Tea crude extracts effectively inactivate severe acute respiratory syndrome coronavirus 2.

It is well known that black and green tea extracts, particularly polyphenols, have antimicrobial activity against various pathogenic microbes including viruses. However, there is limited data on the antiviral activity against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which emerged rapidly in China in late 2019 and which has been responsible for coronavirus disease 2019 (COVID-19) pandemic globally. In this study, 20 compounds and three extracts were obtained from black and green tea and found that three tea extracts showed significant antiviral activity against SARS-CoV-2, whereby the viral titre decreased about 5 logs TCID50 per ml by 1·375 mg ml-1 black tea extract and two-fold diluted tea bag infusion obtained from black tea when incubated at 25°C for 10 s. However, when concentrations of black and green tea extracts were equally adjusted to 344 µg ml-1 , green tea extracts showed more antiviral activity against SARS-CoV-2. This simple and highly respected beverage may be a cheap and widely acceptable means to reduce SARS-CoV-2 viral burden in the mouth and upper gastrointestinal and respiratory tracts in developed as well as developing countries.

Intellectual disability is a risk factor for delayed emergence from total intravenous anaesthesia.

BACKGROUND: Previous studies have suggested that ID influences the depth of general anaesthesia (GA) and delays emergence from GA. In this retrospective cohort study, we investigated whether ID affects the time taken to emerge from GA. METHODS: We selected dental patients who underwent GA at the Department of Dental Anaesthesiology, Okayama University Hospital, using predefined inclusion and exclusion criteria, before dividing the selected participants into ID and non-ID (control) groups. Relevant data were collected from electronic anaesthesia records. Emergence time, the time from the discontinuation of propofol and remifentanil to tracheal extubation, was recorded for each patient. We compared the data of the ID group and control group. The association between ID and the emergence time was tested for statistical significance. Multivariate linear regression analysis was used to control for confounders. RESULTS: A total of 97 cases (control = 50, ID = 47) were included in the study. The emergence time was significantly longer in the ID group (ID group: 15.8 ± 6.6 min, control group: 10.8 ± 3.6 min). The ID group included more men and lower propofol and remifentanil infusion rates. The treatment time was longer, and the mean bispectral index was lower in the ID group. Sevoflurane inhalation was used only for anaesthesia induction in the ID group. In the multivariate linear regression analysis, ID was found to be significantly associated with a longer emergence time. CONCLUSION: Our results suggest that ID is associated with a longer emergence time from GA.

[Management of surgical approach for intractable secondary spontaneous pneumothorax].

Secondary spontaneous pneumothorax (SSP) such as lymphangioleiomyomatosis (LAM), bronchiolitis obliterans (BO) is intractable or repeated the recurrence of pneumothorax. The most effective chemical pleurodesis for intractable pneumothorax is talc poudrage and so on that is associated with a reduction in the rate of pneumothorax recurrence. However, severe and broad pleural adhesion due to the pleural interventional procedures sometimes cause serious bleeding when the patients undergo lung transplantation. We must be considered for new approaches to these intractable secondary pneumothoraces which replaced traditional conservative and surgical approaches. We had proposed new 2 approaches of total pleural covering (TPC) and awake surgical intervention (ASI) for intractable pneumothorax. We applied the TPC modified with coverage of air leak points with polyglycolic acid (PGA) sheet to 5 patients with intractable bilateral pneumothorax to reduce the risk of excessive bleeding by chemical pleurodesis in lung transplantation. The bilateral pneumothorax was well controlled, and no recurrence has been observed. TPC is reliable procedure for management intractable bilateral SSP. For 12 high-risk patients with other underling pulmonary diseases on general poor conditions, a surgical intervention was performed in awake condition. The air leaks were stopped in 11 cases except for 1 case. The recurrence of pneumothorax after surgery was 2 cases. ASI for intractable secondary pneumothorax can be applicable to selected patients with deteriorated general condition.

Effect of flumazenil on disturbance of equilibrium function induced by midazolam.

