Cardiac Acoustic Biomarkers in Patients with Heart Failure during Cardiopulmonary Exercise Testing: An Exploratory Study.

Objective Exercise therapy as part of cardiac rehabilitation is one of the most effective treatments for patients with chronic heart failure (HF). The anaerobic threshold (AT) determined by an exhaled gas analysis during cardiopulmonary exercise testing (CPX) is used to prescribe the appropriate level of exercise therapy. However, CPX using an exhaled gas analysis is not widely performed because of its cost, complexity, and the need for skilled staff. Therefore, a simpler and inexpensive method for determining AT without respiratory gas measurements is required in patients with HF. The present study elucidated the relationship between the AT determined by the CPX ventilatory method (CPX-AT) and the AT determined by cardiac acoustic biomarkers (CABs), which are measured by acoustic cardiography (CAB-AT), in HF patients. Methods Patients underwent symptom-limited ramp CPX twice using a cycle ergometer. The ATs determined from the exhaled gas analysis were identified by three independent physicians. CABs, including S1 and S2 intensities (peak-to-peak amplitudes), electromechanical activation time (EMAT) defined as the time interval from the Q wave onset on electrocardiography to the first heart sound (S1), heart rate (HR), and other parameters, were collected during CPX. Patients Forty patients with HF were included in this study. Results A significant correlation (R=0.70; p<0.001) was found between CPX-AT and CAB-AT, using the double product of S1 intensity and heart rate. CAB-AT using S1 intensity also showed a significant correlation with CPX-AT (R=0.71; p<0.001). Conclusion The present study suggests a possible new method for determining AT without respiratory gas measurements in patients with HF.

Acute Interstitial Nephritis with Glomerular Capillary IgA Deposition Following SARS-CoV-2 mRNA Vaccination.

We herein report a case of acute kidney injury (AKI) presenting as acute interstitial nephritis (AIN) after the first dose of the BNT162b2 mRNA vaccine against coronavirus disease 2019 (COVID-19). A 69-year-old man with a history of diabetes and hypertension presented with AKI 4 days after receiving the vaccine. Despite the administration of methylprednisolone pulse treatment, his renal function worsened, which prompted us to initiate temporal hemodialysis. His renal function subsequently improved, and a renal biopsy confirmed AIN and glomerular capillary IgA deposition without apparent crescents. The clinical history and histological findings suggest a relationship between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination and AIN as a rare side effect.

Morphological Factors affecting Coil-Only Embolization of Small Unruptured Aneurysms.

Objective When small unruptured aneurysms (SUA) are embolized by coils, manipulation of the microcatheter and coil is limited because of their small size. Previous studies suggested that the morphology of the artery and aneurysm is important. In the present study, we clarified the morphological factors affecting coil-only embolization of SUA. Patients and Methods We retrospectively identified 17 patients who underwent embolization for unruptured aneurysm with a maximum diameter less than 5 mm. We investigated the following: (1) the relationships among dome/neck ratio (D/N), height/neck ratio (H/N), height/dome ratio (H/D), projection of aneurysm-parent artery, and adverse events, (2) immediate and late occlusion, and (3) number of coils. Results (1) Adverse events developed in three cases in which the H/D was smaller than 1 ( p < 0.02). There was a significant difference in the rate of adverse events by projection of the aneurysm-parent artery ( p < 0.03), (2) Occlusion rate: Immediately after coil embolization, 71% (12/17) were neck remnant; however, 88% (15/17) of SUA became complete occlusion in the follow-up term, and (3) 1.5 ± 0.6 coils were used. Conclusion To achieve successful coil-only embolization in SUAs, it is important to select aneurysms for which the projection of the parent artery is suitable for embolizing and the H/D ratio is larger than 1. In SUAs, occlusion develops naturally after coil embolization.

Harnessing Insights from Indicators-Based Resilience Assessment for Enhancing Sustainability in the Gurage Socio-Ecological Production Landscape of Ethiopia.

