Formation of xylem tissues and secondary cell walls is diminished by severe and consecutive insect defoliation.

PREMISE: Insect defoliation of trees causes unusual changes to wood anatomy and slows radial growth that decreases tree value; however, the characteristics of these anatomical changes in hardwoods remain unclear. The aim of this study was to characterize the anatomy and histochemistry of the wood in trunks of Betula maximowicziana trees after severe insect defoliation. METHODS: Secondary xylem tissues were sampled from trunks that had been defoliated by Caligula japonica at Naie and Furano in central Hokkaido during 2006-2012, then cross-dated and examined microscopically and stained histochemically to characterize anatomical and chemical changes in the cells. RESULTS: White rings with thin-walled wood fibers and greatly reduced annual ring width in the subsequent year were observed in samples from both sites. From these results, the year that the white rings formed was determined, and severe defoliation was confirmed to trigger white ring formation. The characteristics may prove useful to detect the formation year of white rings. Scanning electron microscopy and histochemical analyses of the white rings indicated that the thickness of the S2 layer in the wall of wood fiber cells decreased, but xylan and lignin were still deposited in the cell walls of wood fibers. However, the walls of the fibers rethickened after the defoliation. CONCLUSIONS: Our results suggest that B. maximowicziana responds to a temporary lack of carbon inputs due to insect defoliation by regulating the thickness of the S2 layer of the cell wall of wood fibers. For B. maximowicziana, insect defoliation late in the growing season has serious deleterious effects on wood formation and radial growth.

Evaluation of the therapeutic effects of AGA drugs by measuring finasteride, dutasteride, and dihydrotestosterone in hair.

BACKGROUND: Androgenetic alopecia (AGA) is treated by 5α-reductase inhibitors (5ARI) such as finasteride and dutasteride, which are widely used as therapeutic agents. However, their pharmacokinetics in target organs (scalp and hair follicles) have not yet been investigated. PURPOSE: To confirm the effective action of finasteride and dutasteride in the hair follicle tissues, we developed a method to measure these concentrations in hair. RESULTS: Compared to the non-detection (N.D.) group, the dihydrotestosterone (DHT) concentrations decreased significantly in both the finasteride and dutasteride groups. The dutasteride group showed significantly lower DHT concentrations among all groups. CONCLUSIONS: Measurement of finasteride, dutasteride, and DHT concentrations in hair would aid in evaluating the drug pharmacokinetics and its therapeutic effects on AGA patients.

Transverse and longitudinal right ventricular fractional parameters derived from four-chamber cine MRI are associated with right ventricular dysfunction etiology.

Studies of the usefulness of transverse right ventricular (RV) shortening are limited. We retrospectively analyzed the CMR images of 67 patients (age: 50.8 ± 19.0 years; men: 53.7%; Control: n = 20, Overloaded RV (atrial septal defect): n = 15, Constricted RV (pericarditis): n = 17, Degenerated RV (arrhythmogenic right ventricular cardiomyopathy): n = 15) (all enrolled consecutively for each disease) in a single center. We defined RV longitudinal (fractional longitudinal change: FLC) and transverse (fractional transverse change: FTC) contraction parameters. We assessed the FTC/FLC (T/L) ratio on four-chamber cine CMR views and compared the four groups regarding the fractional parameters. FTC had a stronger correlation (R2 = 0.650; p < 0.001) with RV ejection fraction than that with FLC (R2 = 0.211; p < 0.001) in the linear regression analysis. Both FLC and FTC were significantly lower in the Degenerated RV and Constricted RV groups compared with those in the Control and Overloaded RV groups. The T/L ratio was significantly lower in the Degenerated RV group (p = 0.008), while the Overloaded RV (p = 0.986) and Constricted RV (p = 0.582) groups had preserved T/L ratios, compared with the Control group. Transverse shortening contributes to RV function more significantly compared with longitudinal contraction. Impaired T/L ratios may reflect RV myocardial degeneration. RV fractional parameters may help precisely understand RV dysfunction.

Healing rate of macular edema secondary to branch retinal vein occlusion in two years after initiation of intravitreal ranibizumab later combined with other treatment as needed and characteristics of refractory cases.

