Constrictive Pericarditis with Cardiac Ascites Caused Spontaneous Bacterial Peritonitis.

Patients with constrictive pericarditis (CP) typically present with symptoms related to right-sided heart failure, such as cardiac ascites. Spontaneous bacterial peritonitis (SBP) usually arises in association with ascites secondary to hepatic cirrhosis. We herein report a rare case of CP in which SBP developed due to cardiac ascites, even in the absence of cirrhosis. In this case, pericardiectomy improved both the hemodynamics and the ascites, while therapy with diuretics alone was insufficient. It is important to consider SBP in the differential diagnosis when any abdominal symptoms or an inflammatory response is found in patients with heart failure and cardiac ascites.

Successful Repair of a Forme Fruste Bicuspid Aortic Valve by the Raphe Suspension Technique.

A 52-year-old man underwent surgery due to shortness of breath caused by severe aortic regurgitation with right coronary cusp prolapse. Operative findings revealed 3 symmetric cusps with small raphe between the right and noncoronary cusps situated lower than the others, indicating a forme fruste bicuspid aortic valve (BAV). The BAV was successfully repaired by tricuspidization, including raphe suspension, right coronary cusp plication, and double annuloplasty. The postoperative course was uneventful, and echocardiography at 3 months showed mild aortic regurgitation with adequate left ventricular reverse remodeling. Here we present the technical details of the raphe suspension procedure for forme fruste BAV.

Lung ventilation/perfusion scintigraphy shows the efficacy of anticoagulant therapy and surgical treatment for papillary fibroelastoma originating from the tricuspid valve.

Papillary fibroelastoma (PFE) is a cardiac tumor that is mainly found on the heart valve and the endocardium of the atria and ventricles. Symptoms such as stroke and myocardial infarction are usually caused by embolization of either the tumor itself or associated thrombus. PFE is known to originate mainly from the left side of the heart, and these cases are-in principle-candidates for surgical resection. On the other hand, cases in which PFE originates from the right side of the heart are rare and reports are limited; thus, the surgical indication is unclear. We herein report a case of symptomatic PFE originating from the tricuspid valve of the heart. In this case, contrast enhanced computed tomography did not show pulmonary embolism; however, lung perfusion scintigraphy showed multiple perfusion defects. The patient was treated by anticoagulant therapy followed by surgical resection. Thereafter, the symptoms disappeared and the multiple perfusion defects improved on lung perfusion scintigraphy, demonstrating the efficacy of the anticoagulant therapy and surgical resection for PFE in the right side of the heart. .

Nanosized and metastable molybdenum oxides as negative electrode materials for durable high-energy aqueous Li-ion batteries.

The development of inherently safe energy devices is a key challenge, and aqueous Li-ion batteries draw large attention for this purpose. Due to the narrow electrochemical stable potential window of aqueous electrolytes, the energy density and the selection of negative electrode materials are significantly limited. For achieving durable and high-energy aqueous Li-ion batteries, the development of negative electrode materials exhibiting a large capacity and low potential without triggering decomposition of water is crucial. Herein, a type of a negative electrode material (i.e., Li x Nb2/7Mo3/7O2) is proposed for high-energy aqueous Li-ion batteries. Li x Nb2/7Mo3/7O2 delivers a large capacity of ∼170 mA ⋅ h ⋅ g-1 with a low operating potential range of 1.9 to 2.8 versus Li/Li+ in 21 m lithium bis(trifluoromethanesulfonyl)amide (LiTFSA) aqueous electrolyte. A full cell consisting of Li1.05Mn1.95O4/Li9/7Nb2/7Mo3/7O2 presents high energy density of 107 W ⋅ h ⋅ kg-1 as the maximum value in 21 m LiTFSA aqueous electrolyte, and 73% in capacity retention is achieved after 2,000 cycles. Furthermore, hard X-ray photoelectron spectroscopy study reveals that a protective surface layer is formed at the surface of the negative electrode, by which the high-energy and durable aqueous batteries are realized with Li x Nb2/7Mo3/7O2 This work combines a high capacity with a safe negative electrode material through delivering the Mo-based oxide with unique nanosized and metastable characters.

Capital and symbolic power in water quality governance: stakeholder dynamics in managing nonpoint sources pollution.