Even though the mosaic of different land-use/land-cover types has long contributed to the resilience of socio-ecological production landscapes and seascapes in Ethiopia, recent data indicate that their sustainability is under threat. This study aims to evaluate landscape resilience by adopting a set of indicators for enhancing sustainability in the Gurage socio-ecological production landscape in Ethiopia. The authors employed a toolkit of indicators in the production landscape through a community-based scoring approach (1-5 Likert scale). The information from household surveys, land-use/land-cover analysis, and satellite-based drought incidents assessment was integrated with the ranking analysis to support the evaluations. The results revealed that landscape diversity, ecosystem protection, local governance, and social equity indicators had the highest landscape resilience ranks. In contrast, lower ranks are associated with knowledge, innovation, livelihoods, and well-being indicators. The overall resilience of the Gurage socio-ecological production landscape was estimated to be below average. Thus, strategies that enhance the resilience and sustainability of this socio-ecological landscape are essential. The findings could help draw the attention of policymakers and natural resource managers to building and strengthening the resilience of the landscape. This study demonstrates that indicators could aid in evaluating landscape resilience status along with other ancillary information, particularly in data-sparse regions. Methods of assessing resilience must be creative in such regions, and this paper may inform such efforts. In addition, the study recommends that landscape resilience indicators be improved by reducing subjective matter and including spatial-explicit dimensions for evaluating resilience.

Clinical characteristics and treatment of IMP-type carbapenemase-producing Enterobacteriaceae bacteremia: Case series and literature review.

BACKGROUND: Several carbapenemases have been identified globally in Enterobacteriaceae. In Japan, IMP-type carbapenemase is the most prevalent, although cases of carbapenemase-producing Enterobacteriaceae (CPE) bacteremia are still scarce. The present case series and literature review aimed to elucidate the clinical characteristics and treatment strategies for IMP-type CPE bacteremia. METHODS: Clinical data on pediatric cases of IMP-type CPE bacteremia at the Tokyo Metropolitan Children's Medical Center between 2010 and 2020 were collected, and a review of past studies of IMP-type CPE bacteremia has been provided. RESULTS: Five pediatric episodes of IMP-type CPE bacteremia were identified. Our review of previous literature on IMP-type CPE bacteremia revealed 24 adult patients, but no pediatric patients. All 29 cases had underlying diseases, and 23 (79%) received combination therapy. The median duration of antibiotic therapy was 14 days (interquartile range: 9-14 days). The overall mortality rate was 38% (11/29). The mortality rates associated with monotherapy and combination therapy were 67% (4/6) and 30% (7/23), respectively. CONCLUSIONS: We report the first case series of IMP-type CPE bacteremia in children. Our review of past studies suggests that combination therapy might lead to better survival outcomes in patients with IMP-type CPE bacteremia. Further research is needed to establish an optimal treatment strategy for IMP-type CPE bacteremia.

[A case of bilingual aphasia with language mixing between Japanese and English caused by superior longitudinal fasciculus lesion-a study using functional MRI and diffusion tensor imaging].

We report a case of left-handed bilingual aphasia with phonemic paraphasia and language mixing from Japanese as a first language to English as a second language. The lesion caused by cerebral infarction was mainly localized in the left parietal lobe white matter. The patient was a 46-year-old, left-handed woman who was bilingual in Japanese and English. Both auditory and visual comprehensions were well maintained after the acute phase of the disease; however, language mixing between Japanese and English was observed during Japanese speech. A pathophysiological interpretation of this case required a focus on the brain network. Our findings suggest that lesions of the superior longitudinal fasciculus and arcuate fasciculus of the white matter fibers just below the left inferior parietal lobule are associated with bilingual aphasia.

Changes Adopted in Asian Pediatric Hospitals during the COVID-19 Pandemic: A Report from the Pediatric Acute and Critical Care COVID-19 Registry of Asia.