PURPOSE: To investigate the 2-year healing rate of macular edema (ME) secondary to branch retinal vein occlusion (BRVO) treated initially with intravitreal ranibizumab (IVR) and later combined with other treatment as needed, and the characteristics of refractory cases. METHODS: 130 patients (130 eyes) with BRVO-ME who received IVR initially were studied. Anti-vascular endothelial growth factor drug was additionally administered when ME relapsed or persisted. Photocoagulation was performed when the non-perfusion area (NPA) was ≥5 disc diameter (DD), and/or when ME relapsed due to microaneurysm. Patients were classified into a healed group [ME resolved in <2 years or mild ME remained without best-corrected visual acuity (BCVA) loss for ≥6 months] or refractory group (ME persisted for ≥2 years). RESULTS: 110 eyes were classified into the healed group, and 20 eyes into the refractory group. The healed group and refractory group had, respectively, mean follow-up periods of 21.2 and 37.4 months, and frequencies of NPA ≥5 DD of 55.5 and 25.0% (p = 0.015). In the healed group, mean BCVA (logMAR) improved significantly compared to baseline in all the periods until 24 months after treatment initiation and at the last visit (p<0.001). In the refractory group, mean BCVA improved significantly compared to baseline until 12 months after treatment initiation (p<0.05 for all periods), but was not significantly different at 18 or 24 months or at the last visit. CONCLUSION: In patients with BRVO-ME treated initially with IVR and later given additional treatments as needed, the healing rate was 84.6%. In eyes that healed within 2 years, BCVA improved relative to baseline throughout 24 months and at the last visit. In refractory eyes, BCVA improved only until 12 months, and thereafter deteriorated to baseline level at the last examination.

Factors that hinder medical career aspirations: A nationwide questionnaire survey of teachers in charge of career guidance in Japanese high schools.

Despite concerns raised on the inequality in healthcare provision in Japan, little is known about the factors that hinder candidates' application to medical schools. A nationwide cross-sectional survey was conducted to identify the impact of economic factors and living place on students' choice of and preparation for medical school. The survey was administered to high school teachers with career advisory roles, as they support and likely influence students' choice and decision on this matter. Responses totaling 1,094 were obtained from 1,746 high schools across Japan. The ratio of high schools with two or more students enrolled in medical schools every year is higher in private schools, those with high tuition, and those located in big cities. Approximately 66.8% of the respondents agreed that "It is difficult for students in economically disadvantaged families to enroll in medical schools;" 42.0% agreed that "Some students gave up on aspiring to enter medical schools because they could not afford it," and 61.2% agreed that "Students living in urban areas are more likely to enroll in medical schools." When asked about the percentage of students attending prep school among those aspiring for a medical career, significantly more respondents from private versus public high schools answered "80% or more." When asked about the percentage of parents who are doctors or dentists among students aspiring for a medical career, significantly more respondents from private versus public high schools answered "50% or more." The results suggest that students from lower-income families and those living in rural areas are more likely to be disadvantaged when choosing a medical career (because of financial difficulties) than those who live in urban areas and come from wealthier families. The results imply that economic and geographical divides in medical admission are reflected in high school teachers' perception of and support provided to students.

Can digital health technologies exacerbate the health gap? A clustering analysis of mothers' opinions toward digitizing the maternal and child health handbook.

BACKGROUND: The use of mobile health has increased worldwide, but along with its increased utilization comes the risk of the digital divide, inequity in access to information and communications technologies, exerting greater influence on health inequity caused by socioeconomic determinants of health. There is a growing need to investigate whether the digitization of existing health interventions has a risk of worsening the health gap. METHODS: We investigated the attitudes of mothers and pregnant women toward digitization of the Maternal and Child Health Handbook (MCHH), a popular personal health record (PHR) used by almost every pregnant woman or mother in Japan, using a cross-sectional survey. We determined sociodemographic factors associated with favorable opinions toward digitization using a multivariate regression model. We then grouped the participants using partitioning around medoids clustering, a machine-learning approach, to interpret their varying attitudes toward digitization in light of their sociodemographic characteristics as well as their affinity toward the paper MCHH. FINDINGS: Higher income and educational level, older age, and less reliance on the MCHH were significantly associated with favorable opinion toward digitization. Clustering analysis identified four latent clusters. The cluster with the highest socioeconomic status (SES) was the most favorable toward digitization, while two clusters with the lowest SES, one of which relied heavily on the paper MCHH, were less favorable of digitization compared to the high SES cluster. The final cluster was comprised of mothers with the experience of raising multiple children and did not rely heavily on the MCHH. INTERPRETATION: Our study identified a socioeconomic divide in opinions toward digitization of an existing health intervention. A hasty digitization may result in an unbalanced uptake of the digitized health intervention among different social classes.

