Effects of sodium-glucose co-transporter 2 inhibitors on ultrafiltration in patients with peritoneal dialysis: a protocol for a randomized, double-blind, placebo-controlled, crossover trial (EMPOWERED).

BACKGROUND: Volume overload is common and associated with high mortality in patients on peritoneal dialysis (PD). Traditional strategies including diuretics, water/salt restriction, and icodextrin-based solutions cannot always fully correct this condition, necessitating novel alternative strategies. Recent studies confirmed the expression of sodium-glucose cotransporter 2 (SGLT2) in the human peritoneum. Experimental data suggest that SGLT2 inhibitors decrease glucose absorption from the PD solution, thereby increasing the ultrafiltration volume. This trial aims to assess whether SGLT2 inhibitors increase the ultrafiltration volume in patients on PD. METHODS: The EMPOWERED trial (trial registration: jRCTs051230081) is a multicenter, randomized, double-blind, placebo-controlled, crossover trial. Patients with clinically diagnosed chronic heart failure are eligible regardless of the presence of diabetes if they use at least 3 L/day glucose-based PD solutions. Participants will be randomly assigned (1:1) to receive empagliflozin 10 mg once daily and then placebo or vice versa. Each treatment period will last 8 weeks with a 4-week washout period. This study will recruit at least 36 randomized participants. The primary endpoint is the change in the daily ultrafiltration volume from baseline to week 8 in each intervention period. The key secondary endpoints include changes in the biomarkers of drained PD solutions, renal residual function, and anemia-related parameters. CONCLUSIONS: This trial aims to assess the benefit of SGLT2 inhibitors in fluid management with a novel mechanism of action in patients on PD. It will also provide insights into the effects of SGLT2 inhibitors on solute transport across the peritoneal membrane and residual renal function.

COVID-19 vaccine effectiveness against severe COVID-19 requiring oxygen therapy, invasive mechanical ventilation, and death in Japan: A multicenter case-control study (MOTIVATE study).

INTRODUCTION: Since the SARS-CoV-2 Omicron variant became dominant, assessing COVID-19 vaccine effectiveness (VE) against severe disease using hospitalization as an outcome became more challenging due to incidental infections via admission screening and variable admission criteria, resulting in a wide range of estimates. To address this, the World Health Organization (WHO) guidance recommends the use of outcomes that are more specific to severe pneumonia such as oxygen use and mechanical ventilation. METHODS: A case-control study was conducted in 24 hospitals in Japan for the Delta-dominant period (August-November 2021; "Delta") and early Omicron (BA.1/BA.2)-dominant period (January-June 2022; "Omicron"). Detailed chart review/interviews were conducted in January-May 2023. VE was measured using various outcomes including disease requiring oxygen therapy, disease requiring invasive mechanical ventilation (IMV), death, outcome restricting to "true" severe COVID-19 (where oxygen requirement is due to COVID-19 rather than another condition(s)), and progression from oxygen use to IMV or death among COVID-19 patients. RESULTS: The analysis included 2125 individuals with respiratory failure (1608 cases [75.7%]; 99.2% of vaccinees received mRNA vaccines). During Delta, 2 doses provided high protection for up to 6 months (oxygen requirement: 95.2% [95% CI:88.7-98.0%] [restricted to "true" severe COVID-19: 95.5% {89.3-98.1%}]; IMV: 99.6% [97.3-99.9%]; fatal: 98.6% [92.3-99.7%]). During Omicron, 3 doses provided high protection for up to 6 months (oxygen requirement: 85.5% [68.8-93.3%] ["true" severe COVID-19: 88.1% {73.6-94.7%}]; IMV: 97.9% [85.9-99.7%]; fatal: 99.6% [95.2-99.97]). There was a trend towards higher VE for more severe and specific outcomes. CONCLUSION: Multiple outcomes pointed towards high protection of 2 doses during Delta and 3 doses during Omicron. These results demonstrate the importance of using severe and specific outcomes to accurately measure VE against severe COVID-19, as recommended in WHO guidance in settings of intense transmission as seen during Omicron.

Immune escape and waning immunity of COVID-19 monovalent mRNA vaccines against symptomatic infection with BA.1/BA.2 and BA.5 in Japan.