There is wide variation in the overall clinical impact of novel coronavirus disease 2019 (COVID-19) across countries worldwide. Changes adopted pertaining to the management of pediatric patients, in particular, the provision of respiratory support during the COVID-19 pandemic is poorly described in Asia. We performed a multicenter survey of 20 Asian pediatric hospitals to determine workflow changes adopted during the pandemic. Data from centers of high-income (HIC), upper middle income (UMIC), and lower middle income (LMIC) countries were compared. All 20 sites over nine countries (HIC: Japan [4] and Singapore [2]; UMIC: China [3], Malaysia [3] and Thailand [2]; and LMIC: India [1], Indonesia [2], Pakistan [1], and Philippines [2]) responded to this survey. This survey demonstrated substantial outbreak adaptability. The major differences between the three income categories were that HICs were (1) more able/willing to minimize use of noninvasive ventilation or high-flow nasal cannula therapy in favor of early intubation, and (2) had greater availability of negative-pressure rooms and powered air-purifying respirators. Further research into the best practices for respiratory support are warranted. In particular, innovation on cost-effective measures in infection control and respiratory support in the LMIC setting should be considered in preparation for future waves of COVID-19 infection.

ARDS Clinical Practice Guideline 2021.

BACKGROUND: The joint committee of the Japanese Society of Intensive Care Medicine/Japanese Respiratory Society/Japanese Society of Respiratory Care Medicine on ARDS Clinical Practice Guideline has created and released the ARDS Clinical Practice Guideline 2021. METHODS: The 2016 edition of the Clinical Practice Guideline covered clinical questions (CQs) that targeted only adults, but the present guideline includes 15 CQs for children in addition to 46 CQs for adults. As with the previous edition, we used a systematic review method with the Grading of Recommendations Assessment Development and Evaluation (GRADE) system as well as a degree of recommendation determination method. We also conducted systematic reviews that used meta-analyses of diagnostic accuracy and network meta-analyses as a new method. RESULTS: Recommendations for adult patients with ARDS are described: we suggest against using serum C-reactive protein and procalcitonin levels to identify bacterial pneumonia as the underlying disease (GRADE 2D); we recommend limiting tidal volume to 4-8 mL/kg for mechanical ventilation (GRADE 1D); we recommend against managements targeting an excessively low SpO2 (PaO2) (GRADE 2D); we suggest against using transpulmonary pressure as a routine basis in positive end-expiratory pressure settings (GRADE 2B); we suggest implementing extracorporeal membrane oxygenation for those with severe ARDS (GRADE 2B); we suggest against using high-dose steroids (GRADE 2C); and we recommend using low-dose steroids (GRADE 1B). The recommendations for pediatric patients with ARDS are as follows: we suggest against using non-invasive respiratory support (non-invasive positive pressure ventilation/high-flow nasal cannula oxygen therapy) (GRADE 2D), we suggest placing pediatric patients with moderate ARDS in the prone position (GRADE 2D), we suggest against routinely implementing NO inhalation therapy (GRADE 2C), and we suggest against implementing daily sedation interruption for pediatric patients with respiratory failure (GRADE 2D). CONCLUSIONS: This article is a translated summary of the full version of the ARDS Clinical Practice Guideline 2021 published in Japanese (URL: https://www.jsicm.org/publication/guideline.html ). The original text, which was written for Japanese healthcare professionals, may include different perspectives from healthcare professionals of other countries.

ARDS clinical practice guideline 2021.