Maintaining quantity and quality is a primary concern in the supply of drinking water. One critical indicator of water quality is nonpoint sources (NPS) pollution. However, persistent risks regarding water quality maintenance have often resulted from compounded social dynamics occurring within and between institutions, while solutions tend to concentrate on scientific/technological treatments. The present study aims to analyse the social dynamics operating within and between such institutions, with a particular focus on the management of NPS pollution that involves the participation of headwater residents. A qualitative case study was conducted on the management of the headwater in Taipei metropolis. The study applied Bourdieu's field theory to understand the mechanism of social interaction and diverse interests among stakeholders. Through in-depth interviews with stakeholders, this research investigated their perceptions regarding various water quality threats and treatments, also mechanisms and gaps in the implementation of NPS pollution-related policies. The study then interpreted emerging issues by considering the stakeholders' various forms of capital input, their strategies in capital exchange and accumulation, as well as the diverse symbolic powers in water quality governance. The research indicates that the ambiguous character of NPS pollution leads to diverse perceptions towards water quality risk, and the ambivalent strategies in negotiation also create barriers to stable stakeholder relationships. Consequently, the research suggests that technocratic-centred governance should also contain sociological perspectives on personal mentality and power dynamic in the society.

Seasonal Variations in the Incidence of Ischemic Stroke, Extracranial and Intracranial Hemorrhage in Atrial Fibrillation Patients.

BACKGROUND: Ischemic stroke (IS) and major bleeding, which are serious adverse events in patients with atrial fibrillation (AF), could have seasonal variations, but there are few reports.Methods and Results:In the Shinken Database 2004-2016 (n=22,018), 3,581 AF patients (average age, 63.5 years; 2,656 men, 74.2%; 1,388 persistent AF, 38.8%) were identified. Median CHADS2and HAS-BLED scores were both 1 point. Oral anticoagulants were prescribed for 2,082 (58.1%) patients (warfarin, 1,214; direct oral anticoagulants [DOACs], 868). Incidence and observation period (maximum 3 years) of IS, extracranial hemorrhage (ECH), and intracranial hemorrhage (ICH) were counted separately for the northern hemisphere seasons. During the mean follow-up period of 2.4 years, there were totals of 90 IS, 73 ECH, and 33 ICH cases. The respective incidence rates per 1,000 patient-years in spring, summer, autumn, and winter were 8.5, 8.8, 7.5, and 16.8 for IS, 7.2, 9.7, 3.8, and 13.1 for ECH, and 2.7, 1.9, 3.8, and 7.0 for ICH. The number of patients with DOACs relatively increased among those with ECH in summer. CONCLUSIONS: Significant seasonal variations were observed for IS, ECH, and ICH events in AF patients, and were consistently the highest in winter. A small peak of ECH was observed in summer, which seemed, in part, to be related to increased DOAC use.

The Reconfigurable Maze Provides Flexible, Scalable, Reproducible, and Repeatable Tests.

Multiple mazes are routinely used to test the performance of animals because each has disadvantages inherent to its shape. However, the maze shape cannot be flexibly and rapidly reproduced in a repeatable and scalable way in a single environment. Here, to overcome the lack of flexibility, scalability, reproducibility, and repeatability, we develop a reconfigurable maze system that consists of interlocking runways and an array of accompanying parts. It allows experimenters to rapidly and flexibly configure a variety of maze structures along the grid pattern in a repeatable and scalable manner. Spatial navigational behavior and hippocampal place coding were not impaired by the interlocking mechanism. As a proof-of-principle demonstration, we demonstrate that the maze morphing induces location remapping of the spatial receptive field. The reconfigurable maze thus provides flexibility, scalability, repeatability, and reproducibility, therefore facilitating consistent investigation into the neuronal substrates for learning and memory and allowing screening for behavioral phenotypes.

Continuous Positive Airway Pressure Therapy Improves Heterogeneity of R-R intervals in a Patient with Obstructive Sleep Apnea Syndrome.

Obstructive sleep apnea (OSA) is associated with the occurrence of various kinds of bradyarrhythmia and tachyarrhythmia. The activation of the autonomic nerve system is an important causative factor of the pathogenesis of the arrhythmia in OSA patients. Previous studies have shown that the R-R interval is an effective parameter for evaluating autonomic nerve activities. However, whether or not OSA can induce variations in the R-R interval and whether or not continuous positive airway pressure (CPAP) therapy can improve these variations in OSA patients are unclear. The present study explored whether or not CPAP therapy could improve the regularity of the R-R interval.

