study aimed to assess clinical outcomes after EVT or OS for acute superior mesenteric artery occlusion and identify predictors of mortality and bowel resection.
METHODS AND RESULTS
Data from the Japanese Registry of All Cardiac and Vascular Diseases-Diagnosis Procedure Combination (JROAD-DPC) database from April 2012 to March 2020 were retrospectively analyzed. Overall, 746 patients with acute superior mesenteric artery occlusion who underwent revascularization were classified into 2 groups: EVT (n=475) or OS (n=271). The primary clinical outcome was in-hospital mortality. The secondary outcomes were bowel resection, bleeding complications (transfusion or endoscopic hemostasis), major adverse cardiovascular events, hospitalization duration, and cost. The in-hospital death or bowel resection rate was ≈30%. In-hospital mortality (22.5% versus 21.4%, =0.72), bowel resection (8.2% versus 8.5%, =0.90), and major adverse cardiovascular events (11.6% versus 9.2%, =0.32) were comparable between the EVT and OS groups. Hospitalization duration in the EVT group was 6 days shorter than that in the OS group, and total hospitalization cost was 0.88 million yen lower. Interaction analyses revealed that EVT and OS had no significant difference in terms of in-hospital death in patients with thromboembolic and atherothrombotic characteristics. Advanced age, decreased activities of daily living, chronic kidney disease, and old myocardial infarction were significant predictive factors for in-hospital mortality. Diabetes was a predictor of bowel resection after revascularization.
CONCLUSIONS
EVT was comparable to OS in terms of clinical outcomes in patients with acute superior mesenteric artery occlusion. Some predictive factors for mortality or bowel resection were obtained.
REGISTRATION
URL: www.umin.ac.jp/ctr/; Unique Identifier: UMIN000045240.
Topics: Humans; Male; Female; Endovascular Procedures; Aged; Mesenteric Vascular Occlusion; Mesenteric Artery, Superior; Hospital Mortality; Retrospective Studies; Registries; Japan; Middle Aged; Treatment Outcome; Acute Disease; Databases, Factual; Vascular Surgical Procedures; Aged, 80 and over; Risk Factors
PubMed: 38879458
DOI: 10.1161/JAHA.124.035017 -
Vascular Jun 2024A current and ongoing challenge is to reduce patient mortality after endovascular abdominal aortic repair (EVAR). This study aimed to assess the predictors of all-cause...
OBJECTIVES
A current and ongoing challenge is to reduce patient mortality after endovascular abdominal aortic repair (EVAR). This study aimed to assess the predictors of all-cause mortality after EVAR.
METHODS
Data regarding the demographic characteristics, comorbidities, laboratory values, selected anatomical factors, post-EVAR treatment, surveillance and complications of patients who underwent elective EVAR for non-ruptured abdominal aortic aneurysm (AAA) between January 2010 and January 2021 were evaluated. Mortality was assessed until 10 October 2023. Multivariate analyses were performed after adjusting for age, hypertension, diabetes mellitus, dyslipidaemia, sex, smoking, number of lumbar arteries, patency of inferior mesenteric artery (IMA), IMA diameter and reinterventions.
RESULTS
This study included 196 patients (183 men and 13 women) with a mean age of 72.4 ± 7.67 years. The overall mortality rate during a mean follow-up period of 5.75 ± 3.1 years was 50.0% ( = 98). The 2-, 5- and 10-year mortality rates were 9.7%, 32.0% and 66.6%, respectively. The mortality rates decreased by 59% in patients with reinterventions (hazard ratio [HR]: 0.41; 95% confidence interval [CI]: 0.23-0.73; = .002) and by 59% in patients treated with angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) (HR: 0.41; 95% CI: 0.26-0.66; < .001). Chronic anticoagulation was associated with 2.09-fold higher mortality (HR: 2.09; 95% CI: 1.19-3.67; = .010), and coronary artery disease (CAD) was associated with 1.74-fold higher mortality (HR: 1.74; 95% CI: 1.09-2.78; = .021). Pre-EVAR AAA diameter and 1-year post-EVAR sac diameter were positively associated with mortality (HR: 1.05; 95% CI: 1.03-1.08; < .001, and HR: 1.05; 95% CI: 1.03-1.07; < .001, respectively), that is, an increase of pre-EVAR and/or 1-year post-EVAR AAA diameter by 1 mm was associated with a 5% higher risk of all-cause mortality.
CONCLUSIONS
Reinterventions and treatment with ACE inhibitors or ARBs may be associated with decreased post-EVAR mortality. A greater pre-EVAR, a post-EVAR AAA diameter, CAD and chronic anticoagulation were associated with higher all-cause mortality post-EVAR.
PubMed: 38872254
DOI: 10.1177/17085381241262350 -
Zhongguo Zhen Jiu = Chinese Acupuncture... Jun 2024To observe the effects of acupuncture on blood pressure, fecal short-chain fatty acids (SCFAs) and toll-like receptor 4 (TLR4)/myeloid differentiation factor 88...
OBJECTIVE
To observe the effects of acupuncture on blood pressure, fecal short-chain fatty acids (SCFAs) and toll-like receptor 4 (TLR4)/myeloid differentiation factor 88 (MyD88)/nuclear factor-κB (NF-κB) signaling pathway in spontaneously hypertensive rats (SHR), and to explore the mechanism of acupuncture for anti-hypertension.
