Practical use of the central venous access port for contrast-enhanced CT: comparison with peripheral intravenous access regarding enhancement and safety.

AIM: To evaluate the efficacy of using the central venous (CV) port compared with peripheral intravenous access for contrast-material injection for contrast enhancement during the portal venous phase. MATERIALS AND METHODS: Patients were divided into three groups: CV delay, CV routine, and peripheral access (PA) groups. Patients in the CV delay group underwent injection in the arm-down position with an additional delay, while those in the CV routine and PA groups underwent injections with the routine injection protocol for portal venous phase imaging. Contrast enhancement was evaluated by measuring the mean radiodensity (Hounsfield units) values for the aortic arch, abdominal aorta, inferior vena cava, portal vein, and spleen. The peak injection pressure was recorded and compared among the three groups. RESULTS: No complications related to power injection were observed during 119 contrast-material injections performed using the CV port device. The CV delay group showed significantly lower radiodensity values than the PA group (165.7 ± 20.1 versus 181 ± 19 HU [p<0.01] for the portal vein); however, no significant differences in mean radiodensity values were observed between the CV routine and PA groups (p>0.05). The median peak injection pressure was 73.5, 67, and 47 psi in the CV delay, CV routine, and PA groups, respectively (p<0.01). CONCLUSION: The CV port can be used for safe contrast-material injection while maintaining contrast enhancement on portal venous phase comparable to that achieved with peripheral intravenous access.

A de novo 2.3 kb structural variant in MITF explains a novel splashed white phenotype in a Thoroughbred family.

Splashed white in horses is characterized by extensive white patterning on the legs, face and abdomen and may be accompanied by deafness. To date, seven variants in microphthalmia-associated transcription factor (MITF) and two variants in Paired Box 3 (PAX3) have been identified to explain this phenotype. A splashed white Thoroughbred stallion, whose sire and dam were not patterned, was hypothesized to have a de novo variant leading to his white coat pattern. A whole-genome sequencing candidate gene approach identified two single nucleotide variants (SNVs) in SOX10, four SNVs in MITF and a 2.3 kb deletion in MITF with the alternative allele present in this stallion but absent in the other 18 horses analyzed. All six SNVs were annotated as modifiers and were not further considered. The deletion in MITF (NC_009159.3:g.21555811_21558139delinsAAAT) encompasses exon 9 encoding a part of the helix-loop-helix domain required for DNA binding. Sanger sequencing and parentage testing confirmed that this deletion was a de novo mutation of maternal origin. Consistent with the published nomenclature, we denote this likely causal variant as SW8. Genotyping three of this stallion's offspring identified SW8 only in the nearly all-white foal that was confirmed deaf by brainstem auditory evoked response testing. This foal was also a compound heterozygote for dominant white variants (W20/W22), but to date, W variants alone have not been connected to deafness. SW8 marks the fourth de novo MITF variant in horses reported to cause white patterning. The link between deafness and all MITF variants with and without other variants impacting melanocyte development and function needs to be further explored.

Importance of internal vaginal pelvic floor muscle exams for women with external lumbar/hip/pelvic girdle pain.

INTRODUCTION AND HYPOTHESIS: The relationship between external lumbar, hip, and/or pelvic girdle pain and internal vaginal pelvic floor myofascial pain is not well described. We assessed this relationship in a cohort of adult women. METHODS: The cohort included women ≥ 18 years old who received care for external lumbar, hip, and/or pelvic girdle pain (reported or elicited on physical examination) who then underwent internal vaginal myofascial levator ani pain assessments, in a tertiary care Female Pelvic Medicine and Reconstructive Surgery pelvic pain clinic over a 2-year period (2013 and 2014). RESULTS: The cohort of 177 women had an average age of 44.9±16.0 years, an average body mass index of 27.2±7.0 kg/m2, and the majority (79.2%) were white. Most patients presented with a chief complaint of pelvic (51.4%), vulvovaginal (18.6%), and/or lumbar (15.3%) pain. Women who reported symptoms of lumbar, hip, or pelvic girdle pain were more likely to have pain on vaginal pelvic floor muscle examination than women without this history (OR, 7.24; 95% CI, 1.95-26.93, p=0.003). The majority (85.9%) of women had bilateral internal vaginal pelvic floor myofascial pain on examination. CONCLUSIONS: Although participants did not describe "vaginal pelvic floor myofascial pain," the high detection rate for internal vaginal pelvic floor myofascial pain on clinical examination highlights an opportunity to improve treatment planning. These findings suggest that the vaginal pelvic floor muscle examination should be part of the assessment of all women with lumbar, hip, and/or pelvic girdle pain. The relationship between this finding and clinical outcomes following directed treatment warrants additional study.