BACKGROUND: The joint committee of the Japanese Society of Intensive Care Medicine/Japanese Respiratory Society/Japanese Society of Respiratory Care Medicine on ARDS Clinical Practice Guideline has created and released the ARDS Clinical Practice Guideline 2021. METHODS: The 2016 edition of the Clinical Practice Guideline covered clinical questions (CQs) that targeted only adults, but the present guideline includes 15 CQs for children in addition to 46 CQs for adults. As with the previous edition, we used a systematic review method with the Grading of Recommendations Assessment Development and Evaluation (GRADE) system as well as a degree of recommendation determination method. We also conducted systematic reviews that used meta-analyses of diagnostic accuracy and network meta-analyses as a new method. RESULTS: Recommendations for adult patients with ARDS are described: we suggest against using serum C-reactive protein and procalcitonin levels to identify bacterial pneumonia as the underlying disease (GRADE 2D); we recommend limiting tidal volume to 4-8 mL/kg for mechanical ventilation (GRADE 1D); we recommend against managements targeting an excessively low SpO2 (PaO2) (GRADE 2D); we suggest against using transpulmonary pressure as a routine basis in positive end-expiratory pressure settings (GRADE 2B); we suggest implementing extracorporeal membrane oxygenation for those with severe ARDS (GRADE 2B); we suggest against using high-dose steroids (GRADE 2C); and we recommend using low-dose steroids (GRADE 1B). The recommendations for pediatric patients with ARDS are as follows: we suggest against using non-invasive respiratory support (non-invasive positive pressure ventilation/high-flow nasal cannula oxygen therapy) (GRADE 2D); we suggest placing pediatric patients with moderate ARDS in the prone position (GRADE 2D); we suggest against routinely implementing NO inhalation therapy (GRADE 2C); and we suggest against implementing daily sedation interruption for pediatric patients with respiratory failure (GRADE 2D). CONCLUSIONS: This article is a translated summary of the full version of the ARDS Clinical Practice Guideline 2021 published in Japanese (URL: https://www.jrs.or.jp/publication/jrs_guidelines/). The original text, which was written for Japanese healthcare professionals, may include different perspectives from healthcare professionals of other countries.

Impact Damage Detection Using Chirp Ultrasonic Guided Waves for Development of Health Monitoring System for CFRP Mobility Structures.

When impact damage occurs in carbon fiber-reinforced plastic (CFRP) structures, it is barely visible but may cause significant degradation in the mechanical properties of the structure. Hence, a structural health monitoring (SHM) system that can be installed in CFRP mobility structures and is sensitive to impact damage is needed. In this study, we attempted to establish an SHM system based on ultrasonic guided waves, which are generated by inputting a broadband chirp signal into a film-like piezoelectric actuator. The relationship between impact damage size and maximum time-of-flight (ToF) delay was investigated for three types of CFRP plates: woven, non-woven, and hybrid laminates. As a result, it was found that the maximum ToF delay increased linearly with an increase in the damage size for all CFRP laminates. Moreover, the amplitude of the A0 mode was found to be significantly affected by the damage length in the wave propagation direction. Thus, this SHM method using chirp ultrasonic waves can quantitatively evaluate the size and extent of the impact damage in CFRP laminates.

Landscape products for sustainable agricultural landscapes.

Landscape products link to low-input practices and traditional ecological knowledge, and have multiple functions supporting human well-being and sustainability. Here we explore seven landscape products worldwide to identify these multiple functions in the context of food commodification and landscape sustainability. We show that a landscape products lens can improve food systems by fostering sustainability strategies and standards that are place-sensitive, and as such can mitigate conflicts related to food production, social justice and the environment. Co-management strategies and information policies, such as certification, labelling, product information and raising of awareness could accelerate, incentivize and catalyse actions to support landscape products in the context of sustainability strategies.

Histopathological Composition of Thrombus in Acute Ischemic Stroke May Vary Even Within the Same Patient: A Preliminary Study Examining Clots According to Their Area of Retrieval.

Objective: Mechanical thrombectomy enables histopathological examination of clots in patients who have suffered acute ischemic strokes. Many studies have described about the relationship between the histopathological compositions of retrieved thrombi and imaging findings, clinical outcomes, and stroke etiology without consensus. In this study, we examined the histological composition of thrombi according to their retrieval site and methods. Methods: We divided retrieved clots into three parts (those retrieved from the proximal and distal parts of the stent retriever, and those aspirated through the guiding catheter) and then histopathologically analyzed their compositions by measuring the area occupied by red blood cells (RBCs), fibrin/platelets (F/Ps), and white blood cells (WBCs). Results: Each specimen showed various composition even within the same patient. For example, the area occupied by RBCs was 20.9% ± 12.1%, 30.5% ± 13.5%, and 41.3% ± 16.1% in the clot retrieved from the proximal and distal parts of the stent retriever, and those aspirated through the guiding catheter, respectively. Conclusion: Histopathological clot composition may vary even within the patient. Further research is needed to investigate more objective methods of histopathological analysis and their clinical significance.