BACKGROUND: Repeated emergence of variants with immune escape capacity and waning immunity from vaccination are major concerns for COVID-19. We examined whether the surge in Omicron subvariant BA.5 cases was due to immune escape or waning immunity through vaccine effectiveness (VE) evaluation. METHODS: A test-negative case-control study was conducted in 16 clinics/hospitals during the BA.1/BA.2-dominant and BA.5-dominant periods. VE against symptomatic infection was estimated after adjusting for age, sex, comorbidity, occupation, testing frequency, prior infection, close contact history, clinic/hospital, week, and preventive measures. Absolute VE (aVE) was calculated for 2/3/4 doses, compared to the unvaccinated. Relative VE (rVE) was calculated, comparing 3 vs 2 and 4 vs 3 doses. RESULTS: 13,025 individuals were tested during the BA.1/BA.2-dominant and BA.5-dominant periods with similar baseline characteristics. For BA.1/BA.2, aVE was 52 % (95 %CI:34-66) 14 days-3 months post-dose 2, 42 % (29-52) > 6 months post-dose 2, 71 % (64-77) 14 days-3 months post-dose 3, and 68 % (52-79) 3-6 months post-dose 3. rVE was 49 % (38-57) 14 days-3 months post-dose 3 and 45 % (18-63) 3-6 months post-dose 3. For BA.5, aVE was 56 % (27-73) 3-6 months post-dose 2, 32 % (12-47) > 6 months post-dose 2, 70 % (61-78) 14 days-3 months post-dose 3, 59 % (48-68) 3-6 months post-dose 3, 50 % (29-64) > 6 months post-dose 3, and 74 % (61-83) ≥ 14 days post-dose 4. rVE was 56 % (45-65) 14 days-3 months post-dose 3, 39 % (27-48) 3-6 months post-dose 3, 25 % (-2-45) > 6 months post-dose 3, and 30 % (-6-54) ≥ 14 days post-dose 4. CONCLUSIONS: Booster doses initially provided high protection against BA.5 at a level similar to that against BA.1/BA.2. However, the protection seemed shorter-lasting against BA.5, which likely contributed to the surge. Furthermore, rVE post-dose 4 was low even among recent vaccinees. These results support the introduction of variant-containing vaccines and emphasize the need for vaccines with longer duration of protection.

Effectiveness of BA.1- and BA.4/BA. 5-Containing Bivalent COVID-19 mRNA Vaccines Against Symptomatic SARS-CoV-2 Infection During the BA.5-Dominant Period in Japan.

In this multicenter, prospective, test-negative, case-control study in Japan, the effectiveness of both BA.1-containing and BA.4/BA.5-containing bivalent coronavirus disease 2019 mRNA vaccines against symptomatic infection during the BA.5-dominant period was high compared with no vaccination (65% and 76%) and moderate compared with monovalent vaccines administered over half a year earlier (46% combined).

Inflammation as an exacerbation marker and target for prophylaxis against Coronavirus Disease 2019-related thrombosis.

Objectives: There are currently no appropriate markers and target for prophylaxis against COVID-19-related thrombosis, especially in the not-severe cases. We tested the hypothesis that inflammation is a suitable marker and target for prophylaxis against COVID-19-related thrombosis. Methods: Data of all 32 COVID-19 patients admitted to Saitama Medical Center between January 1 and March 30, 2021, were analyzed. Patients were divided into severe (requiring oxygen, n=12) and non-severe (no requirement for oxygen, n=20), and also those with high C-reactive protein (CRP) level (cutoff value: 30 mg/L, n=21) and low-CRP (n=11). We also compared the clinical and laboratory data of a 46-year-old post-liver transplant male patient, who was treated with a combination of immunosuppressants (methylprednisolone, fludrocortisone, cyclosporine, and everolimus) with those of other COVID-19 patients, using the Smirnoff-Grubbs and Box plots tests. Results: The levels of CRP, ferritin, lactate dehydrogenase, aspartate aminotransferase, and thrombin-antithrombin complex (TAT) were significantly higher in the high-severity group than the low-severity group; while other coagulation parameters were comparable. The time between onset of illness and blood levels of lactate dehydrogenase, fibrinogen, D-dimer, TAT, and plasmin alpha2-plasmin inhibitor complex (PIC) were significantly higher whereas lymphocyte count was significantly lower in the high-CRP group. Extremely low levels of TAT, PIC, and plasminogen activator inhibitor-1 (PAI-1) were recorded in the liver transplant patient treated with immunosuppressants. The TAT, PIC, and PAI-1 levels were deemed outliers. Conclusions: Inflammation is a potentially suitable marker and target for prophylaxis against COVID-19-related thrombosis.