Benzodiazepines in intravenous sedation are useful, owing to their outstanding amnesic effect when used for oral surgery as well as dental treatments on patients with intellectual disability or dental phobia. However, compared with propofol, the effect of benzodiazepine lasts longer and may impede discharge, especially when it is administered orally because of fear of injections. Although flumazenil antagonizes the effects of benzodiazepine quickly, its effect on the equilibrium function (EF) has never been tested. Since EF is more objective than other tests, the purpose of this study is to assess the sedation level and EF using a computerized static posturographic platform. The collection of control values was followed by the injection of 0.075 mg/kg of midazolam. Thirty minutes later, 0.5 mg or 1.0 mg of flumazenil was administered, and the sedation level and EF were measured until 150 minutes after flumazenil administration. Flumazenil antagonized sedation, and there was no apparent resedation; however, it failed to antagonize the disturbance in EF. This finding may be due to differences in the difficulty of assessing the sedation level and performing the EF test, and a greater amount of flumazenil may effectively antagonize the disturbance in EF.

Autonomic, neuro-immunological and psychological responses to wrapped warm footbaths--a pilot study.

UNLABELLED: This study examined the immediate effects of wrapped warm footbaths (WW Footbath) on the autonomic, neuroimmunological and psychological activities in healthy middle-aged volunteers. Thirteen subjects were divided into a footbath group (n=7) and a control group (n=6). Immediate changes in autonomic activities were recorded with wavelet analysis of heart rate variability. Salivary secretory immunoglobulin A (sIgA) and serum cortisol levels were used as neuroimmunological parameters. Psychological conditions were measured using a Visual Analog Scale. Parasympathetic activity tended to increase and sympathetic activity decrease after footbaths. RESULTS: Changes in the relaxation indices, that is, sIgA and serum cortisol levels showed that both lying down and footbath resulted in a relaxed state. CONCLUSION: WW Footbaths can be an effective method of relaxation, since it induces both a significant increase in parasympathetic activity and significant decrease in sympathetic activity.

Capnography Prevents Hypoxia during Sedation for Dental Treatment: A Randomized Controlled Trial.

Intravenous sedation is useful for dental treatment in patients with intellectual disabilities. However, it is often necessary to manage such patients with deep sedation because their cooperation cannot be obtained. During deep sedation, undetected hypoventilation can lead to severe complications, such as hypoxia. Recently, capnographic monitoring has been advocated as a useful technique for preventing hypoxia during sedation. This randomized control trial evaluated whether the use of capnography reduces the incidence of hypoxia during the deep sedation of patients for dental treatment. This study involved patients with intellectual disabilities who underwent dental treatment under sedation. The subjects were randomized to the intervention group (I-group) or control group (C-group). All of the patients underwent routine monitoring, as well as bispectral index (BIS) and capnographic monitoring; however, only an independent observer had access to the patients' capnographic data during the dental procedures. Sedation was maintained at a BIS of 50 to 70 by administration of propofol. In the I-group, the independent observer signaled to the dental anesthesiologist if the capnogram indicated that the patient had been suffering from alveolar hypoventilation or apnea for >15 s. In the C-group, the observer signaled to the dental anesthesiologist if the capnogram indicated that the patient had been suffering from alveolar hypoventilation or apnea for >60 s. In both groups, the dental anesthesiologists responded to the signals using appropriate airway management strategies. The primary endpoint of this study was the incidence of hypoxia during dental treatment, which was defined as oxygen saturation of <95%. Hypoxemic episodes occurred in 13.4% and 34.8% of cases in the I-group and C-group, respectively. The incidence of hypoxia was significantly lower in the I-group. These results suggest that capnographic monitoring during deep sedation for dental treatment prevents hypoxemic episodes by allowing the early detection of hypoventilation. Knowledge Transfer Statement: This is the first randomized controlled trial to examine whether the use of capnography reduces the incidence of hypoxia during deep sedation for dental treatment. The findings of this study can be used by clinicians to aid decision-making regarding dental sedation standards at individual clinics. Moreover, they can be used as high-level evidence during the production or updating of clinical guidelines for dental sedation by leading associations.

Activation of latent transforming growth factor beta1 by stromelysin 1 in extracts of growth plate chondrocyte-derived matrix vesicles.

