Transvaginal three-dimensional ultrasound assessment of embryonic genital tubercle at 8-10+6 weeks of gestation.

OBJECTIVES: To assess embryonic genital tubercle using transvaginal three-dimensional (3D) ultrasound at 8-10+6 weeks of gestation. METHODS: One-hundred and two transvaginal 3D ultrasound scans were performed for first-trimester dating at 8-10+6 weeks of gestation. The genital tubercle angle (GTA) and genital tubercle length (GTL) were measured with a mid-sagittal view of the embryo using the 3D ultrasound multiplanar mode. Intra- and inter-observer agreements regarding GTA and GTL were also assessed with Bland-Altman plots and intra- and inter-correlation coefficients. RESULTS: There were no significant differences in GTA between male and female embryos at 8, 9, 10 weeks, or 8-10+6 weeks of gestation, respectively. There were also no significant differences in GTL between male and female embryos at 8, 9, 10 weeks, or 8-10+6 weeks of gestation, respectively. However, GTL increased linearly with advancing gestation (r=0.8276, p<0.00001). Mean GTL (SD) values at 8, 9, and 10 weeks were 0.833 mm (0.274), 1.623 mm (0.262), and 2.152 mm (0.420), respectively (p<0.001). Intra- and inter-reproducibilities of GTA and GTL were excellent. The intra- and inter-correlation coefficients of GTA and GTL were 0.964 and 0.995, and 0.996 and 0.9933, respectively. CONCLUSIONS: The genital tubercle could be identified using transvaginal 3D ultrasound at 8-10+6 weeks of gestation. However, sex differentiation could not be performed at this age. The genital tubercle linearly developed with advancing gestation during the mid-first trimester of pregnancy.

A case of progressive xanthogranulomatous pancreatitis with splenic abscess.

Xanthogranulomatous inflammation is a chronic inflammatory reaction microscopically characterized by aggregation of foamy histiocytes, fibrous tissue, and infiltration of various inflammatory cells. In contrast to xanthogranulomatous inflammation in the gallbladder or kidney, xanthogranulomatous pancreatitis is rare. We herein present a case of xanthogranulomatous pancreatitis in a patient who underwent distal pancreatectomy with splenectomy under preoperative suspicion of a pancreatic pseudocyst or pancreatic tumor. A 77-year-old woman with a 1 month history of epigastric pain, anorexia, and general fatigue was admitted to our hospital. Contrast-enhanced computed tomography revealed a cystic mass with ill-defined margins at the pancreatic tail together with a splenic abscess. Contrast-enhanced endoscopic ultrasound detected a hyperechoic cystic lesion at the tail of the pancreas with heterogeneous internal echogenicity, and part of the intra-cystic content was enhanced by the contrast agent. Endoscopic retrograde cholangiopancreatography showed a cystic lesion at the tail of the pancreas that continued into the main pancreatic duct, and the main pancreatic duct was slightly narrowed downstream of the cystic lesion. Pancreatic juice cytology revealed suspicious cells, leading to the possibility of intraductal papillary mucinous carcinoma. Distal pancreatectomy with splenectomy was performed, and the histopathological diagnosis was xanthogranulomatous pancreatitis with no malignant findings.

A case of spindle and giant cell-type undifferentiated carcinoma of the extrahepatic bile duct.

Spindle and giant cell type undifferentiated carcinoma of the extrahepatic bile duct is an uncommon malignancy. We report a case involving the common bile duct in a 72-year-old male with jaundice who was admitted to our hospital. Diagnostic imaging, including abdominal computed tomography and magnetic resonance imaging, revealed a mass in the distal common bile duct, accompanied by dilatation of both intra- and extrahepatic bile ducts and regional lymph node enlargement. Endoscopic retrograde cholangiography demonstrated stenosis in the distal common bile duct, with a biopsy confirming adenocarcinoma. The patient underwent endoscopic retrograde biliary drainage followed by a subtotal stomach-preserving pancreaticoduodenectomy with regional lymphadenectomy. Microscopic examination revealed that the tumor predominantly comprised spindle and giant atypical cells within the stroma. Immunohistochemical analysis showed the tumor cells expressing cytokeratins and mesenchymal markers, confirming the diagnosis of spindle and giant cell type undifferentiated carcinoma of the common bile duct. Ki-67 labeling index was observed to be above 80%. Postoperatively, intra-abdominal lymph node recurrence was noted at two months, and multiple liver metastases were identified at three months. The patient died seven months post-surgery. The literature pertaining to this rare disease is reviewed and discussed.