Proton Distribution Radii of

The root mean square radii of the proton density distribution in ^{16-24}O derived from measurements of charge changing cross sections with a carbon target at ∼900A MeV together with the matter radii portray thick neutron skin for ^{22-24}O despite ^{22,24}O being doubly magic. Imprints of the shell closures at N=14 and 16 are reflected in local minima of their proton radii that provide evidence for the tensor interaction causing them. The radii agree with ab initio calculations employing the chiral NNLO_{sat} interaction, though skin thickness predictions are challenged. Shell model predictions agree well with the data.

Absence of the Anterior Communicating Artery on Selective MRA is Associated with New Ischemic Lesions on MRI after Carotid Revascularization.

BACKGROUND AND PURPOSE: ICA-selective MRA using a pencil beam presaturation pulse can accurately visualize anterior communicating artery flow. We evaluated the impact of anterior communicating artery flow on the perioperative hemodynamic status and new ischemic lesions after carotid revascularization. MATERIALS AND METHODS: Eighty-three patients with carotid artery stenosis were included. We assessed anterior communicating artery flow using ICA-selective MRA. The preoperative hemodynamic status was measured using SPECT. We also measured the change in regional cerebral oxygen saturation after temporary ICA occlusion. New ischemic lesions were evaluated by DWI on the day after treatment. RESULTS: Anterior communicating artery flow was detected in 61 patients, but it was not detected in 22 patients. Preoperative cerebrovascular reactivity was significantly higher in patients with (versus without) anterior communicating artery flow with a mean peak systolic velocity of ≥200 cm/s (39.6% [SD, 23.8%] versus 25.2% [SD, 16.4%]; P = .030). The decrease in mean regional cerebral oxygen saturation was significantly greater in patients without (versus with) anterior communicating artery flow (8.5% [SD, 5.6%] versus 3.7% [SD, 3.8%]; P = .002). New ischemic lesions after the procedure were observed in 23 patients. The multivariate logistic regression analysis revealed that anterior communicating artery flow (OR, 0.07; 95% CI, 0.012-0.45; P = .005) was associated with new ischemic lesions. CONCLUSIONS: The absence of anterior communicating artery flow influenced the perioperative hemodynamic status in patients with carotid stenosis and was associated with an increased incidence of new ischemic lesions after carotid revascularization.

A preoperative prognostic nutritional index is a prognostic indicator in oral squamous cell carcinoma patients undergoing radical surgery.

The purpose of this study was to investigate the prognostic value of prognostic nutritional index (PNI) in oral squamous cell carcinoma (OSCC) patients and to undertake a comparative evaluation of the prognostic value of comparing PNI, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and lymphocyte-to-monocyte ratio (LMR) in terms of prognostic utility. A retrospective study was conducted involving 203 consecutive patients with OSCC who were treated with radical surgery with curative intent. The PNI and systemic inflammatory response were developed, and their prognostic utility was evaluated. Kaplan-Meier curve analysis and log-rank testing showed that PNI (P< 0.001), NLR (P=0.011), PLR (P=0.013), and LMR (P=0.014) were significantly associated with overall survival. Multivariate analysis identified PNI as an independent prognostic factor for OSCC patients (P=0.029). In time-dependent receiver operating characteristic curve analysis, PNI was continuously superior to that of NLR, PLR, and LMR. In conclusion, this study suggested that PNI offered an independent prognostic biomarker in OSCC patients undergoing radical surgery. However, this study was small and retrospective, thus further investigations are needed to clarify the utility of PNI for tailor-made treatments in clinical settings.

Cervical carcinoma in the setting of uterovaginal prolapse: comparing standard versus tailored management.