Previous studies have shown that matrix vesicles isolated from cultures of costochondral growth zone chondrocytes and treated with 1alpha,25-dihydroxyvitamin D3 [1alpha,25(OH)2D3] can activate recombinant human latent transforming growth factor beta1 (rhTGF-beta1). It is unknown what enzyme or other factor in the extracellular organelles is responsible for the activation. This study tested the hypothesis that enzymes present in matrix vesicles can activate latent TGF-beta1 and that this is regulated by 1alpha,25(OH)2D3. To do this, we examined the ability of matrix vesicle extracts to activate small latent rhTGF-beta1. In addition, enzymes previously determined to be present in matrix vesicles were screened for their ability to activate small latent rhTGF-beta1. Recombinant human matrix metalloproteinase 2 (rhMMP-2; 72 kDa gelatinase), rhMMP-3 (stromelysin 1), purified human plasminogen, and purified urokinase (plasminogen activator) were each tested at varying concentrations. To assess the role of cell maturation, we used a cell culture model in which chondrocytes are derived from two distinct zones of rat costochondral cartilage, the resting zone and the growth zone. Matrix vesicles were isolated from these cultures and then tested. The results showed that extracts of matrix vesicles produced by both growth zone and resting zone chondrocytes were able to activate small latent rhTGF-beta1. The effects were dose and time dependent, with greater activity being found in extracts of matrix vesicles from the growth zone chondrocyte cultures. Only rhMMP-3 was able to activate small latent rhTGF-beta1, indicating that stromelysin-1, but not MMP-2, plasminogen, or urokinase, was involved. As observed in the extracts, the effect of rhMMP-3 was time and dose dependent. When anti-MMP-3 antibody was added to matrix vesicle extracts from both cell types, activation of small latent rhTGF-beta1 was dose-dependently blocked. Neither 1alpha,25(OH)2D3 nor 24R,25(OH)2D3 had a direct effect on activation of small latent rhTGF-beta1 by the extracts. However, when intact matrix vesicles were treated with 1alpha,25(OH)2D3, their ability to activate small latent rhTGF-beta1 was increased. Inhibition of phospholipase A2 with quinacrine blocked the 1alpha,25(OH)2D3-dependent effect. These results suggest that the ability of 1alpha,25(OH)2D3-treated matrix vesicles to activate small latent TGF-beta1 is via action of the secosteroid on the matrix vesicle membrane, not on the enzymes responsible for activating latent TGF-beta1. Because matrix vesicles isolated from growth zone chondrocytes have been shown to contain increased phospholipase A2 activity after treatment with 1alpha,25(OH)2D3, it is likely that this secosteroid promotes loss of membrane integrity through phospholipase A2-dependent formation of lysophospholipids, resulting in the release of MMP-3 into the matrix, where latent TGF-beta1 is stored. Taken together, the results of the current study show that matrix vesicles produced by growth plate chondrocytes contain MMP-3, that this enzyme is at least partially responsible for activation of small latent TGF-beta1 in the matrix, and that 1alpha,25(OH)2D3 regulates MMP release from matrix vesicles.

Transfection of wild-type TP53 induces differentiation in human gingival carcinoma cells.

We investigated the effects of transfection of wild-type TP53 on the growth properties of a human gingival carcinoma cell line, KOSC-3, in which the TP53 gene is mutated at codon 248 and overexpressed. The wild-type TP53 expression plasmid, pCDM8-p53/neo and the control plasmid, pCDM8/neo, were each stably transfected into KOSC-3 cells by using the calcium phosphate method. The number of G418-resistant colonies from wild-type TP53-transfected cells was approximately half that from plasmid controls. Exogenous wild-type TP53 transcripts were identified in four of the 20 G418-resistant clones analysed by reverse transcription PCR. Although the growth rates of the wild-type TP53+ clones did not drastically change during log phase, their saturation density was significantly reduced. The wild-type TP53+ cells were morphologically flat and enlarged when cultured in vitro, and were less able to form colonies in soft agar. In nude mice, the wild-type TP53+ clones formed subcutaneous tumours with conspicuous keratinisation and notable cell death that was not manifested in the parental and plasmid control cells. These findings indicate that the wild-type TP53 gene, even when it coexists with a mutated form, may function as a growth suppressor and differentiation inducer under restricted conditions in gingival squamous cell carcinoma.

Inhibition by nifedipine of adherence- and activated macrophage-induced death of human gingival fibroblasts.