Chemical and thermal properties of VO2 mechanochemically derived from V2O5 by co-milling with paraffin wax.

A novel mechanochemical reduction process of V2O5 to VO2 was established by milling with paraffin wax (PW, average molecular weight 254-646), serving as a reductant. The reduction progressed with increasing milling time and mass ratio V2O5 : PW (MRVP). The mechanochemically derived VO2 became phase pure after milling for 3 h with an MRVP of 30 : 1 and exhibited a reversible polymorphic transformation between tetragonal and monoclinic phases at around 53-60 °C and 67-79 °C during heating and cooling, respectively. The latent heat was above 20 J g-1 in both processes, being superior to those of commercial VO2. Doping of starting V2O5 with Cr, Mo or W at 1 at% in the form of oxide did not increase the latent heat. This is another difference from the conventionally prepared doped VO2. These anomalous heat storage properties of mechanochemically derived VO2 were discussed mainly on the basis of X-ray photoelectron spectroscopy V2p3/2 peaks combined with ion etching. The observed relatively high heat storage capacity of undoped VO2 is primarily ascribed to the abundance of V4+ ionic states introduced during milling with PW, which were stabilized with simultaneously introduced structural degradation throughout the entire particles. The possible role of a remaining small amount of PW was also discussed.

Three-port (one incision plus two-port) endoscopic mitral valve surgery without robotic assistance.

OBJECTIVES: Totally endoscopic minimally invasive mitral valve surgery (MIMVS) is technically demanding and often performed with robotic assistance. We hypothesized that three-port video-assisted thoracic surgery (VATS) would facilitate endoscopic MIMVS and evaluated its feasibility and safety. METHODS: From October 2010 to June 2016, we performed first-time MIMVS in 250 consecutive patients (122 male), with median age of 65 years (54-73 years, 25-75 percentile). The thoracic access ports comprised one small (3-5 cm) thoracotomy without a rib spreader plus two trocars (one for the endoscope and one for left-handed instruments), thus establishing triangular three-port VATS. Cannulas, an aortic clamp, and a left atrial retractor were inserted through the thoracotomy, and right-handed instruments were inserted through the remaining space. Cardiopulmonary bypass was established through a groin incision. RESULTS: The etiology of the mitral valve lesion was myxomatous degeneration in 70% of patients, rheumatic disease in 9%, infectious endocarditis in 6%, and other conditions in 15%. Mitral valve repair was performed in 233 patients and replacement in 27. Two patients underwent conversion to replacement after attempted repair. Forty-nine patients underwent tricuspid annuloplasty, and 45 underwent the Maze procedure. One in-hospital death occurred within 30 days. Two patients developed stroke, three underwent re-exploration for bleeding, one developed low output syndrome, and one required new haemodialysis. The aortic clamp, bypass, and total operation times were 119 (94-149), 166 (134-200) and 237 (204-285) min, respectively, median (25-75%). The 5-year survival and reoperation-free rates were 98.3% ± 0.9% and 96.9% ± 1.2%, respectively. CONCLUSIONS: Three-port endoscopic MIMVS appears reproducible and safe.

Prognosis of severe carpal tunnel syndrome with absent compound muscle action potential.

INTRODUCTION: Opponensplasty is a surgical option for patients with severe carpal tunnel syndrome (CTS). We investigated prognostic factors of patients who lack a preoperative compound muscle action potential (CMAP) of the abductor pollicis brevis (APB) muscle to determine the necessity for single-stage opponensplasty. METHODS: We retrospectively enrolled 22 hands of 22 CTS patients. Prognostic factors considered were age, diabetes mellitus, the median sensory nerve action potential, distal motor latency of the second lumbrical (2L) CMAP (2L-DML), and its amplitude (2L-Amp). Postoperative APB-CMAP amplitude (post APB-Amp) at 12 months was used as the outcome measure. RESULTS: Only 2L-DML showed a significant correlation with post APB-Amp (r = -0.56). The contribution of 2L-Amp was not significant, although 3 hands with absent 2L-CMAP had a poor electrophysiological recovery. CONCLUSIONS: Prolonged 2L-DML and absent 2L-CMAP seem to be poor prognostic factors. Concurrent opponensplasty may not be necessary in patients with 2L-DML of 8 ms or less. Muscle Nerve 54: 427-431, 2016.