An analytical survey of benzotriazole UV stabilizers in plastic products and their endocrine-disrupting potential via human estrogen and androgen receptors.

Benzotriazole UV stabilizers (BUVSs) are added to various materials to prevent damage from UV-irradiation. Recently, there has been great concern regarding the endocrine-disrupting effects of exposure to microplastic-derivative BUVSs in particular. In this study, we measured the concentrations of nine representative BUVSs in the plastic bottle caps of 10 beverages, 4 food packages, and 4 plastic shopping bags purchased from Japanese grocery stores by GC-MS analysis, and found that eight BUVSs, except for 2-(3,5-di-tert-butyl-2-hydroxyphenyl)-2H-benzotriazole (UV-320), were detected from these plastic products. In particular, 2-(2-hydroxy-5-methylphenyl) benzotriazole (UV-P) and 2-(2-hydroxy-3-tert-butyl-5-methylphenyl)-5-chlorobenzotriazole (UV-326) were detected from all the bottle caps at concentrations in the order of ng/g. In addition, we characterized the agonistic and/or antagonistic activities against human estrogen receptors (ERα/ß) and androgen receptor (AR) of 13 BUVSs. Results revealed that, among the 13 BUVSs, UV-P, 2-(5-tert-butyl-2-hydroxyphenyl) benzotriazole (UV-PS), 2-[2-hydroxy-5-[2-(methacryloyloxy)ethyl]phenyl]-2H-benzotriazole (UV-090) and 2-(2-hydroxy-5-tert-octylphenyl)-benzotriazole (UV-329) showed ERα and/or ERß agonistic activity, with UV-P being the most potent based on these assays. On the other hand, UV-320 and 2-(3-s-butyl-5-tert-butyl-2-hydroxyphenyl) benzotriazole (UV-350) showed both ERα and ERß antagonistic activities, and 2-(3,5-di-tert-amyl-2-hydroxylphenyl) benzotriazole (UV-328) and UV-329 acted as ERß antagonists. In the AR assay, UV-P and 2-(3-allyl-2-hydroxy-5-methylphenyl)-2H-benzotriazole (UV-9) showed AR antagonistic activity although none of the test compounds showed AR agonistic activity. Taken together, our findings suggest that a series of BUVSs are present in our environments via plastic materials and several of these compounds possess endocrine-disrupting potential, such as ERα/ß agonistic and/or antagonistic activity and AR antagonistic activity. UV-P and its structurally similar compounds, in particular, appear to be a cause for concern.

Cost-Effectiveness Analysis of Tisagenlecleucel for the Treatment of Pediatric and Young Adult Patients with Relapsed or Refractory B Cell Acute Lymphoblastic Leukemia in Japan.