Color Doppler, HDlive, and HDlive Silhouette features of an umbilical cord cyst before 11 weeks of gestation: Diagnostic value.

OBJECTIVE: We describe transvaginal color Doppler, HDlive, and HDlive Silhouette features of an umbilical cord cyst (UCC) before 11 weeks of gestation. METHODS: In this cohort study, 135 transvaginal dating scans were performed at 7 to 10 + 6 weeks of gestation, and 17 UCCs were identified (12.6%). UCC was evaluated using color Doppler, HDlive, and HDlive Silhouette. The clinical characteristics, pregnancy courses, and outcomes were also investigated. RESULTS: UCC location was on the fetal side in six cases, at the free loop in 10 cases, and on the placental side in one case. There were seven single and 10 multiple cysts. Cyst diameters ranged from 3.3 to 11.3 mm (mean, 5.6; standard deviation, ±2.1). Blood flow inside the cyst was noted in three cases (17.6%). HDlive clearly showed the spatial relationships among UCC, the umbilical cord, midgut herniation, yolk sac, and embryo. Location of UCC could be clearly identified with HDlive. HDlive Silhouette showed central cysts inside UCCs in seven cases (41.2%). HDlive Silhouette also clearly demonstrated the sac of midgut herniation in the umbilical cord in 12 cases (70.6%). All UCCs resolved before 15 weeks (mean, 11.1 weeks; standard deviation, ±1.5). All fetuses with UCCs showed good neonatal outcomes. CONCLUSION: The incidence of UCC was high compared with that in previous reports. Color Doppler, HDlive, and HDlive Silhouette may provide information on the nature and origin of UCCs before 11 weeks of gestation. UCC before 11 weeks of gestation may be a common, transient, and benign finding.

Isolated small ventricular septal defects in utero: HDlive Flow with spatiotemporal image correlation and HDlive Silhouette case study.

Purpose: To demonstrate shunt flow through small ventricular septal defects (VSDs) using HDlive Flow with spatiotemporal image correlation (STIC) and HDlive Silhouette. Methods: Four cases of isolated small VSDs were evaluated using colour Doppler, and HDlive Flow with STIC and HDlive Silhouette. Results: HDlive Flow with STIC and HDlive Silhouette can improve the ability to depict shunt flow through small VSDs compared with colour Doppler. Conclusion: This technique provides information on spatial recognition of the shunt flow through isolated small VSDs in real time.

Anti-SARS-CoV-2 Agents in Artemisia Endophytic Fungi and Their Abundance in Artemisia vulgaris Tissue.

Coronavirus disease 2019 is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Therapeutic agents for the disease are being developed. Endophytes are diverse and produce various secondary metabolites and bioactive substances. We isolated 13 endophytes from the leaves and stems of Artemisia vulgaris. Antiviral testing using the culture extracts of these endophytic fungi revealed that five isolates effectively inhibited the replication of SARS-CoV-2. These extracts were used to study the inhibitory effect of SARS-CoV-2 on 3C-like protease, and two isolates proved useful. Both isolates were from the genus Colletotrichum; therefore, the percentage of Artemisia endophytic fungi in the plant tissue was observed to be an important factor in plant site selection. Thus, we conducted a macroanalysis using next-generation sequencing to analyze the percentage of endophytes in the stems (whole, skin, and inner), leaves, roots, and cultivating soil, as well as to determine the location of each genus. To the best of our knowledge, this study is the first to report that Colletotrichum spp. are abundant in stems and that stem-based methods are the most efficient for isolating endophytes targeting Colletotrichum spp.

Embryonic and fetal tiny pericardial fluid collections at less than 12 weeks of gestation.