A Simple, Effective, and Inexpensive Technique for Exposure of Papillary Muscles in Minimally Invasive Mitral Valve Repair: Wakka Technique.

Obtaining excellent exposure of the papillary muscles is challenging in minimally invasive mitral valve repair. We have developed a simple and effective technique using a sterile paper ruler. The ruler is cut to the proper length (8 to 12 cm) depending on the valve size, then rolled and sutured. The rolled ruler, 7 to 11 cm in circumference, is placed inside the mitral leaflets. This technique provides excellent exposure of the papillary muscles without damaging the leaflets and prevents chordal injury during artificial chordal implantation.

Outcomes of video-assisted minimally invasive approach through right mini-thoracotomy for resection of benign cardiac masses; compared with median sternotomy.

BACKGROUND: We performed a retrospective study of patients who underwent a video-assisted minimally invasive right mini-thoracotomy approach for cardiac benign tumor resection compared with median sternotomy. METHODS: Of 23 patients who underwent isolated benign cardiac mass resection at the Japanese Red Cross Nagoya Daiichi Hospital from 2001 to 2014, 16 patients were treated through median sternotomy and seven were operated through right mini-thoracotomy. RESULTS: No hospital deaths occurred. The duration of operation, cardiopulmonary bypass time, and aortic clamp time showed no significant differences. Although the postoperative intubation time and intensive care unit stay time did not differ significantly between the groups, the duration of hospital stay was significantly shorter in the minimally invasive group (17.5 ± 5.6 vs. 10.4 ± 1.5 days; p = 0.004). All of the patients except two were followed to the late phase (late follow-up rate, 91.3%), for a mean duration of 4.7 ± 3.7 years. There were two late deaths in the sternotomy group and no recurrences in either group during the follow-up period. CONCLUSIONS: We concluded that the clinical outcome of the minimally invasive technique for myxoma resection was acceptable and the technique is feasible.

[Reoperative cardiac surgery after previous coronary artery bypass grafting].

Reoperative cardiac surgery after coronary artery bypass grafting( CABG) has been increasing. We reviewed 25 cases of reoperative cardiac surgery after CABG. Re-CABG was not included in this study. The patients consisted of 15 men and 10 women. The mean patient age was 74.4±6.3 years old. The reoperations were performed 6.3±5.1 years after CABG. They consisted of 7 aortic valve surgeries, 2 double valve surgeries, 12 mitral valve surgeries, and 4 total arch replacements. Resternotomy was performed in 20 cases, while right thoracotomy was performed in 5 cases. Internal thoracic artery( ITA)grafts had been used in 24 cases, and 22 of them were patent. Fifteen operations were performed under cardioplegic arrest with the patent ITA graft clamped from the left pleural space, while 5 operations were performed under perfused ventricular fibrillation with hypothermia. No differences were observed between the 2 groups in terms of cardiopulmonary bypass (CPB) time and peak creatine kinase MB (CK-MB). Operative mortality was 4% (1/25). To clamp left internal thoracic artery (LITA) graft from the left pleural space is easy and safe. In case clamping the patent graft is difficult, perfused ventricular fibrillation with hypothermia is a useful alternative.

Seamless reconstruction of mitral leaflet and chordae with one piece of pericardium.