The effects of nifedipine on the death and proliferation of gingival fibroblasts were investigated to elucidate the mechanism of gingival overgrowth that is associated with chronic administration of Ca2+ channel blockers. The number of adhered viable and dead fibroblasts obtained from healthy human gingiva increased after confluence, whereas cell death was inhibited by nifedipine in a concentration-dependent manner. A similar inhibition was also observed in the presence of other calcium channel blockers, such as nicardipine, diltiazem, and verapamil. When gingival fibroblasts were co-cultured with RAW264 (macrophage-like) cells, lipopolysaccharide (LPS) caused the concentration-dependent death of fibroblasts. Nifedipine significantly inhibited the LPS-induced cell death. Although neither LPS nor N-ethyl-2-(1-ethyl-2-hydroxy-2-nitroso-hydrazino)-ethanamine, a nitric oxide donor, directly caused fibroblast death, 3-morpholino-sydnonimine (SIN-1), a peroxynitrite donor, induced fibroblast death, regardless of the presence of RAW cells. The cell death induced by SIN-1 was not affected by nifedipine treatment. LPS stimulation caused an increase in the immunoreactivity of inducible nitric oxide synthase (iNOS) and in the nitrite concentration in the incubation medium of RAW cells. The induction of iNOS was completely prevented by the incubation with nifedipine. The inhibition by nifedipine of nitrite production in RAW cells was also observed after treatment with nicardipine, but not with either diltiazem or verapamil. Therefore, the inhibition by nifedipine of both adherence- and LPS-stimulated macrophage-induced death of fibroblasts may be the mechanism of gingival overgrowth seen during chronic treatment with Ca(2+) channel blockers.

Fully mechanized latex immunoassay for serum lipoprotein(a).

We have developed a fully automated system to quantify lipoprotein(a) (Lp(a)) in human serum, based on the latex-enhanced turbidimetric immunoassay by application of the Immuno Chemistry Analyzer 501X. This assay was carried out with undiluted serum and was able to detect at Lp(a) levels higher than 4.0 mg/l. When judged to be out of range of the calibration (> 600 mg/l), the sample was automatically re-tested after automatic 10-fold dilution. Within-run C.V.s ranged from 1.9 to 2.1% and between-run C.V.s from 2.7 to 3.9%. Results by the present method were in good agreement with those by the in-house ELISA (r = 0.978) and the commercial ELISA (r = 0.990). The distribution of Lp(a) levels in sera from 508 healthy donors was highly skewed; the mean and median were 158 mg/l and 105 mg/l, respectively.

Intercapsular cataract surgery with lens epithelial cell removal. Part IV: Capsular fibrosis induced by poly(methyl methacrylate).

Characteristic lens epithelial cell behavior in the pseudophakic eye was examined by comparing 30 eyes that had extracapsular cataract surgery by the intercapsular technique and posterior chamber intraocular lens (IOL) implantation with lens epithelial cell removal but without anterior capsule capsulectomy and nine aphakic eyes that had the same procedure but without posterior chamber lens implantation over a mean follow-up period of 30 and 23 months, respectively. Fibrous anterior capsule opacification was observed in 83% of the pseudophakic eyes in the area of contact with the IOL, while the region beyond the margin of the IOL remained transparent. Fibrous anterior capsular opacification was not noted in the aphakic eyes. This suggests that the IOL material, poly(methyl methacrylate), stimulates lens epithelial cells to undergo fibrous metaplasia and to produce collagen fibers. Various cytokines such as IL-1 and TGF-beta synthesized by lens epithelial cells may play a crucial role as mediators in the process. We recommend that this effect be considered as a parameter of biocompatibility in developing and evaluating new biomaterials.

A possible relationship between processing from precursor proteins to opioid peptides and noxious stimulation in the rat incisor pulp.

The content of met-enkephalin (met-EK)-like peptides in a crude extract from intact pulp of the rat markedly increased with tryptic digestion but not with carboxypeptidase B(CPase B) digestion, while the content of leu-enkephalin (leu-EK)-like peptides more markedly with CPase B- than with tryptic digestion. On the other hand, results by High Performance Liquid Chromatography (HPLC) showed that the contents of both met-EK-Arg-Phe and leu-EK in cavity formed pulp increased 6 times as much as those contents in intact pulp, while the met-EK content in cavity formed pulp increased 2 times as much as that in intact pulp. Furthermore, results by gel filtration of crude extract from intact pulp showed that one peak of met-EK-like immunoreactivity (met-EK-IR) appeared at position of approximately 30,000 of molecular weight and a broad peak of leu-EK-IR appeared at position of approximately 60,000 of molecular weight following tryptic digestion. From these results, it was suggested that noxious stimuli might cause activation of trypsin-like enzymes followed by processing from one precursor protein to met-EK-like peptides as well as from another to leu-EK-like peptides in the rat incisor pulps.