Comparative Impact of Isolated Ultrafiltration and Hemodialysis on Fluid Distribution: A Bioimpedance Study.

INTRODUCTION: Isolated ultrafiltration (IUF) is an alternative treatment for diuretic-resistant patients with fluid retention. Although hemodialysis (HD) predominantly decreases extracellular water (ECW), the impact of IUF on fluid distribution compared with HD remains unclear. METHODS: We compared the effect of HD (n = 22) and IUF (n = 10) sessions on the body fluid status using a bioimpedance analysis device (InBody S10). RESULTS: The total ultrafiltration volume was similar between HD and IUF (HD 2.5 ± 0.3 vs. ICF 2.1 ± 0.3 L/session, p = 0.196). The reduction rate of ECW was significantly higher than that of intracellular water (ICW) after HD (ECW -7.9% ± 0.8% vs. ICW -3.0% ± 0.9%, p < 0.001) and IUF (ECW -5.8% ± 0.9% vs. ICW -3.6% ± 0.8%, p = 0.048). However, the change in the ratio of ECW to total body water in HD was significantly larger than that in IUF (HD -3.2% ± 0.3% vs. ICF -1.1% ± 0.4%, p < 0.001). The reduction rates in serum tonicity (effective osmolality) were higher after HD than after IUF (HD -1.8% ± 0.5% vs. IUF -0.6% ± 0.2%, p = 0.052). Among the components of effective osmolality, the reduction rates of serum K+ and glucose levels after HD were significantly higher than those after IUF (serum K+: HD -30.5% ± 1.6% vs. IUF -0.5% ± 3.8%, p < 0.001; serum glucose: HD -15.4% ± 5.0% vs. IUF 0.7% ± 4.8%, p = 0.026), while the serum Na+ level was slightly and similarly reduced (HD -0.8% ± 0.4% vs. IUF -0.8% ± 0.4%, p = 0.500). The reduction in the osmolal gap value (measured osmolality-calculated osmolarity) was significantly greater after HD sessions than after IUF sessions (HD -12.4 ± 1.4 vs. IUF 2.0 ± 1.0 mOsm/kg, p = 0.001). CONCLUSION: The extracellular fluid reduction effect of HD is stronger than that of IUF. The different changes in effective osmolality and osmolal gap after HD and IUF sessions may be related to the different effects of HD and IUF on fluid distribution.

Tubulointerstitial nephritis in antineutrophil cytoplasmic antibody-associated vasculitis with monoclonal gammopathy.

Isolated tubulointerstitial nephritis (TIN) without glomerular crescent formation is a rare manifestation of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). Some patients with monoclonal gammopathy of undetermined significance present with renal complications due to serum monoclonal protein. Here, we present a case of TIN presumably attributable to AAV with monoclonal gammopathy. Laboratory data revealed acute kidney injury, elevated C-reactive protein (CRP) and ANCA titers, and elevated tubular injury markers. Renal biopsy revealed TIN with no apparent glomerular lesion. The findings of peritubular capillaritis and tubulitis indicated that AAV had contributed to the development of TIN. However, in situ hybridization for free light chains revealed kappa light chain restriction, indicating that the involvement of monoclonal gammopathy in the pathogenesis of TIN remains possible. The patient also developed ophthalmic neuropathy, probably caused by AAV. Oral prednisone (0.6 mg/kg/day) administration improved both the ocular symptoms and the laboratory parameters. Our case demonstrated that the concurrence of AAV and monoclonal gammopathy could pose a diagnostic dilemma in distinguishing the cause of TIN. Besides, some reports suggest an association between AAV and monoclonal gammopathy, although direct evidence is lacking. Further research is needed to establish this association.