OBJECTIVES: Mitral valve repair is challenging when enough pliable mitral leaflets and chordae are not left intact because of extensive infective endocarditis or chronic sclerotic degeneration. For those cases, we developed a simple method to reconstruct defective leaflets and chordae en bloc with a piece of pericardium, and the mid-term results were evaluated. METHODS: From January 2009 to November 2013, 25 patients with the mean age of 63 (range 20-88) years underwent this operation. The causes of mitral regurgitation were infective endocarditis in 8, sclerotic degeneration in 8, leaflet dehiscence of previous repair in 2, mitral annular calcification in 3, rheumatic in 2 and congenital in 2. After complete debridement of infected or consolidated tissue, we reconstructed defective mitral leaflets and chordae en bloc with a piece of glutaraldehyde-treated autologous pericardium. To substitute posterior leaflet and chordae, the pericardium was trimmed into a narrow pentagonal shape. The pointed end was attached directly to the corresponding papillary muscle, basal side edges to remnant leaflets on both sides, and the base to the annulus. For anterior leaflet, the pericardium was trimmed into a triangular shape if the lesion was confined in the left or right half or into a double-triangle shape if the lesion involved whole anterior leaflet. The summit of triangle was fixed to corresponding papillary muscle, and the base to remnant anterior leaflet, thus reconstructing coaptation zone and chordae seamlessly. RESULTS: There was no hospital death, and mitral regurgitation at discharge was none or trivial in all patients. During 1-59 months (mean 12.7) of complete follow-up, death, infection or hemolysis was not observed. In one patient, mitral regurgitation recurred 8 months postoperatively because the fixation suture of the pericardium to the papillary muscle broke. The valve was re-repaired with re-attaching the leg of the pericardium. Regurgitation was less than moderate in all other patients. One patient with rheumatic lesion who underwent anterior leaflet repair and Maze operation suffered minor stroke 1 month postoperatively but fully recovered. CONCLUSIONS: Seamless reconstruction of leaflets and chordae with pericardium seemed promising to repair extensively destructed mitral valve.

[Measures to prevent patient identification errors in blood collection/physiological function testing utilizing a laboratory information system].

We constructed an integrated personal identification workflow chart using both bar code reading and an all in-one laboratory information system. The information system not only handles test data but also the information needed for patient guidance in the laboratory department. The reception terminals at the entrance, displays for patient guidance and patient identification tools at blood-sampling booths are all controlled by the information system. The number of patient identification errors was greatly reduced by the system. However, identification errors have not been abolished in the ultrasound department. After re-evaluation of the patient identification process in this department, we recognized that the major reason for the errors came from excessive identification workflow. Ordinarily, an ultrasound test requires patient identification 3 times, because 3 different systems are required during the entire test process, i.e. ultrasound modality system, laboratory information system and a system for producing reports. We are trying to connect the 3 different systems to develop a one-time identification workflow, but it is not a simple task and has not been completed yet. Utilization of the laboratory information system is effective, but is not yet perfect for patient identification. The most fundamental procedure for patient identification is to ask a person's name even today. Everyday checks in the ordinary workflow and everyone's participation in safety-management activity are important for the prevention of patient identification errors.

[Ascending aorta replacement late after aortic valve replacement].

Replacement of the asceding aorta is indicated in patients undergoing aortic valve replacement( AVR), if the diameter of the ascending aorta is greater than 5.0 cm. If the diameter of the asceding aorta is from 4.0 to 5.0 cm, it was arguable whether replacement of the ascending aorta should be performed. Nine patients who underwent reoperative ascending aorta replacement after AVR were reviewed retrospectively. Reoperation on the asending aorta replacement was performed 11.8±7.2 years (range 1y5m~23y3m) after AVR. Mean patient age was 69.9±6.3 (range 60~81). In 2 cases, reoperations were performed early year after AVR. Although ascending aorta was dilated at the 1st operation, replacement wasn't performed for the age and minimally invasive cardiac surgery (MICS). In 3 cases, reoperations were performed more than 10 years later. On these cases, ascending aorta aneurysm and dissection occurred with no pain and were pointed out by computed tomography(CT) or ultrasonic cardiogram(UCG). We think that patients with dilatation of the ascending aorta should undergo AVR and aorta replacement at the 1st operation regardness of age. It is important that patients who underwent AVR should undergo a regular checkup on the ascending aorta.

Right infraaxillary thoracotomy for minimally invasive aortic valve replacement.

Minimally invasive aortic valve replacement has been performed via partial sternotomy, the parasternal approach, and anterior intercostal approaches. We successfully performed aortic valve replacement through a small right infraaxillary thoracotomy in 25 patients, with the aid of a thoracoscope and a knot-pusher. The patients were 9 men and 16 women with a mean age of 72.6 years. Our approach had better cosmetic results than traditional approaches through the anterior chest wall. This method did not require rib transection or sacrifice of the internal thoracic artery.