METHODS
Twenty-four male SHR of SPF grade were randomly divided into a model group, a western medication group, an acupuncture group and a sham acupuncture group, with 6 rats in each group, and 6 male Wistar-Kyoto rats were selected as the blank group additionally. Hydrochlorothiazide solution was given by gavage in the western medication group; acupuncture was applied at bilateral "Renying" (ST 9) and "Zusanli" (ST 36) in the acupuncture group, 20 min a time; acupuncture was applied at the non-meridian and non-acupoint points close to bilateral "Renying" (ST 9) and "Zusanli" (ST 36) in the sham acupuncture group, 20 min a time. The intervention was adopted once a day for 4 weeks continuously in each group. The systolic blood pressure (SBP) of the caudal artery was measured before intervention and after 1, 2, 3 and 4 weeks of intervention. After intervention, the morphology of colonic tissue was observed by HE staining; the fecal level of SCFAs was detected by gas chromatography; the serum levels of interleukin (IL)-6, IL-1βand tumor necrosis factor-α (TNF-α) were detected by ELISA; the protein expression of TLR4, MyD88 and NF-κB p65 in the mesenteric artery was detected by Western blot.
RESULTS
Compared with the blank group, in the model group, the SBP was increased (<0.05), significant pathological changes could be found in the colonic tissue, the fecal SCFAs level was decreased (<0.05), the serum levels of IL-6, IL-1β and TNF-α were increased (<0.05), the protein expression of TLR4, MyD88 and NF-κB p65 in the mesenteric artery was increased (<0.05). Compared with the model group, the SBP after 2, 3 and 4 weeks of intervention was decreased (<0.05), the serum levels of IL-6, IL-1β and TNF-α were decreased (<0.05) in the acupuncture group and the western medication group; the mucosal epithelium of colonic tissue was intact, the number of intestinal glands was abundant, the fecal SCFAs level was increased (<0.05), and the protein expression of TLR4, MyD88 and NF-κB p65 in the mesenteric artery was decreased (<0.05) in the acupuncture group. Compared with the sham acupuncture group, the SBP after 2, 3 and 4 weeks of intervention was decreased (<0.05), the fecal SCFAs level was increased (<0.05), the serum levels of IL-6, IL-1β and TNF-α were decreased (<0.05), the protein expression of TLR4, MyD88 and NF-κB p65 in the mesenteric artery was decreased (<0.05) in the acupuncture group.
CONCLUSION
Acupuncture at bilateral "Renying" (ST 9) and "Zusanli" (ST 36) can effectively play an anti-hypertensive role in SHR. Its mechanism may be related to regulating fecal SCFAs level and inhibiting the TLR4/MyD88/NF-κB signaling pathway.
Topics: Animals; Toll-Like Receptor 4; Myeloid Differentiation Factor 88; Male; Rats; Acupuncture Therapy; NF-kappa B; Rats, Inbred SHR; Signal Transduction; Humans; Rats, Inbred WKY; Feces; Fatty Acids, Volatile; Hypertension; Blood Pressure; Acupuncture Points
PubMed: 38867628
DOI: 10.13703/j.0255-2930.20230710-k0001 -
Cirugia Y Cirujanos 2024Superior mesenteric artery syndrome (SMAS) is a rare cause of duodenal obstruction which is characterized by compression of the duodenum due to narrowing of the space... (Review)
Review
Superior mesenteric artery syndrome (SMAS) is a rare cause of duodenal obstruction which is characterized by compression of the duodenum due to narrowing of the space between the superior mesenteric artery and aorta. Incomplete duodenal obstruction due to SMAS in neonates is rarely reported in the literature. In this case, it is a full-term 2-day-old male with the complaint of recurrent vomiting starting soon after birth. The patient was diagnosed with SMAS and duodenoduodenostomy was performed. Accompanying Meckel's diverticulum was excised.
Topics: Humans; Meckel Diverticulum; Superior Mesenteric Artery Syndrome; Male; Infant, Newborn; Duodenostomy; Duodenal Obstruction; Vomiting
PubMed: 38862114
DOI: 10.24875/CIRU.22000281 -
Surgical Case Reports Jun 2024Thromboembolic occlusion of the superior mesenteric artery (SMA) is a grave complication in individuals diagnosed with atrial fibrillation (AF). This condition often...
BACKGROUND
Thromboembolic occlusion of the superior mesenteric artery (SMA) is a grave complication in individuals diagnosed with atrial fibrillation (AF). This condition often necessitates extensive bowel resection, culminating in short bowel syndrome, which presents challenges for anticoagulant administration and/or antiarrhythmic therapy.
CASE PRESENTATION
Presented here are findings of two patients, aged 78 and 72 years, respectively, who underwent comprehensive thoracoscopic AF surgery subsequent to extensive small bowel resection following SMA embolization. In each, onset of AF precipitated an embolic event, while the concurrent presence of short bowel syndrome complicated anticoagulation management. Total thoracoscopic AF surgery, comprised stapler-closure of the left atrial appendage (LAA) and bilateral epicardial clamp-isolation of the pulmonary veins, an operative modality aimed at addressing AF rhythm control and mitigating embolic events such as cerebral infarction, led to favorable outcomes in both cases. Additionally, computed tomography (CT) conducted one month post-surgery revealed the absence of residual tissue in the LAA, with the left atrium demonstrating a well-rounded, spherical shape. At the time of writing, the patients have remained asymptomatic following surgery regarding thromboembolic and arrhythmic manifestations for 29 and 10 months, respectively, notwithstanding the absence of anticoagulant or antiarrhythmic pharmacotherapy. Additionally, electrocardiographic surveillance has revealed persistent sinus rhythm.
CONCLUSIONS
The present findings underscore the feasibility and efficacy of a total thoracoscopic AF surgery procedure for patients presented with short bowel syndrome complicating SMA embolization, thus warranting consideration for its broader clinical application.
PubMed: 38861227
DOI: 10.1186/s40792-024-01938-2