OBJECTIVES: Cervical cancer in the setting of uterovaginal prolapse is exceedingly rare. Altered anatomy can complicate treatment of underlying cancer. We first present a rare case of cervical cancer with invasion of uterovaginal prolapse as well as a systematic review of similar reported cases in the literature. The objective of this study was to compare the practice patterns and outcomes regarding cervical cancer with invasion of procidentia. METHODS: We conducted a systematic search of online databases (PubMed, Embase, Medline and the Cochrane Library) from 1990 to 2018 of all the cases of cervical cancer associated with stage III-IV uterovaginal prolapse. Patient demographics, pathology, surgical management, chemotherapy, radiation and disease-free survival were compared. RESULTS: Fifteen reported cases of cervical cancer in the setting of procidentia were identified (squamous cell carcinoma-14, clear cell carcinoma-1). The mean age at diagnosis was 74 years (range 54-89). Thirteen percent (n = 2) of cases presented with FIGO stage I disease, 67% (n = 10) with stage II, and 20% (n = 3) with stage III. All cases had stage III-IV uterovaginal prolapse. 73% (11) were treated surgically including nine patients who underwent vaginal hysterectomy. Among patients who underwent primary surgery, 7% (1) received adjuvant chemotherapy, 33% (5) adjuvant radiotherapy and 21% (3) both adjuvant chemotherapy and radiation. 33% (5) of surgical cases included procedures to address the pelvic organ prolapse (colpoclesis (n = 3), uterosacral suspension (n = 1) and anterior posterior repair (n = 1)). Two patients died from the disease within 12 months, one patient died from other causes within 1 month, and the remainder of patients were free of disease at last reported follow-up (Table 1). CONCLUSIONS: Cervical cancer in the setting of stage III-IV uterovaginal prolapse can be managed successfully with standard treatment strategies (primary surgery with adjuvant therapy as necessary versus chemoradiation). When patients are surgical candidates, techniques to address the underlying prolapse can be used for symptomatic improvement.

Screening for Microscopic Hematuria in a Urogynecologic Population.

OBJECTIVES: The objectives of this were to determine the correlation of greater than or equal to 3 red blood cells per high-power field (RBCs/HPF) with a positive urine dipstick for blood and to identify clinically relevant factors than can influence this relationship. METHODS: The charts of women with positive blood urine dipsticks were reviewed from August 2012 to August 2013. The cohort of women was divided into 2 groups; those with urine with greater than or equal to 3 RBCs/HPF on microscopy and those without. Relevant clinical and demographic variables were extracted from the electronic medical record. Data analysis was conducted using SAS version 9.4 (SAS Institute, Cary, NC). RESULTS: Most of the 203 patients eligible for analysis were Caucasian, and the total cohort had a mean age of approximately 62.8 years. Microscopy confirmed greater than or equal to 3 RBCs/HPF in 25.6% of the urine samples. A dipstick finding of moderate or large blood was significantly more likely to have greater than or equal to 3 RBCs/HPF on univariate and multivariable analyses (P < 0.001). Factors significantly associated with greater than or equal to 3 RBCs/HPF were increasing age, recurrent urinary tract infections, and urinary specific gravity of greater than 1.010. CONCLUSIONS: Lower urinary specific gravities appear to be associated with underestimating microhematuria, likely owing to the underrepresentation of the true number of red blood cells. Urine dipstick indicators of moderate or large blood increase the likelihood the microscopy samples demonstrated greater than or equal to 3 RBCs/HPF. These findings suggest that clarification of microhematuria detection and evaluation guidelines should be considered, given both important clinical and economic consequences.

Relationship between dietary patterns and stunting in preschool children: a cohort analysis from Kwale, Kenya.

OBJECTIVES: Stunting is a significant cause of poor cognitive performance and lower school achievement. Stunting is observed among pre-school children in several areas in Africa; however, not all children are affected, and children with and without stunting are seen in the same communities. Therefore, this study aimed to identify nutritional and other factors that prevent stunting that may exist in local communities. STUDY DESIGN: This is a prospective cohort study. METHODS: Data were extracted from the Health and Demographic Surveillance System conducted in Kwale County, Kenya. The cohort consisted of all households with children less than five years old, within a radius of 2.2 km from a local health centre. A dietary pattern (DP) survey with a semi-quantitative food frequency questionnaire was conducted on caretakers of children who were voluntary participated from the cohort between June 2012 and August 2012. Using cluster analysis, the children were assigned to a DP group. Logistic regression analysis was applied to calculate the adjusted odds ratios (aORs) of DPs for stunting controlling for other factors. RESULTS: In total, 402 children were included in the analysis. By cluster analysis, three DPs were identified: protein-rich DP; traditional DP; and traditional DP complemented by breastfeeding. The aOR of a child becoming stunted from a normal height during the study period among children who received a traditional DP compared with those who had a protein-rich DP was 2.78 (95% confidence interval [CI]: 1.02-7.55). However, the aOR for children who were already stunted at the start of the study and had a traditional DP was 1.49 (95% CI: 0.82-2.72). Increased aORs of stunting were observed among children aged over 12 months compared with children aged 6-11 months, and the effects of DPs were modified by age in months from 12 to 35 months; however, the effects were near the null value for children over 36 months of age, although these were not statistically significant. CONCLUSIONS: We found that the traditional DP showed a higher risk for stunting compared with the protein-rich DP, and the most vulnerable age range for stunting was between 12 and 35 months. Interventions to prevent stunting should focus on providing 12- to 35-month-old children with locally available, protein-rich foods.