Atypical clinical and radiological presentations of lumbar spinal tuberculosis mimicking a spinal tumor: A case report.

INTRODUCTION: Tuberculosis (TB) is an important infectious disease worldwide. Classical spinal TB has specific radiological findings involving adjacent vertebral bodies with destruction of the intervertebral disc and involvement of paravertebral soft tissues with cold abscess formation. However, a few cases not exhibiting the radiological characteristics of TB spondylitis have been reported. We report a rare case of lumbar spinal TB with atypical clinical and radiological presentations that was difficult to differentiate from a malignant spinal tumor. PATIENT CONCERNS: A 21-year-old man, who had immigrated to Japan from the Philippines 5 years ago, without a significant medical history, presented with back pain lasting 1 month and progression of gait disturbance 2 weeks prior to presentation. DIAGNOSIS: Laboratory tests showed normal blood cell counts and normal value of C-reactive protein levels. Preoperative imaging studies indicated a possible spinal tumor. However, histopathologic findings of the epidural soft tissues at the first surgery led to the diagnosis of spinal mycobacterial infection. The diagnosis of spinal TB was confirmed by a positive culture of Mycobacterium tuberculosis obtained at the second surgery. INTERVENTIONS: Given the progressive nature of neurologic deterioration, instead of needle biopsy, we proceeded with surgical intervention 8 days after admission; simultaneous neural decompression and open biopsy. Histological findings of the excised epidural soft tissues led to the diagnosis of spinal mycobacterial infection. We performed the second surgery involving additional resection of epidural soft tissues for further dural decompression and to obtain specimens for mycobacterial culture. Immediately after the second surgery, the patient commenced combination therapy with anti-tuberculous drugs. OUTCOMES: The patient demonstrated significant recovery of motor function in the lower extremities, and was able to run at 2 months after the second surgery. The epidural granulomas completely disappeared on magnetic resonance imaging 3 months postoperatively. CONCLUSION: Atypical clinical and radiological presentations of spinal TB present a challenge for appropriate diagnosis and early treatment. Even in developed countries where there are very few spinal TB patients, clinicians should be aware that spinal TB is an important differential diagnosis, especially in elderly patients or patients coming from countries with a middle-high prevalence of TB.

Coronavirus Disease 19 (COVID-19) Vaccine Effectiveness Against Symptomatic Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection During Delta-Dominant and Omicron-Dominant Periods in Japan: A Multicenter Prospective Case-control Study (Factors Associated with SARS-CoV-2 Infection and the Effectiveness of COVID-19 Vaccines Study).

BACKGROUND: Although several coronavirus disease 2019 (COVID-19) vaccines initially showed high efficacy, there have been concerns because of waning immunity and the emergence of variants with immune escape capacity. METHODS: A test-negative design case-control study was conducted in 16 healthcare facilities in Japan during the Delta-dominant period (August-September 2021) and the Omicron-dominant period (January-March 2022). Vaccine effectiveness (VE) against symptomatic severe acute respiratory syndrome coronavirus 2 infection was calculated for 2 doses for the Delta-dominant period and 2 or 3 doses for the Omicron-dominant period compared with unvaccinated individuals. RESULTS: The analysis included 5795 individuals with 2595 (44.8%) cases. Among vaccinees, 2242 (55.8%) received BNT162b2 and 1624 (40.4%) received messenger RNA (mRNA)-1273 at manufacturer-recommended intervals. During the Delta-dominant period, VE was 88% (95% confidence interval [CI], 82-93) 14 days to 3 months after dose 2 and 87% (95% CI, 38-97) 3 to 6 months after dose 2. During the Omicron-dominant period, VE was 56% (95% CI, 37-70) 14 days to 3 months since dose 2, 52% (95% CI, 40-62) 3 to 6 months after dose 2, 49% (95% CI, 34-61) 6+ months after dose 2, and 74% (95% CI, 62-83) 14+ days after dose 3. Restricting to individuals at high risk of severe COVID-19 and additional adjustment for preventive measures (ie, mask wearing/high-risk behaviors) yielded similar estimates, respectively. CONCLUSIONS: In Japan, where most are infection-naïve, and strict prevention measures are maintained regardless of vaccination status, 2-dose mRNA vaccines provided high protection against symptomatic infection during the Delta-dominant period and moderate protection during the Omicron-dominant period. Among individuals who received an mRNA booster dose, VE recovered to a high level.