OBJECTIVES: To describe embryonic and fetal tiny pericardial fluid collections (PFCs) using transvaginal sonography and HDlive Silhouette at less than 12 weeks of gestation. METHODS: During an 8-month period from November 2021 to June 2022, one-hundred and thirty transvaginal scans were performed for first-trimester dating, and eleven tiny PFCs of the embryo or fetus were identified at 8+4 - 11+3 weeks of gestation (three at 8, six at 9, and two at 11 weeks). HDlive Silhouette features of PFC were evaluated. Their clinical characteristics and outcomes were also investigated. RESULTS: The incidence of tiny PFCs was 8.5 % at less than 12 weeks of gestation. The mean gestational age at the initial examination was 9.5 weeks (SD: ± 0.9). The mean crown-rump length was 25.0 mm (SD: ± 8.5). The mean PFC dimension was 0.8 mm (range: 0.5-1.3, SD: ± 0.2). Pleural effusion was associated with 3 out of 11 PFCs (27.2 %). Ascites was noted in 2 cases (18.2 %). Skin edema was identified in only in 1 case (0.09 %). There was no arrhythmia. Tiny PFC could also be depicted using HDlive Silhouette. First-trimester fetal ultrasound scans at 11 - 13+6 weeks showed no abnormal findings. PFCs resolved until 13 weeks of gestation (Mean: 12 weeks, SD: ± 1.2). All PFC pregnancies resulted in healthy neonates. CONCLUSIONS: The incidence of tiny PFCs was relatively high in early pregnancy. HDlive Silhouette can depict tiny PFCs of the embryo. Tiny PFCs in early gestation are transient, benign findings in utero.

Environmental differences between Japan and Indonesia provide endophyte diversity associated with Artemisia plant and variety of artemisinin derivatives in microbial conversion.

We compared the endophytic compositions of Artemisia plant from different environments (Japan and Indonesia) to demonstrate that the endophytic filamentous fungi in both species differed based on their environments. To prove that the species were identical, both Artemisia plants were identified by comparing the scanning electron micrographs of their pollens, as well as the nucleotide sequences (ribosomal internal transcribed spacer and mitochondrial maturase K) of the two gene regions. After isolating the endophytic filamentous fungi from each plant, we observed that those from Japan and Indonesia comprised 14 and 6 genera, respectively. We assumed that the genera, Arthrinium and Colletotrichum, which exist in both Artemisia species, were species-specific filamentous fungi, while the other genera were environment-dependent. In the microbial-conversion reaction with artemisinin as a substrate using Colletotrichum sp., the peroxy bridge of artemisinin, which is an active site for achieving antimalarial effect, was converted into an ether bond. However, the reaction using the environment-dependent endophyte did not eliminate the peroxy bridge. These endophytic reactions indicated the different roles of endophytes within Artemisia plants.

Fetal brain activity and the free energy principle.

OBJECTIVES: To study whether the free energy principle can explain fetal brain activity and the existence of fetal consciousness via a chaotic dimension derived using artificial intelligence. METHODS: In this observational study, we used a four-dimensional ultrasound technique obtained to collect images of fetal faces from pregnancies at 27-37 weeks of gestation, between February and December 2021. We developed an artificial intelligence classifier that recognizes fetal facial expressions, which are thought to relate to fetal brain activity. We then applied the classifier to video files of facial images to generate each expression category's probabilities. We calculated the chaotic dimensions from the probability lists, and we created and investigated the free energy principle's mathematical model that was assumed to be linked to the chaotic dimension. We used a Mann-Whitney test, linear regression test, and one-way analysis of variance for statistical analysis. RESULTS: The chaotic dimension revealed that the fetus had dense and sparse states of brain activity, which fluctuated at a statistically significant level. The chaotic dimension and free energy were larger in the sparse state than in the dense state. CONCLUSIONS: The fluctuating free energy suggests consciousness seemed to exist in the fetus after 27 weeks.

Indoleamine 2, 3-dioxygenase is responsible for low stress tolerance after intracerebral hemorrhage.