Patients' Knowledge of and Attitude Toward Robotic Surgery for Pelvic Organ Prolapse.

OBJECTIVES: Robotic sacrocolpopexy for pelvic organ prolapse (POP) has increased, along with marketing and media coverage. It is unknown whether this exposure influences patients' opinions on POP repair. This study describes the preference for and knowledge of robotic surgery in women with POP. METHODS: We performed a cross-sectional survey of new patients presenting with POP at 7 academic sites. Subjects had no prior surgical counseling. A self-administered questionnaire was designed to investigate robotic surgery knowledge, preference, and exposure. Subjects expressed their preferred route of POP repair (robotic, vaginal, abdominal, laparoscopic, or no preference). Knowledge was determined by the number of correctly answered questions (range, 0-7). Perception of robotic surgery was compared with other surgical routes. RESULTS: One hundred seventy-six subjects were included. Most had no surgical preference (66.3%), whereas 27.3% preferred nonrobotic and 6.4% preferred robotic routes. The mean knowledge score was 2.3 (SD, 1.7). Women preferring robotic surgery were more likely to view it as faster than laparoscopic surgery (P < 0.001). These same subjects did not perceive any advantages for robotic surgery related to blood loss, pain, and organ injury (P > 0.05). Most reported no prior exposure to robotic surgery information (56.2%) or advertisements (65.2%). Those with prior exposure most frequently obtained information via the Internet and encountered hospital advertisements. CONCLUSIONS: The majority of women with POP reported no preference for robotic approach to POP surgery. Knowledge about robotic surgery was low, even among subjects who expressed preference. Comprehensive counseling may help patients make informed decisions even when surgical preferences exist.

Evidence for prevalent Z = 6 magic number in neutron-rich carbon isotopes.

The nuclear shell structure, which originates in the nearly independent motion of nucleons in an average potential, provides an important guide for our understanding of nuclear structure and the underlying nuclear forces. Its most remarkable fingerprint is the existence of the so-called magic numbers of protons and neutrons associated with extra stability. Although the introduction of a phenomenological spin-orbit (SO) coupling force in 1949 helped in explaining the magic numbers, its origins are still open questions. Here, we present experimental evidence for the smallest SO-originated magic number (subshell closure) at the proton number six in 13-20C obtained from systematic analysis of point-proton distribution radii, electromagnetic transition rates and atomic masses of light nuclei. Performing ab initio calculations on 14,15C, we show that the observed proton distribution radii and subshell closure can be explained by the state-of-the-art nuclear theory with chiral nucleon-nucleon and three-nucleon forces, which are rooted in the quantum chromodynamics.

Viral eradication reduces both liver stiffness and steatosis in patients with chronic hepatitis C virus infection who received direct-acting anti-viral therapy.