Until recently, treatment options were relatively limited for children and young adults with relapsed or refractory (r/r) acute lymphoblastic leukemia (ALL). Tisagenlecleucel is a chimeric antigen receptor T cell (CAR-T) immunotherapy with promising efficacy and manageable safety that was approved in Japan in 2019 for the treatment of CD19-positive r/r B cell ALL (B-ALL). However, there is no publication assessing the cost-effectiveness of CAR-T in Japan. The objective of this study was to assess the cost-effectiveness of a tisagenlecleucel treatment strategy compared to a blinatumomab treatment strategy and a clofarabine combination treatment strategy (i.e., clofarabine + cyclophosphamide + etoposide) in Japan for pediatric and young adult patients up to 25 years of age with r/r B-ALL. A partitioned survival model with a lifetime horizon and monthly cycle was constructed from a Japanese public healthcare payer's perspective. Patients were distributed across the following partitioned health states: event-free survival (EFS), progressive disease, and death, which were informed by the EFS and overall survival (OS) data of respective clinical trials before year 5. For the tisagenlecleucel arm, a decision-tree structure was used to partition patients based on the infusion status; those who discontinued prior to receiving infusion were assigned efficacy and cost inputs of blinatumomab and those who received infusion were assigned efficacy and costs inputs based on tisagenlecleucel-infused patients. As trial data for blinatumomab and clofarabine ended before year 5, matching-adjusted indirect comparisons were used to extrapolate OS between the end of trial observation and up to year 5. All surviving patients followed the mortality risk of long-term ALL survivors without additional risk of disease relapse after year 5, regardless of initial treatment strategies. The model accounted for pretreatment costs, treatment costs, adverse event costs, follow-up costs, subsequent allogeneic hematopoietic stem cell transplantation costs, and terminal care costs. Incremental cost-effectiveness ratios (ICERs) per life-years (LYs) gained and ICERs per quality-adjusted life-years (QALYs) gained were evaluated using a 2% discount rate, and a threshold of ¥7.5 million was used to assess cost-effectiveness. Deterministic and probabilistic sensitivity analyses were performed. The total LYs (discounted) for tisagenlecleucel, blinatumomab, and clofarabine combination treatment strategies were 13.3, 4.0, and 2.7 years, respectively; the corresponding QALYs were 11.6, 3.1, and 2.1 years, respectively. The ICERs per QALY gained for tisagenlecleucel were ¥2,035,071 versus blinatumomab and ¥2,644,702 versus clofarabine combination therapy. Extensive sensitivity analyses supported the findings. Tisagenlecleucel is a cost-effective treatment strategy for pediatric and young adult patients with r/r B-ALL from a Japanese public healthcare payer's perspective.

Safety and effectiveness of everolimus in maintenance kidney transplant patients in the real-world setting: results from a 2-year post-marketing surveillance study in Japan.

BACKGROUND: Data on real-world use of everolimus (EVR) in Japanese maintenance kidney transplant (KTx) patients are limited. This post-marketing surveillance study was conducted to assess the safety and effectiveness of EVR, and identify factors affecting renal impairment. METHODS: Adult maintenance KTx patients were enrolled within 14 days of initiating EVR. Patient medical data were collected using electronic data capture case report forms at 6 months, 1, and 2 years after initiating EVR, or at discontinuation. RESULTS: All patients receiving EVR in Japan during the surveillance period were enrolled (N = 263). Mean time from transplantation to EVR initiation was 75.7 months. Decreased renal function (31.56%) was the primary reason for initiating EVR. In combination with EVR, the mean daily dose of tacrolimus and cyclosporine could be reduced to ~ 79 and ~ 64%, by 2 years, respectively. Incidences of serious adverse events and adverse drug reactions were 15.97 and 49.43%, respectively. Two-year graft survival rate was 95.82% and low in patients with baseline estimated glomerular filtration rate (eGFR; modification of diet in renal disease) < 30 mL/min/1.73 m2 (69.57%; P < 0.0001) and urinary protein/creatinine ratio (UPCR) ≥ 0.55 g/gCr (84.21%; P = 0.0206). Throughout the survey, mean eGFR values were stable (> 55 mL/min/1.73 m2). Renal impairment was influenced by patient and donor age, eGFR, and UPCR at baseline. CONCLUSIONS: No new safety concerns for the use of EVR in adult maintenance KTx patients were identified. Early EVR initiation may be considered in these patients before renal function deterioration occurs.

Defoliation by Gypsy Moth (Lepidoptera, Erebidae) Induces Differential Delayed Induction of Trichomes in Two Birch Species.

Outbreaks of the gypsy moth (Lymantria dispar japonica Motschulsky) cause serious defoliation in birch. A single year of defoliation has no significant impact on the trees, whereas continuous defoliation events could be fatal. How birch species avoid serious damage caused by gypsy moth outbreak is yet to be revealed. Trichomes on leaf surfaces of birch trees are an effective antiherbivore defense strategy. We examined a 1-yr delayed induction of glandular (GT) and nonglandular trichomes (NGT) on leaf surfaces caused by stress in white birch (Betula platyphylla Sukaczev var. japonica [Miq.] Hara) and monarch birch (Betula maximowicziana Regel). Saplings were subjected to four treatments in June 2009: herbivory (50% of the leaf area was grazed by gypsy moths), mechanical cutting (50% of the leaf area was cut using scissors), shading (50% light shading with a black sheet), and control (covered with a net to prevent herbivory). Then, the density of GT and NGT on early leaves was determined in April 2010. In both birch species, the density of GT was higher in herbivory than in other treatments. The density of GT due to mechanical cutting was higher than that in the control, but only for white birch. However, the density of NGT was lower after mechanical cutting than in other treatments for white birch. There were no differences in the density of NGT among treatments for monarch birch. These results show that 1-yr delayed induction of GT by herbivory was stronger in white birch than in monarch birch.