Changes of the Met-enkephalin-like peptide content induced by noxious stimuli in the rat incisor pulp.

It was examined what mechanism involved in an increase of met-enkephalin (met-EK)-like peptide content in the pulp induced by noxious stimuli. The increased content of the peptides by cavity formation as noxious stimulation was not influenced by cycloheximide, but attenuated by FOY-305 [N,N-dimethyl carbamoyl-methyl 4-(4-guanidinobenzoyloxy) phenyl acetate methanesulfonate], a trypsin-like enzyme inhibitor, and enhanced by captopril, and attenuated by infusion of saline in the pulp cavity. From these results, it was suggested that noxious stimuli on the pulp led to activation of trypsin-like enzymes followed by an increased content of met-EK-like peptides, and thereafter, the peptides, such as met-EK, might be degraded by angiotensin converting enzyme (ACE). Furthermore, an immunohistochemical study demonstrated that met-EK-like immunoreactivity (met-EK-IR) of cells in the rat incisor pulp was clearly increased following tryptic digestion of the pulp section, supporting a suggestion mentioned above.

Cell-colony hybridization on a nitrocellulose filter to identify clones expressing a transfected gene.

Cells that are transfected with a growth-inhibitory gene can be isolated by using a dominant selective marker. Such isolated clones, however, do not always express the transfected gene. Therefore, clones in which a transfected gene is integrated and expressed should be selected further. We have developed a simple method of identifying such expression-positive clones. We modified the filter hybridization process so that cultured cells are directly transferred to a nitrocellulose filter, immobilized, and hybridized with radiolabeled DNA probes. This method is sensitive enough to detect the presence or the expression of a single-copy gene, and ideal for identifying clones that stably express a transfected gene.

Elevation of plasma interleukin-6 level in patients undergoing oral and maxillofacial surgery.

OBJECTIVE: The purpose of this study was to evaluate the response of peripheral interleukin-6 associated with oral and maxillofacial surgery. STUDY DESIGN: Fifteen patients undergoing elective oral and maxillofacial surgery were studied. We investigated the change in plasma interleukin-6 level during and after surgery and the correlation between plasma interleukin-6 level and surgical procedure. Plasma interleukin-6 levels were measured by enzyme-linked immunosorbent assay. Statistical significance was determined by nonparametric methods. RESULTS: Elevation of plasma interleukin-6 level was detected at 2 to 6 hours after incision and observed to reach a peak level within 6 hours after the end of surgery. There were significant correlations between plasma interleukin-6 level and duration of surgery or response of C-reactive protein. CONCLUSION: The results suggested that interleukin-6 would be released by surgical injury and elevation of plasma interleukin-6 level would be associated with magnitude of tissue damage in oral and maxillofacial surgery.

Elevation of plasma interleukin-6 level is involved in postoperative fever following major oral and maxillofacial surgery.

OBJECTIVE: The purpose of this study was to evaluate whether the changes in plasma cytokine levels including interleukin-6 (IL-6) interleukin-1 beta (IL-1 beta), and tumor necrosis factor-alpha (TNF-alpha) are involved in postoperative fever following oral and maxillofacial surgery. STUDY DESIGN: Ten patients undergoing elective oral and maxillofacial surgery were studied. We investigated the plasma cytokine levels by using an enzyme-linked immunosorbent assay and measured the core temperature and degree of postoperative shivering and peripheral vasoconstriction after surgery. The relationships between the changes in plasma cytokine levels and postoperative fever were statistically evaluated using Spearman's rank correlation coefficients. RESULTS: The elevation of plasma IL-6 level was significantly correlated with the increase in core temperature after surgery and with the degree of postoperative shivering and vasoconstriction, whereas the changes in plasma II-1 beta or TNF-alpha levels were not. CONCLUSIONS: Elevation of plasma IL-6 level is probably involved in postoperative fever following oral and maxillofacial surgery.