In the chronic phase after intracerebral hemorrhage (ICH), the aftereffect-associated lowering of motivation burdens many patients; however, the pathogenic mechanism is unclear. Here, we revealed for the first time that indoleamine 2, 3-dioxygenase (IDO) expression and enzyme activity are increased in the collagenase-induced murine ICH model. IDO is a rate-limiting enzyme situated at the beginning of the kynurenine pathway and converts tryptophan, a source of serotonin (5-hydroxytryptamine; 5-HT), to kynurenine. In this study, we showed that IDO is localized in 5-HTergic neurons. After ICH, the synaptosomal 5-HT level decreased, but this effect was neutralized by subcutaneous injections of 1-methyl tryptophan (MT), a specific IDO inhibitor. These results suggest that ICH-induced IDO weakens the activity of 5-HTergic neurons. Accordingly, we next investigated whether the IDO increase contributes to the depression-like behaviors of ICH mice. The immobility times of tail suspension and forced swimming tests were significantly prolonged after ICH but shortened by the administration of 1-MT. In conclusion, the increased IDO after ICH was found to decrease 5-HT levels and subsequently reduce stress tolerance. These findings indicate that IDO is a novel therapeutic target for the ICH aftereffect-associated lowering of motivation.

Isolated tortuous ductus arteriosus in a fetus: HDlive Flow with spatiotemporal image correlation (STIC) study.

OBJECTIVES: To describe prevalence, outcome, color Doppler, and HDlive Flow (Silhouette) with spatiotemporal image correlation (STIC) features of isolated tortuous ductus arteriosus in Japanese fetuses at 28-31 + 6 weeks of gestation. METHODS: During a 37-month period, 3,150 fetal screenings were performed at 28-31 + 6 weeks of gestation. Isolated tortuous ductus arteriosus was evaluated using color Doppler and HDlive Flow (Silhouette) with STIC. Prevalence and outcomes were also assessed. RESULTS: There were 22/3,150 fetuses (0.7%) had isolated tortuous ductus arteriosus at 28-31 + 6 weeks of gestation. According to color Doppler and HDlive Flow findings, two types of isolated tortuous ductus arteriosus (Right-angled and Loop shapes) were classified. There were 20 Right-angled and 2 Loop shapes. One fetus with a Right-angled shape was associated with aortic tortuosity. HDlive Flow with STIC revealed spatial relationships of tortuous ductus arteriosus, aortic arch, and descending aorta. All fetuses with isolated tortuous ductus arteriosus had good neonatal outcomes. CONCLUSIONS: The incidence of isolated tortuous ductus arteriosus in Japanese fetuses was low compared with those in previous reports. HDlive Flow with STIC provides precise information for spatial recognition and differentiation of isolated tortuous ductus arteriosus, resulting in two type classifications. Isolated tortuous ductus arteriosus in a fetus may be a transient, benign finding in utero.

Artificial intelligence to understand fluctuation of fetal brain activity by recognizing facial expressions.

OBJECTIVE: To examine whether artificial intelligence can achieve discoveries regarding fetal brain activity. METHODS: In this observational study, the authors collected images of fetal faces using a four-dimensional ultrasound technique obtained from singleton pregnancies of outpatients in routine practice at 27 to 37 weeks of gestation between February 1 and December 31, 2021. The authors developed an artificial intelligence classifier to recognize seven facial expressions of fetuses, then applied it to video files of fetal facial images to generate the probabilities, as confidence scores, of each expression category. Discrete Fourier transform and chaotic analysis were used to investigate the scores. Mann-Whitney test, t test, variance test, and one-way analysis of variance were used for statistical analysis. RESULTS: Facial expression changes were observed in cycles averaging 66 to 73 s. The power spectrum showed that mouthing and neutral expressions were the most prevalent. There was a difference between categories for the spectrum (p = 0.004). Two different states--dense and sparse--of confidence scores were discovered. The correlation dimension was 1.19 ± 0.22 and 1.33 ± 0.27 for dense and sparse, respectively (p = 0.047). CONCLUSION: This method objectively and quantitatively demonstrated fetal brain activity and may provide insight into how the fetus spends its time in utero.

