Detection of space-time clusters using a topological hierarchy for geospatial data on COVID-19 in Japan.

In this paper, we detected space-time clusters using data on coronavirus disease 2019 (COVID-19) collected daily by each prefecture in Japan. COVID-19 has spread globally since the first confirmed case in China, in December 2019. Several people have to date been infected in Japan since the first confirmed case in January 2020. The outbreak of COVID-19 has had a significant impact on many people's lives. Studies are being conducted to detect regions, called clusters, which pose a significantly higher risk of infection than their surrounding areas, based on a spatial scan statistics of COVID-19 infections. Among these studies, space-time cluster detection has to date been actively performed to gain knowledge regarding infection status. Based on the spatial scan statistic, the cylindrical scan method is a widely used space-time cluster detection method. This method enables concurrent detection of the location and time of a cluster occurrence. However, this method cannot capture spatial changes in a cluster over time. When applying the existing method to a cluster whose shape changes over time, the number of calculations required becomes extremely large, and the analysis may become difficult. In this study, we focused on the hierarchical structure of the data obtained by conducting an echelon analysis and applied the space-time cluster detection method based on this structure to enable the capture of changes in a cluster's shape. Furthermore, we visualized the location and period of a cluster's occurrence and considered the cause of the cluster.

Comparative assessment of 24-hr primary skin irritation test and human patch test data with in vitro skin irritation tests according to OECD Test Guideline 439 (for quasi-drugs in Japan).

The Organisation for Economic Co-operation and Development (OECD) Test Guideline (TG) 439 is an in vitro test method of reconstructed human epidermis (RhE), which was developed for hazard identification of irritating chemicals in accordance with a primary skin irritation test using rabbits with 4-hr exposure. A regulation for quasi-drugs in Japan requires data from primary skin irritation tests using rabbits to undergo 24-hr exposure, and this is used as an evidence for 24-hr closed patch tests in humans. In this study with the same chemicals, primary skin irritation test data using rabbits undergoing 24-hr exposure and a 24-hr occlusive human patch test data were analyzed by comparing the results obtained with four test methods adopted in OECD TG 439. The performances of in vitro test methods showed a positive predictive value of 72.7-85.7% to predict the results of 24-hr primary rabbit skin irritation test knowing that its positive predictive value was 57.1% against humans only. The prediction factors of in vitro test methods were higher for the human patch test data with a sensitivity reaching 60 to 80%. Three surfactants gave false negatives in some of the RhE methods evaluated with the human patch test, but in each case, they were correctly classified as positive when evaluated at double concentration. Therefore, the approach of setting the margin to 2 was effective in eliminating false negatives. This suggests that in vitro test methods are useful for assessing skin irritation potential without animal testing for the application of quasi-drugs in Japan.

Clinical Usefulness of Corticotropin Releasing Hormone Testing in Subclinical Cushing's Syndrome for Predicting Cortisol Replacement after Adrenalectomy.

PURPOSE: The purpose of this study was to investigate the clinical and hormonal features of patients with incidentally discovered adrenal adenomas in relation to corticotropin releasing hormone (CRH) testing and the clinical outcome of adrenalectomy. MATERIALS AND METHODS: Twenty-three consecutive patients with incidentally detected adrenal adenomas were included in this retrospective study. All the patients underwent abdominal computed tomography scans and hormonal assays, including assessment of circadian rhythms of plasma cortisol and corticotropin (adrenocorticotropic hormone, ACTH), a corticotropin stimulation test, and low-dose and high-dose dexamethasone tests. The patients were reevaluated at regular intervals (6, 12, and 24 months) for a median period of 24 months. Subclinical Cushing's syndrome (SCS) was diagnosed in patients with subtle hypercortisolism who did not present clinical signs of Cushing's syndrome. RESULTS: We calculated the responsive index (peak value of ACTH in CRH test/baseline value of ACTH in CRH test). Of 23 patients, 6 had Cushing's syndrome, 8 had SCS, and 9 had a non-functioning tumor. All patients underwent laparoscopic adrenalectomy. Several patients (5 of 6 with Cushing's syndrome and 2 of 8 with SCS) required cortisol replacement therapy after surgery. The remaining patients required no hormonal replacement after surgery. Those who required hormone replacement had a responsive index of less than 1.2. Those who did not need hormone replacement therapy had a responsive index of more than 2.0. CONCLUSIONS: In our limited experience, the responsive index of the CRH test might be a valuable tool for predicting the need for cortisol replacement after surgery in patients with SCS.

Discriminant analysis of native thoracic aortic curvature: risk prediction for endoleak formation after thoracic endovascular aortic repair.