Heterophyllous Shoots of Japanese Larch Trees: The Seasonal and Yearly Variation in CO2 Assimilation Capacity of the Canopy Top with Changing Environment.

Japanese larch (Larix kaempferi = L. leptolepis) is often characterized by its high growth rate with heterophyllous shoots, but the functional differences of heterophyllous shoots still remain unclear. Recently, abrupt high temperature and drought during spring induced high photosynthetic rate via change in leaf morphology of the deciduous habit. In order to reveal the photosynthetic characteristics of both short and long-shoot needles of sunny canopy of the larch trees using a canopy tower, we calculated the seasonal change of gas exchange characters and leaf mass per area (LMA) and foliar nitrogen content (N) of heterophyllous needles: short and long-shoot needles over 3 years. No marked difference in light-saturated photosynthetic rates (Psat) was observed between short and long shoots after leaf maturation to yellowing, although the difference was obvious in a specific year, which only shows that seasonal change in temperature and soil moisture determines the in situ photosynthetic capacity of needles. The large annual and seasonal variations in Psat in both shoots were found to be mainly determined by climatic variations, while shoot types determined the strategy of their photosynthetic N utilization as well as the stomatal regulation.

A Review of Environmental Context Detection for Navigation Based on Multiple Sensors.

Current navigation systems use multi-sensor data to improve the localization accuracy, but often without certitude on the quality of those measurements in certain situations. The context detection will enable us to build an adaptive navigation system to improve the precision and the robustness of its localization solution by anticipating possible degradation in sensor signal quality (GNSS in urban canyons for instance or camera-based navigation in a non-textured environment). That is why context detection is considered the future of navigation systems. Thus, it is important firstly to define this concept of context for navigation and to find a way to extract it from available information. This paper overviews existing GNSS and on-board vision-based solutions of environmental context detection. This review shows that most of the state-of-the art research works focus on only one type of data. It confirms that the main perspective of this problem is to combine different indicators from multiple sensors.

Inhibitory effects of organophosphate esters on carboxylesterase activity of rat liver microsomes.

We investigated the inhibitory effects of 13 organophosphate esters (OPEs) and hydrolytic metabolites on the carboxylesterase activity of rat liver microsomes in vitro in order to examine whether there might be a potential impact on human health, and to elucidate the structure activity relationship. Among the test compounds, 2-ethylhexyl diphenyl phosphate (EDPhP) was the most potent inhibitor of carboxylesterase activity, as measured in terms of 4-nitrophenol acetate hydrolase activity, followed by tri-m-cresyl phosphate (TmCP), cresyl diphenyl phosphate (CDPhP) and triphenyl phosphate (TPhP). The IC50 values were as follows: EDPhP (IC50: 0.03 µM) > TmCP (0.4 µM) > CDPhP (0.8 µM) > TPhP (14 µM) > tris(1,3-dichloro-2-propyl) phosphate (17 µM) > tris(2-ethylhexyl) phosphate (77 µM) > tri-n-propyl phosphate (84 µM) > tris(2-chloroethyl) phosphate (104 µM) > tris(2-butoxyethyl) phosphate (124 µM) > tri-n-butyl phosphate (230 µM). The IC50 value of EDPhP was three orders of magnitude lower than that of bis(4-nitrophenyl) phosphate, which is widely used as an inhibitor of carboxylesterase. Trimethyl phosphate, triethyl phosphate and tris(2-chloroisopropyl) phosphate slightly inhibited the carboxylesterase activity; their IC50 values were above 300 µM. Lineweaver-Burk plots indicated that the inhibition by several OPEs was non-competitive. Diphenyl and monophenyl phosphates, which are metabolites of TPhP, showed weaker inhibitory effects than that of TPhP.

Efficacy and safety of tisagenlecleucel in Japanese pediatric and young adult patients with relapsed/refractory B cell acute lymphoblastic leukemia.