BACKGROUND: Whether direct-acting anti-viral therapy can reduce liver fibrosis and steatosis in patients with chronic hepatitis C virus (HCV) infection is unclear. AIMS: To evaluate changes in liver stiffness and steatosis in patients with HCV who received direct-acting anti-viral therapy and achieved sustained virological response (SVR). METHODS: A total of 198 patients infected with HCV genotype 1 or 2 who achieved SVR after direct-acting anti-viral therapy were analysed. Liver stiffness as evaluated by magnetic resonance elastography, steatosis as evaluated by magnetic resonance imaging-determined proton density fat fraction (PDFF), insulin resistance, and laboratory data were assessed before treatment (baseline) and at 24 weeks after the end of treatment (SVR24). RESULTS: Alanine aminotransferase and homeostatic model assessment-insulin resistance levels decreased significantly from baseline to SVR24. Conversely, platelet count, which is inversely associated with liver fibrosis, increased significantly from baseline to SVR24. In patients with high triglyceride levels (≥150 mg/dL), triglyceride levels significantly decreased from baseline to SVR24 (P = 0.004). The median (interquartile range) liver stiffness values at baseline and SVR24 were 3.10 (2.70-4.18) kPa and 2.80 (2.40-3.77) kPa respectively (P < 0.001). The PDFF values at baseline and SVR 24 were 2.4 (1.7-3.4)% and 1.9 (1.3-2.8)% respectively (P < 0.001). In addition, 68% (19/28) of patients with fatty liver at baseline (PDFF ≥5.2%; n = 28) no longer had fatty liver (PDFF <5.2%) at SVR24. CONCLUSION: Viral eradication reduces both liver stiffness and steatosis in patients with chronic HCV who received direct-acting anti-viral therapy (UMIN000017020).

Urine trouble: should we think differently about UTI?

Urinary tract infection (UTI) is clinically important, given that it is one of the most common bacterial infections in adult women. However, the current understanding of UTI remains based on a now disproven concept that the urinary bladder is sterile. Thus, current standards for UTI diagnosis have significant limitations that may reduce the opportunity to improve patient care. Using data from our work and numerous other peer-reviewed studies, we identified four major limitations to the contemporary UTI description: the language of UTI, UTI diagnostic testing, the Escherichia coli-centric view of UTI, and the colony-forming units (CFU) threshold-based diagnosis. Contemporary methods and technology, combined with continued rigorous clinical research can be used to correct these limitations.

Trends in the total numbers of HBV and HCV carriers in Japan from 2000 to 2011.

We estimated the total number of undiagnosed HBV and HCV carriers and patients with hepatitis virus-related disease in Japan according to 6 different groups classified by their natural histories during 2011. In 2011, the total number of carriers and patients infected with HBV or HCV was estimated according to 6 groups using government reports and reports from the hepatitis epidemiology research group of The Ministry of Health, Labor and Welfare in Japan. In 2011, the total number of hepatitis virus carriers was estimated to be 2 090 128-2 840 128 in which the estimated number of undiagnosed HCV and HBV carriers was 776 826 (HBV: 481 470; HCV: 295 356). The total number of treated patients, as either inpatients or outpatients, was estimated to be 811588 (HBV: 303 366; HCV: 520 600) in 2011. It is presumed that many carriers shirk consultation for many reasons, such as patients' misunderstanding, lack of awareness and forgetfulness of their positive status. The numbers of infected patients who did not seek treatment increased gradually to 501 714-1 251 714 (HBV: 333 791-483 791; HCV: 167 923-767 923) in 2011. Compared to 2000, the number of undiagnosed carriers was significantly reduced in 2011 probably because of the well-organized, effective national hepatitis virus screening system that has been launched by the Japanese government since 2002. Moreover, the increase in the number of untreated persons who are aware of their positive status shows that more effort should be invested in improving the referral system from screening centres to core hospitals.

Urinary Symptoms and Their Associations With Urinary Tract Infections in Urogynecologic Patients.

OBJECTIVE: To assess urinary symptoms associated with urinary tract infection (UTI) in a urogynecologic population of women. METHODS: In this cohort study, we enrolled 150 urogynecologic patients who completed the validated UTI Symptom Assessment questionnaire and contributed transurethral catheterized urine samples. The primary measure (UTI diagnosis) was defined in three ways. Self-report (a nonculture-based UTI diagnosis) was defined by a yes or no response to the query "Do you think you have a UTI?" Two culture-based UTI diagnoses also were analyzed: standard urine culture (10 colony-forming units [CFU]/mL or greater) and enhanced quantitative urine culture (10 CFU/mL or greater) of any uropathogen. Statistical analyses were performed on patient demographics and urinary symptom prevalence among patient groups. RESULTS: Although the presence of the urinary symptoms of frequency and urgency (respectively) differ somewhat between UTI-positive and UTI-negative women (self-report [P=.005 and P<.001], standard urine culture [P=.038 and P=.044], or enhanced quantitative urine culture [P=.059 and P=.098]), the presence of dysuria (pain or burning) during urination was significantly more prevalent in UTI-positive women for all UTI definitions (self-report P<.001, standard urine culture P<.001, and enhanced quantitative urine culture P=.010). Furthermore, women reporting dysuria had higher severity and bother scores for all other urinary symptoms assessed by the UTI Symptom Assessment questionnaire compared with women not reporting dysuria (frequency P=.001, urgency P=.006, dysuria P<.001). CONCLUSION: Our findings show that, in women seeking urogynecologic care, the presence of frequency and urgency of urination does not confirm a culture-based UTI diagnosis. Instead, clinicians can more readily detect UTI using the presence of dysuria, which more effectively discriminates UTI-positive and UTI-negative individuals, regardless of the culture-based method used to diagnose UTI.