PURPOSE: To determine the association of native thoracic aortic curvature measured from computed tomographic (CT) angiography categorized by discriminant analysis with the development of endoleaks after thoracic endovascular aortic repair (EVAR). MATERIALS AND METHODS: Forty patients (28 men, 12 women; mean age, 74 y; range, 40-89 y) with aortic diseases treated with thoracic EVAR were evaluated. Diseases treated included atherosclerotic aneurysm (n = 27), penetrating atherosclerotic ulcer (n = 4), intramural hematoma (n = 3), mycotic aneurysm (n = 3), and anastomotic pseudoaneurysm (n = 3). Quantitative analysis of native aortic morphology was performed on preprocedural CT angiograms with an original customized computer program, and regional curvature indices in each anatomic segment of the aorta were calculated. Patterns of native thoracic aortic morphology were analyzed by discriminant analysis. The association between the morphologic pattern of the aorta and the presence and type of endoleak was assessed. RESULTS: After leave-one-out cross-validation methods had been applied, the sensitivity, specificity, and accuracy to detect endoleak formation in a new population group by discriminant analysis of the patterns of native aortic curvature were estimated as 84.0%, 58.8%, and 73.8%, respectively. Compared with the no-endoleak group, the type Ia endoleak group had greater curvature at the aortic arch, the type Ib endoleak group had greater curvature at the thoracoabdominal junction, and the type III endoleak group had greater curvature in the midportion of the descending aorta. CONCLUSIONS: Discriminant analysis of native thoracic aortic morphology measured from CT angiography is a useful tool to predict the risk of endoleak formation after thoracic EVAR and should be implemented during treatment planning and follow-up.

Anesthesia for extracorporeal shockwave lithotripsy: Teikyo University Hospital experience using the third generation lithotripter.

A single-board certified urologist with training and experience in anesthesiology was assigned to treat 502 patients (185 with renal stones, 317 with ureteral stones) using the Dornier Compact Delta lithotripter under general or epidural anesthesia. Data were obtained regarding stone location, stone size, shockwave use, stone-free rate, and complications. In all, 502 stones were treated with the Dornier Compact Delta lithotripter. Among renal stones, 73% were in the renal pelvis. Among ureteral stones, 60% were in the upper, 10% in the middle, and 30% in the lower ureter. Diameters of 61.8% of stones were less than 1 cm. The mean number of shocks was 3,471 at a mean power setting of 5. The stone-free rate for renal stones was 71.5%, while for ureteral stones this reached 99%. The efficiency quotient was calculated as 0.65. One patient with a renal stone developed perinephric hematoma requiring 3 units of transfusion. With a success rate higher than that reported for other lithotripters, the Dornier Compact Delta lithotripter represents a feasible treatment for urolithiasis. We stress that even in the third generation machines the lithotripsy under anesthesia can improve the treatment efficacy.

[A case of a giant adrenal myelolipoma in a man with spinal cord injury].

A 38-year-old man in a wheelchair for spinal cord injury from a traffic accident was referred to our hospital with complaint of dull right flank pain. The patient had a history of skin ulcer formation on both toes due to poor circulation. Abdominal ultrasonography and computed tomographic scan revealed a huge retroperitoneal tumor compressing the right kidney. Serum levels of cortisol, adrenocorticotropic hormone, aldosterone, adrenalin, noradrenalin, urinary levels of vanillylmandelic acid, homovanillic acid, 17-ketosteroid and 17-hydroxycorticosteroid were all within normal limits. Combining all preoperative diagnostic information, the possibility of retroperitoneal liposarcoma could not be thoroughly ruled out. The patient consented to undergo resection of the tumor with the right kidney. Prior to the scheduled operation simulation of the positioning on the operation table was done to evaluate the compressing pressure. During operation decompressing pads were used to minimize the compressing pressure and intermittent pneumatic compression was also used to prevent pressure ulcer and facilitate circulation to the lower extremities. Five thousands units of heparin (FragminR, Pfizer, USA) was used daily to prevent deep vein thrombosis until the patient could use his wheelchair. Perioperative rehabilitation was conducted by a team of physical therapists. The excised tumor weighed 1,320 g. Pathologic diagnosis was an adrenal myelolipoma. Convalescence was uneventful and the patient was discharged on the 10th post operative day. Between 1992 and 2006, 80 cases of adrenal myelolipoma were reported in Japan. Our case was found to be the second largest one. We reviewed these 80 cases and discussed the diagnosis and treatment strategy of the adrenal myelolipoma. We also discussed the perioperative management for patients with spinal cord injury.

[Clinico-statistical analysis of renal cell carcinomas in patients on hemodialysis].

Eleven patients on hemodialysis that were surgically treated for renal cell carcinomas during the recent 10 years at our institutes were clinically analyzed. Patients' ages at presentation ranged from 35 to 70 years with an average of 54.8 years. Nine of the 11 patients were males and 2 were females. Periods between the introduction of hemodialysis and the presentation ranged from 1 to 21 years with an average of 11.7 years. The most frequent cause of hemodialysis was chronic glomerulonephritis. Five patients presented with macroscopic hematuria, which was the most frequent clinical manifestation. Transperitoneal nephrectomy through a lumbar oblique incision was performed in 9 of 12 surgical procedures. Transperitoneal resection and retroperitoneal endoscopic resection were performed on 2 patients and 1 patient, respectively. Blood transfusion was performed on 2 patients with retroperitoneal hemorrhage before or after operation and 2 patients with pre-existing renal anemia. Pathologically, 9 patients had pT1a disease. Patients were followed up for up to 7 years and 11 months. One patient died of the disease and 2 patients died of unknown causes. In conclusion, surgical removal of renal cell carcinomas was well tolerated, safe and effective treatment in patients under hemodialysis.