Tisagenlecleucel is an autologous T cell genetically modified ex vivo using a lentiviral vector encoding an anti-CD19 chimeric antigen receptor. Here, we present the efficacy and safety of tisagenlecleucel in a subgroup of Japanese patients with relapsed/refractory (r/r) B-cell acute lymphoblastic leukemia (ALL). ELIANA was a single-arm, open-label, multicenter, phase 2 study. Patients were aged ≥ 3 years at screening to ≤ 21 years at the time of diagnosis, and had ≥ 5% lymphoblasts in bone marrow at screening. Primary endpoint was overall remission rate [ORR; complete remission (CR) + CR with incomplete blood recovery (CRi)] within 3 months after infusion. As of April 13, 2018, eight patients were enrolled and six had been infused. ORR was 66.7% (95% confidence interval 22.3-95.7); three patients achieved CR and one patient had CRi. All patients with CR/CRi were negative for minimal residual disease. One patient had CR/CRi lasting 19.5 + months. Cytokine release syndrome (CRS) and neurological events occurred in 83% and 17% of patients, respectively. CRS resolved with anti-cytokine therapy and supportive care. Two deaths occurred due to disease progression. No cases of cerebral edema were observed. Tisagenlecleucel produced high remission rates and durable responses offering a new treatment option for Japanese pediatric and young adults with r/r B-ALL.

Activation of PXR, CAR and PPARα by pyrethroid pesticides and the effect of metabolism by rat liver microsomes.

In this study, we used reporter gene assays in COS-1 cells to examine the activation of rat pregnane X receptor (PXR), rat constitutive androstane receptor (CAR) and rat peroxisome-proliferator activated receptor (PPAR)α by pyrethroid pesticides, and to understand the effects of metabolic modification on their activities. All eight pyrethroids tested in this study showed rat PXR agonistic activity; deltamethrin was the most potent, followed by cis-permethrin and cypermethrin. However, when the pyrethroids were incubated with rat liver microsomes, their rat PXR activities were decreased to various extents. Cis- and trans-permethrin showed weak rat CAR agonistic activity, while the other pyrethroids were inactive. However, fenvalerate showed dose-dependent inverse agonistic activity toward rat CAR, and this activity was reduced after metabolism. None of the pyrethroids showed rat PPARα agonistic activity, but a metabolite of cis-/trans-permethrin and phenothrin, 3-phenoxybenzoic acid, activated rat PPARα. Since PXR, CAR and PPARα regulate various xenobiotic/endobiotic-metabolizing enzymes, activation of these receptors by pyrethroids may result in endocrine disruption due to changes of hormone-metabolizing activities.

Comparative study of the effect of 17 parabens on PXR-, CAR- and PPARα-mediated transcriptional activation.

Parabens are widely used as preservatives in personal care products, medicines and foods, resulting in substantial human exposures, even though some harmful effects, such as endocrine-disrupting activity, have been reported. Pregnane X receptor (PXR), constitutive androstane receptor (CAR) and peroxisome proliferator-activated receptor α (PPARα), which are members of the nuclear receptor superfamily, regulate the metabolism of endogenous substrates including hormones. Therefore, we hypothesized that parabens may alter hormone-metabolizing activities by acting on these receptors, and such changes could contribute to the endocrine-disrupting activity. To test this idea, we systematically examined the effects of 17 parabens on these receptors using reporter gene assays. Nine parabens significantly activated human and rat PXR. Parabens with C2-C5 (linear and branched) side chains were most active. Butylparaben and isobutylparaben also significantly activated rat CAR. We found that long-side-chain (C7-C12) parabens showed up to 2-fold activation of PPARα at 10 µM. Furthermore, pentylparaben and hexylparaben showed rat PXR antagonistic activity and rat CAR inverse agonistic activity. The activity of butylparaben towards PXR and CAR was lost after carboxylesterase-mediated metabolism. These findings confirm that parabens influence the activities of PXR, CAR and PPARα, and thus have the potential to contribute to endocrine disruption by altering hormone metabolism.

Adrenocortical carcinoma characterized by gynecomastia: A case report.