Nuclear Force Imprints Revealed on the Elastic Scattering of Protons with

How does nature hold together protons and neutrons to form the wide variety of complex nuclei in the Universe? Describing many-nucleon systems from the fundamental theory of quantum chromodynamics has been the greatest challenge in answering this question. The chiral effective field theory description of the nuclear force now makes this possible but requires certain parameters that are not uniquely determined. Defining the nuclear force needs identification of observables sensitive to the different parametrizations. From a measurement of proton elastic scattering on ^{10}C at TRIUMF and ab initio nuclear reaction calculations, we show that the shape and magnitude of the measured differential cross section is strongly sensitive to the nuclear force prescription.

Ready or Not? Obstetrics and Gynecology Resident Preparedness for Female Pelvic Medicine and Reconstructive Surgery Training.

OBJECTIVE: The aim of this study was to assess the perception of female pelvic medicine and reconstructive surgery (FPMRS) program directors (PDs) and obstetrics and gynecology (OG) FMPRS fellows regarding the adequacy of OG residency as preparation for FPMRS fellowship. METHODS: Electronic invitations to complete a modified version of a validated survey were extended to FPMRS PDs and their second- and third-year OG FPMRS fellows who had just completed their first or second year of FPMRS fellowship, respectively. The survey consisted of 5 domains; qualitative questions and recommendations for improvement were elicited. RESULTS: Program directors (33%, 16/48) and second-year (64%, 29/45) and third-year (53%, 26/49) fellows completed the surveys. While incoming fellows were deemed professional, serious surgical skill competency issues were identified: (1) PDs felt they could not leave their incoming fellow to operate independently on a major case for 30 minutes while in the next room compared with fellow responses (PDs: 33.3% vs second-year fellows: 67.9%; P = 0.03); (2) no PDs felt their fellows could suture laparoscopically; and (3) there was group consensus that incoming fellows were not proficient at cystoscopy (PDs: 40.0%, second-year fellows: 39.3%, third-year fellows: 32.0%; P = 0.82). Mostly, fellows could clinically evaluate and manage patients. Program directors thought their fellows had better understanding of statistics than fellows believed of themselves (P = 0.05). Increasing FPMRS exposure during residency was favored as the method to better prepare OG residents for fellowship. CONCLUSIONS: Quantitative and emerging qualitative outcomes highlight that fellows are professional and are largely able to evaluate and care for patients but that achieving independence, surgical skills, and scholarship requires further training.

Hierarchical viscosity of aqueous solution of tilapia scale collagen investigated via dielectric spectroscopy between 500 MHz and 2.5 THz.

Aqueous solutions of biomolecules such as proteins are very important model systems for understanding the functions of biomolecules in actual life processes because interactions between biomolecules and the surrounding water molecules are considered to be important determinants of biomolecules' functions. Globule proteins have been extensively studied via dielectric spectroscopy; the results indicate three relaxation processes originating from fluctuations in the protein molecule, the bound water and the bulk water. However, the characteristics of aqueous solutions of collagens have rarely been investigated. In this work, based on broadband dielectric measurements between 500 MHz and 2.5 THz, we demonstrate that the high viscosity of a collagen aqueous solution is due to the network structure being constructed of rod-like collagen molecules surrounding free water molecules and that the water molecules are not responsible for the viscosity. We determine that the macroscopic viscosity is related to the mean lifetime of the collagen-collagen interactions supporting the networks and that the local viscosity of the water surrounded by the networks is governed by the viscosity of free water as in the bulk. This hierarchical structure in the dynamics of the aqueous solution of biomolecules has been revealed for the first time.