How Fluorine Introduction Solves the Spinel Transition, a Fundamental Problem of Mn-Based Positive Electrodes.

In pursuit of high-capacity Mn-based oxides as positive electrode materials for lithium-ion batteries, the changes in the charge-discharge curve due to the spinel transition still stand in the way of the cycling stability. We found in this study that Li1.12Mn0.74O1.60F0.40 (LMOF05) positive electrodes with a loose-crystalline rock salt structure (LCRS), in which F is placed near Mn, show a stable and high capacity (300 mA h g-1, 952 W h kg-1) with little change in the charge-discharge curve. We demonstrated by F K-edge soft X-ray absorption spectroscopy and X-ray diffraction (XRD) that a part of F in the LCRS positive electrode forms F-Mn bonds. Operando XRD/X-ray absorption fine structure measurements revealed the lattice size and Mn surrounding environment during charge/discharge of F-containing LCRS positive electrodes (LMOF05), LCRS-LiMnO2 (LMO), and a spinel-like Li1.1Al0.1Mn1.8O4 positive electrode (SPINEL). Micro- and macroscopic structural changes indicate how the introduction of F suppresses the local spinel transition in Mn-based positive electrodes. These findings should be an effective tool for applying Co-free positive electrode materials for lithium-ion batteries.

SARS-CoV-2 RNA load and detection rate in exhaled breath condensate collected from COVID-19 patients infected with Delta variant.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Delta variant is considered responsible for worldwide surges in coronavirus disease 2019 (COVID-19) cases in 2021, with increased infectivity compared to the wild type (Wuhan-1). In a previous study, we identified temporal changes in wild-type SARS-CoV-2 RNA load and detection rate in EBC collected from COVID-19 patients. The primary objective of this study was to clarify temporal changes in Delta-variant SARS-CoV-2 RNA load and detection rates in EBC collected from patients, and to validate the feasibility of Delta-variant SARS-CoV-2 RNA detection from EBC for diagnosing COVID-19. The secondary objective was to compare SARS-CoV-2 RNA loads in EBC between Delta-variant and wild-type. Subjects were 41 COVID-19 patients infected with the Delta-variant. EBC samples were collected from subjects on the day of or the day after admission using R-tube® (Respiratory Research, Austin, Texas, USA), as in our previous study. SARS-CoV-2 RNA in EBC samples was detected and quantified by RT-PCR assay targeting the E gene, using the same settings and reagents as in the previous study. The results indicated that SARS-CoV-2 RNA load in EBC collected from subjects infected with Delta-variant decreased exponentially with the passage of days from symptom onset. Sustained high detection rates support the feasibility of Delta-variant SARS-CoV-2 RNA detection from EBC by RT-PCR assay as a diagnostic test for COVID-19 within 8 d of onset. SARS-CoV-2 RNA load in EBC collected 2-8 d from onset was significantly higher in Delta-variant-infected subjects than in wild-type-infected subjects on a day-to-day basis (p= 0.005-0.029). However, because of the heterogeneity of the study cohort, conclusions cannot be reached regarding differences in viral RNA load between strains, regardless of the timing of EBC collection.

Behavioral factors associated with SARS-CoV-2 infection in Japan.

BACKGROUND: The relative burden of COVID-19 has been less severe in Japan. One reason for this may be the uniquely strict restrictions imposed upon bars/restaurants. To assess if this approach was appropriately targeting high-risk individuals, we examined behavioral factors associated with SARS-CoV-2 infection in the community. METHODS: This multicenter case-control study involved individuals receiving SARS-CoV-2 testing in June-August 2021. Behavioral exposures in the past 2 weeks were collected via questionnaire. SARS-CoV-2 PCR-positive individuals were cases, while PCR-negative individuals were controls. RESULTS: The analysis included 778 individuals (266 [34.2%] positives; median age [interquartile range] 33 [27-43] years). Attending three or more social gatherings was associated with SARS-CoV-2 infection (adjusted odds ratio [aOR] 2.00 [95% CI 1.31-3.05]). Attending gatherings with alcohol (aOR 2.29 [1.53-3.42]), at bars/restaurants (aOR 1.55 [1.04-2.30]), outdoors/at parks (aOR 2.87 [1.01-8.13]), at night (aOR 2.07 [1.40-3.04]), five or more people (aOR 1.81 [1.00-3.30]), 2 hours or longer (aOR 1.76 [1.14-2.71]), not wearing a mask during gatherings (aOR 4.18 [2.29-7.64]), and cloth mask use (aOR 1.77 [1.11-2.83]) were associated with infection. Going to karaoke (aOR 2.53 [1.25-5.09]) and to a gym (aOR 1.87 [1.11-3.16]) were also associated with infection. Factors not associated with infection included visiting a cafe with others, ordering takeout, using food delivery services, eating out by oneself, and work/school/travel-related exposures including teleworking. CONCLUSIONS: We identified multiple behavioral factors associated with SARS-CoV-2 infection, many of which were in line with the policy/risk communication implemented in Japan. Rapid assessment of risk factors can inform decision making.