We present a 4-yr-old boy with adrenocortical carcinoma (ACC), diagnosed due to the appearance of gynecomastia as the presenting symptom. Six months prior to admission, an acute growth spurt along with the development of bilateral breast swelling was observed. He did not present any features of virilization, including enlargement of the testes, increase in testis volume, and penis size. Laboratory investigations showed gonadotropin-independent hypergonadism, with low LH/ FSH levels and elevated estradiol/testosterone levels. Abdominal computed tomography revealed a large heterogeneous mass adjacent to the right kidney and below the liver. Pathological investigations of the biopsy specimen demonstrated that the tumor was an ACC. Pre- and post-operative combination chemotherapy with mitotane was administered and surgical resection was carried out. Post-surgery, the elevated estradiol/testosterone concentrations reverted to within the reference range. Urinary steroid profile and tissue concentration analysis of estradiol and testosterone indicated the presence of estrogen in the ACC tissue. An investigation for TP53 gene aberrations revealed the presence of a germline point mutation in exon 4 (c.215C>G (p.Pro72Arg)). In ACC, the most common symptom is virilization, and feminization, characterized by gynecomastia, is very rare. However, a diagnostic possibility of ACC should be considered when we encounter patients who have developed gynecomastia without the influence of causative factors such as obesity or puberty, and do not present with the typical signs of virilization.

High urinary albumin/creatinine ratio at admission predicts poor functional outcome in patients with acute ischaemic stroke.

AIM: Albuminuria and a low estimated glomerular filtration rate (eGFR) are widely recognized indices of kidney dysfunction and have been linked to cardiovascular events, including stroke. We evaluated albuminuria, measured using the urinary albumin/creatinine ratio (UACR), and the eGFR in the acute phase of ischaemic stroke, and investigated the clinical characteristics of ischaemic stroke patients with and those without kidney dysfunction. METHODS: The study included 422 consecutive patients admitted between June 2010 and May 2012. General blood and urine examinations were performed at admission. Kidney dysfunction was defined as a low eGFR (<60 mL/min per 1.73 m2 ), high albuminuria (≥30 mg/g creatinine), or both. Neurological severity was evaluated using the National Institutes of Health Stroke Scale (NIHSS) at admission and the modified Rankin scale (mRS) at discharge. A poor outcome was defined as a mRS score of 3-5 or death. The impacts of the eGFR and UACR on outcomes at discharge were evaluated using multiple logistic regression analysis. RESULTS: Kidney dysfunction was diagnosed in 278 of the 422 patients (65.9%). The eGFR was significantly lower and UACR was significantly higher in patients with a poor outcome than in those with a good outcome. In multivariate analyses performed after adjusting for confounding factors, UACR >31.2 mg/g creatinine (OR, 2.58; 95% CI, 1.52-4.43; P = 0.0005) was independently associated with a poor outcome, while a low eGFR was not associated. CONCLUSIONS: A high UACR at admission may predict a poor outcome at discharge in patients with acute ischaemic stroke.

Factors affecting the early post-operative prognosis in morbidly obese surgical patients after laparoscopic sleeve gastrectomy - a retrospective cohort study.

BACKGROUND: The number of morbidly obese patients who have undergone bariatric surgery has been gradually increasing in Japan. These obese patients are often complicated with metabolic, cardiac, respiratory, and other diseases. The aim of this study was to analyze the perioperative clinical course in a retrospective cohort with respect to the utility of anesthesia management in order to prevent longer hospital stays after surgery. FINDINGS: Sixty-seven morbidly obese patients who had undergone sleeve gastrectomy were divided into two groups, based upon the duration of postoperative hospital stay; group S was comprised of the patients who were discharged within 5 days after surgery (n = 57) and group L was comprised of those who were discharged after 6 days or more (n = 10). The mean duration of the hospital stay was 4.8 ± 0.4 days and 7.8 ± 1.4 days in groups S and L, respectively. Multivariate logistic regression analysis showed that prolonged anesthesia was a predictor of a longer postoperative hospital stay (p < 0.05). While the difference in BMI was not significantly different, the percentage of patients with BMI ≥ 50 was 12 and 30% in groups S and L, respectively. CONCLUSIONS: Longer duration of anesthesia affected the duration of postoperative hospital stay in morbidly obese patients undergoing sleeve gastrectomy. In addition, patients with BMI ≥ 50 might be at risk of longer hospitalization after surgery.