In Vitro and in Silico Studies of Potential Coronavirus-Specific 3C-Like Protease Inhibitors.

We investigated similar compounds to ebselen and tideglusib, which exhibit strong activity against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), using Molecular ACCess System (MACCS) keys. Four candidate compounds were identified. One of them, phenyl-benzothiazol-3-one, showed coronavirus-specific 3C-like (3CL) protease inhibitory activity. The results indicated that a similarity score above 0.81 is a good indicator of activity for ebselen-and-tideglusib-like compounds. Subsequently, we simulated the ring-cleavage Michael reaction of ebselen at the Se center, which is responsible for its 3CL protease inhibitory activity, and determined the activation free energy of the reaction. The results showed that reaction simulation is a useful tool for estimating the activity of inhibitory compounds that undergo Michael addition reactions with the relevant cysteine S atom of 3CL proteases.

Natural Course of Fetal Hyaloid Artery: SlowflowHD Longitudinal Study.

OBJECTIVE: To assess the natural course of the fetal hyaloid artery (FHA) using SlowflowHD during pregnancy. METHODS: One-hundred and eighteen normal fetuses were studied longitudinally using SlowflowHD to assess the natural course of FHA at 18-21 + 6, 28-31 + 6, and after 35 weeks of gestation. Blood flow of FHA with/without its branches (BF) was evaluated using SlowflowHD, and the band of FHA without blood flow (Band) was identified in each gestational period. The natural course of FHA was classified into six types: Type A, not detected (ND) in each gestational period; Type B, Band at 18-21 + 6 weeks; Type C, Band at 18-21 + 6 and 28-31 + 6 weeks; Type D, BF at 18-21 + 6 weeks; Type E, BF at 18-21 + 6 weeks and Band at 28-31 + 6 weeks; Type F, BF at 18-21 + 6 and 28-31 + 6 weeks. RESULTS: BF, Band, and ND were 83.5, 15.5, and 1.0% at 18-21 + 6 weeks, 8.8, 15.5, and 75.7% at 28-31 + 6 weeks, and 0, 0, and 100% after 35 weeks, respectively. Type A was 1.0%, Type B was 13.6%, Type C was 1.9%, Type D was 61.2%, Type E was 13.6%, and Type F was 8.7%. CONCLUSIONS: The presence of FHA blood flow before 30 weeks of gestation should be regarded as a physiologic phenomenon in normal fetuses.

Evaluation of 24-segment sphericity index of fetal heart using FetalHQ.

OBJECTIVE: To evaluate the 24-segment sphericity index (SI) of the fetal heart using FetalHQ regarding the change with advancing gestation and reproducibility. METHODS: Eighty-one pregnant women at 18-21 + 6 and 28-31 + 6 weeks were studied using FetalHQ to calculate 24-segment SI of left and right ventricles. Intra- and inter-class correlation coefficients and intra- and inter-observer agreements of measurements for SI were assessed in each segment. RESULTS: With respect to intra-observer reproducibility, all SI values showed correlations between 0.596 and 0.774 for the left ventricle, and between 0.491 and 0.764 for the right ventricle, with good intra-observer agreements except for right ventricular segment 11-15. With respect to inter-observer reproducibility, all SI values showed correlations between 0.473 and 0.755 for the left ventricle, and between 0.48 and 0.767 for the right ventricular segment 1-18. However, right ventricular segment 19-24 showed no correlations. Good inter-observer agreements were noted in the right ventricle, whereas poor inter-observer agreements were evident in the left ventricle.There were significant differences in the mean SI values in the apical segment of the left ventricle between 18-21 + 6 and 28-31 + 6 weeks (p < .05), whereas there were no significant differences in the mean SI values in the right ventricle between both gestational ages. CONCLUSION: These results show that measurements of 24-segment SI of fetal heart had relatively low reliability of measurements performed by experienced sonographers. This may suggest that more training on proper placement of the 3 end-systolic and end-diastolic reference points during the initial analysis may be relevant.

HDlive Flow Silhouette with spatiotemporal image correlation for assessment of fetal cardiac structures at 12 to 14 + 6 weeks of gestation.