Experimental studies on application of small-caliber vascular prosthesis produced by polyurethane.

It has been suggested that a microporous structure enhances fast and complete endothelialization. For long-term patency, antithrombogenicity and microporous structure are very important factors. In this paper, we have developed a new technique to give a micro-porous structure to small-caliber vascular prosthesis produced by polyurethane which has favorable antithrombogenecity. A mixed solution (tetrahydrofuran: dimethylformamide = 1:1) containing 13 wt% of segmented polyurethane and a variable amount of calcium carbonate (mean particle size of 8 mm in diameter) was dip-coated on a glass mandril of 3 mm and 6 mm in diameter and placed into distilled water for 24 hours. After the glass mandrill was removed, this polyurethane tube was placed into 1 mmol hydrochloric acid for 1 hour, and a microporous polyurethane vascular prosthesis of 20 mm in length was completed. These prostheses of 3 mm and 6 mm in diameter were implanted into the femoral and the carotid arteries, and the abdominal aorta of the dogs, respectively. Patency was recognized by arteriography and Duplex scanning and the removed grafts were inspected macro- and microscopically. Greater hydraulic permeability of this graft was obtained with an increase in the quantity of calcium carbonate mixed with polyurethane. In elasticity, this graft was more similar to the canine jugular vein than the polytetrafluoroethylene graft. Patency was observed 8 weeks after implantation on the arteriogram, and neointima was observed microscopically on the smooth and lustrous lumen. The new polyurethane vascular prosthesis we developed might provide a potential prosthesis for small-caliber vascular reconstruction.

Geographical variation of mandible size and shape in the Ryukyu wild pig (Sus scrofa riukiuanus).

We measured adult mandibles of Ryukyu wild pigs from Amami-Oshima, Kakeroma, Okinawa, Ishigaki and Iriomote Islands. The size cline was not statistically recognized among the populations of Nansei Islands. The Ishigaki population was significantly larger than Iriomote one in mandible length. Some measurement ratios indicated that the ramus is enlarged laterally and that the body of mandible is dorso-ventrally developed in Ishigaki and Iriomote populations. The Amami-Oshima mandibles were relatively smaller than those of Okinawa and Iriomote populations in length item of body of mandible. These results will contribute to the zoo-archaeology on the historical change of size and shape in the island populations, and to the evolutionary biology on the morphological adaptation of this animal.

A trigeminal neuralgia-like paroxysmal pain condition presumably due to buccal nerve compression in the temporalis muscle.

We encountered three patients with trigeminal neuralgia-like paroxysmal pain in the buccal nerve region. In all cases, paroxysmal pain was felt spreading to the receptive field of the ipsilateral buccal nerve, and clear tenderness was observed during intraoral palpation at the inner side of the mandibular ramus where the temporalis muscle runs and attaches. It was assumed that the paroxysmal pain might be caused by nerve compression related to temporalis muscle hyperactivity. To lend support to this hypothesis, we also studied the anatomical relationship between the buccal nerve and the masticatory muscles. In this autopsy study, the buccal nerve pierced the temporalis muscle in six (12%) of 52 specimens from 26 cadavers. These findings support the hypothesis that peripheral buccal nerve compression could be an etiology of paroxysmal neuropathic pain in the unilateral orofacial region.

[Clinical use of an expanded polytetrafluoroethylene sheets (GORE-TEX SHEETS) as a pericardial substitute after aorto coronary bypass grafting].

Reoperation after cardiovascular surgical procedures are often accompanied by the possibility of injuring the heart the great vessels, and extracardiac grafts during resternotomy. To reduce the risk associated with resternotomy and to facilitate dissection of intrapericardial adhesion, we have used GORE-TEX SHEET as pericardial substitute since January, 1989. In case GORE-TEX SHEET are implanted in the mediastinum, prolongation of the foreign body reaction, mediastinitis, increasing postoperative hemorrhage should be in mind. In this study, the biocompatibility of GORE-TEX SHEET was examined clinically. The following postoperative indices such as duration of fever, change of the WBC counts, WBC fraction, CRP, mediastinal hemorrhage are evaluated. These results showed no statistical significance between GORE-TEX SHEET group and autologous pericardial group by the randomized study. We recommend use of GORE-TEX SHEET as a pericardial substitute in cases of major cardiovascular operation using median sternotomy.