Retroperitoneal Hemorrhage in Patients with COVID-19 Undergoing Hemodialysis: Three Case Reports.

A 73-year-old man receiving hemodialysis and antiplatelets was admitted with a mild case of COVID-19. Heparin was added, and iliopsoas hemorrhage developed. He was successfully treated by interventional radiology. A 76-year-old man receiving hemodialysis and antiplatelets was admitted with mild COVID-19. Heparin was added, and iliacus hemorrhage developed. Despite heparin discontinuation, he died of worsening pneumonia. A 74-year-old man undergoing hemodialysis was admitted with severe COVID-19. Gastrointestinal bleeding developed during continuous hemodiafiltration with heparin. Upon switching to nafamostat and increasing the dose, iliopsoas hemorrhage developed. Despite interventional radiology, he died of infectious complications. Attention to hemorrhagic complications is therefore needed in patients with COVID-19.

Acute femoral osteomyelitis due to hypermucoviscous Klebsiella pneumoniae.

Hypervirulent hypermucoviscous Klebsiella pneumoniae strains have emerged as clinically important pathogens causing invasive infections. K. pneumoniae osteomyelitis is uncommon in adult patients, and may mimic bone tumors on presentation. We report a patient with left rectus femoris muscle abscess and acute osteomyelitis of the left femur due to hypermucoviscous K. pneumoniae with negative blood culture, who was initially thought to have left thigh tumor. The patient's infection resolved with surgical drainage and debridement and intravenous and antibiotic therapy.

A perspective on hospital-acquired (nosocomial) infection control of COVID-19: usefulness of spatial separation between wards and airborne isolation unit.

The coronavirus disease 2019 (COVID-19) pandemic has imposed a considerable burden on hospitals and healthcare workers (HCWs) worldwide, increasing the risk of outbreaks and nosocomial transmission to 'non-COVID-19' patients, who represent the highest-risk population in terms of mortality, and HCWs. Since HCWs are at the interface between hospitals on the one hand and the community on the other, they are potential reservoirs, carriers, or victims of severe acute respiratory syndrome coronavirus 2 cross-transmission. In addition, there has been a paradigm shift in the management of viral respiratory outbreaks, such as the widespread testing of patients and HCWs, including asymptomatic individuals. In hospitals, there is a risk of aerosol transmission in poorly ventilated spaces, and when performing aerosol-producing procedures, it is imperative to take measures against aerosol transmission. In particular, spatial separation of the inpatient ward for non-COVID-19 patients from that designated for patients with suspected or confirmed COVID-19 as well as negative-pressure isolation on the floor of the ward, using an airborne infection isolation device could help prevent nosocomial infection.

A case of renal abscess and bacteremia caused by Burkholderia pseudomallei that was first unidentifiable by matrix-assisted laser desorption ionization-time of flight mass spectrometry in a Japanese-man.

Melioidosis, an infectious disease caused by Burkholderia pseudomallei, is endemic in specific regions, including Southeast Asia and Northern Australia. In Japan, where no autochthonous has been reported to date, melioidosis is a rare infectious disease. Herein, we report a case of melioidosis in a 68-year-old Japanese man with renal abscess and bacteremia, but without pneumonia. The patient presented to our hospital and was admitted for fever and chills that have persisted for two months. It was speculated that he was infected in Thailand, where his family lives because he shuttled between Thailand and Japan. Blood cultures on admission identified Burkholderia species; however, the species was unidentifiable by matrix-assisted laser desorption ionization-time of flight mass spectrometry. Further re-examination, including culture, loop-mediated isothermal amplification, and multiplex polymerase chain reaction methods, finally identified Burkholderia pseudomallei. We treated the patient with intravenous ceftazidime for four weeks. In addition to the antibiotics administration, puncture drainage of the renal abscess was performed, and he gradually became afebrile. Intravenous ceftazidime was switched to oral sulfamethoxazole/trimethoprim on post-admission day 32, and he was discharged. After five months of oral sulfamethoxazole/trimethoprim, no recurrence was observed one year after discharge. To diagnose melioidosis, especially in non-endemic areas, a precise and thorough understanding of its epidemiology, presentation, and identification methods is necessary.