OBJECTIVES: To assess fetal cardiac structures using HDlive Flow Silhouette with spatiotemporal image correlation (STIC) at 12 to 14 + 6 weeks of gestation, and verify the feasibility of obtaining five cardiac views in the late first and early second trimesters of pregnancy. The fetal cardiac shape and the aspect of the descending aorta were also evaluated. METHODS: Eighty normal fetuses at 12 to 14 + 6 weeks of gestation were studied using trans-abdominal HDlive Flow Silhouette with STIC to assess the feasibility of five fetal cardiac views (frontal, spatial three-vessel, panoramic, posterior, and right lateral views). Target structures in each cardiac view were evaluated. 'Good' was assigned when all structures were noted, 'Fair' when only one structure was missed, and 'Poor' when two and more structures could not be detected. Frequencies of an elongated heart and those of a tortuous descending aorta were counted. RESULTS: Forty-nine fetuses were effectively included in the analysis. Success rates of 'Good' and 'Fair' were significantly higher with spatial three-vessel (p<0.01) and panoramic views (p<0.05). Frequencies of "Elongated heart", "Elongated left ventricle", and "Spherical heart" were 12.2, 6.2, and 81.6%, respectively. Frequencies of "Tortuous descending aorta" and "Straight descending aorta" were 12.2 and 87.8%, respectively. CONCLUSIONS: The feasibility of obtaining fetal five cardiac views using HDlive Flow Silhouette with STIC is good, and this technique provides useful information for evaluating fetal cardiac structures in the late first and early second trimesters of pregnancy.

Achievements and challenges of the Sakigake designation system in Japan.

The Sakigake designation system (Sakigake) has been launched to encourage the pioneered development of innovative new medical products for the effective treatment of severe illness in Japan, which allows leveraging the several advantages in prioritized consultation, rapid review, premium drug pricing and extended data-protection period. We retrospectively analysed the Sakigake products including drugs and regenerative medical products to clarify the achievements and the future issues in this system. From April 2015 to August 2020 (the first 5-year trial period of Sakigake), 37 products were designated, and 10 of those were approved in Japan in which 7 new active substances achieved the first-in-world approvals. Oncology, neurology and cardiovascular disease were the major therapeutic areas, and those 3 accounted for 75.7% of all products. Sakigake achieved some first-in-world approvals by the Pharmaceuticals and Medical Devices Agency/the Ministry of Health, Labor and Welfare of innovative new medical products, although in some therapeutic areas, there remains room in stimulating drug development.

Recognition of facial expression of fetuses by artificial intelligence (AI).

OBJECTIVES: The development of the artificial intelligence (AI) classifier to recognize fetal facial expressions that are considered as being related to the brain development of fetuses as a retrospective, non-interventional pilot study. METHODS: Images of fetal faces with sonography obtained from outpatient pregnant women with a singleton fetus were enrolled in routine conventional practice from 19 to 38 weeks of gestation from January 1, 2020, to September 30, 2020, with completely de-identified data. The images were classified into seven categories, such as eye blinking, mouthing, face without any expression, scowling, smiling, tongue expulsion, and yawning. The category in which the number of fetuses was less than 10 was eliminated before preparation. Next, we created a deep learning AI classifier with the data. Statistical values such as accuracy for the test dataset and the AI confidence score profiles for each category per image for all data were obtained. RESULTS: The number of fetuses/images in the rated categories were 14/147, 23/302, 33/320, 8/55, and 10/72 for eye blinking, mouthing, face without any expression, scowling, and yawning, respectively. The accuracy of the AI fetal facial expression for the entire test data set was 0.985. The accuracy/sensitivity/specificity values were 0.996/0.993/1.000, 0.992/0.986/1.000, 0.985/1.000/0.979, 0.996/0.888/1.000, and 1.000/1.000/1.000 for the eye blinking, mouthing, face without any expression, scowling categories, and yawning, respectively. CONCLUSIONS: The AI classifier has the potential to objectively classify fetal facial expressions. AI can advance fetal brain development research using ultrasound.