RT-PCR diagnosis of COVID-19 from exhaled breath condensate: a clinical study.

Current diagnostic testing for coronavirus disease 2019 (COVID-19) is based on detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in nasopharyngeal swab samples by reverse transcription polymerase chain reaction (RT-PCR). However, this test is associated with increased risks of viral dissemination and environmental contamination and shows relatively low sensitivity, attributable to technical deficiencies in the sampling method. Given that COVID-19 is transmitted via exhaled aerosols and droplets, and that exhaled breath condensate (EBC) is an established modality for sampling exhaled aerosols, detection of SARS-CoV-2 in EBC offers a promising diagnostic approach. However, current knowledge on the detection and load of the virus in EBC collected from COVID-19 patients remains limited and inconsistent. The objective of the study was to quantify the viral load in EBC collected from COVID-19 patients and to validate the feasibility of SARS-CoV-2 detection from EBC as a diagnostic test for the infection. EBC samples were collected from 48 COVID-19 patients using a collection device, and viral loads were quantified by RT-PCR targeting the E gene. Changes in detection rates and viral loads relative to patient characteristics and days since disease onset were statistically evaluated. Need for mechanical ventilation was significantly associated with higher viral load (p< 0.05). Need for oxygen administration or mechanical ventilation, less than 3 d since onset, and presence of cough or fever were significantly associated with higher detection rates (p< 0.05). Among spontaneously breathing patients, viral load in EBC attenuated exponentially over time. The detection rate was 86% at 2 d since onset and deteriorated thereafter. In mechanically ventilated patients, detection rate and viral load were high regardless of days since onset. These results support the feasibility of using RT-PCR to detect SARS-CoV-2 from EBC for COVID-19 patients within 2 d of symptom onset.

A short perspective on a COVID-19 clinical study: 'diagnosis of COVID-19 by RT-PCR using exhale breath condensate samples'.

Diagnosis of SARS-COV-2 infection (COVID-19) is currently based on detection of the viral RNA in nasopharyngeal swab samples by reverse transcription polymerase chain reaction (RT-PCR). However, sampling via nasopharyngeal swabs frequently provokes sneezing or coughing, which results in increased risk of the viral dissemination and environmental contamination. Furthermore, the sensitivity associated with the PCR tests s limited to 60%-70%, which is mainly attributable to technical deficiency in sampling. Given that the disease is transmitted via exhaled aerosol and droplets, and that the exhaled breath condensate (EBC) is the established modality for sampling exhaled aerosol, detection of the viral RNA in EBC is a promising approach for safe and efficient diagnosis of the disease. Subjects are those patients who are diagnosed with COVID-19 by positive nasopharyngeal swab PCR test and admitted to Saitama Medical Center, Japan. EBC samples will be collected using an R-tube® or R-tubeVent® device. Collected EBC samples will be introduced into a nucleic acid purifier. The purified nucleic acids will undergo amplification through RT-PCR for detection and quantification of SARS-COV-2 RNA. To date we have collected eight samples from seven subjects. Among them, two samples from two subjects tested positive for SARS-COV-2 RNA by the RT-PCR. Reflecting the second wave of COVID-19 prevalence in Japan, new admissions of COVID-19 patients to the Saitama Medical Center are increasing, and we are expecting to collect at least 50 EBC samples from 25 patients before the end of this year.

Recommendations for Maintaining the Cardiovascular Care System Under the Conditions of the COVID-19 Pandemic　- 1st Edition, April 2020.

BACKGROUND: The Japanese Circulation Society proposes recommendations for all healthcare professionals involved in cardiovascular medicine to protect them from infection and ensure that seriously ill patients requiring urgent care receive proper treatment.Methods and Results:Patients are divided into "Positive or suspected coronavirus disease 2019 (COVID-19)" and "All others". Furthermore, tests and treatments are divided into emergency or standby. For each category, we propose recommendations. CONCLUSIONS: To maintain the cardiovascular care system, The Japanese Circulation Society recommends completely preventing nosocomial COVID-19 infections, ensuring adequate PPE necessary for healthcare personnel, and learning and implementing standard precautions.