Asymptomatic esophageal perforation discovered after elective cardiac surgery: the importance of clinical awareness.

Transesophageal echocardiography (TEE) has become an indispensable part of cardiothoracic surgery at present and is considered to be a safe procedure, rarely associated with complications. However, TEE may cause serious and life threatening complications, as presented in this case report. We describe a patient who developed an empyema after elective cardiac surgery due to an esophageal perforation caused by TEE, without any clinical symptoms. Risk factors for TEE-related complications, identified in recent literature, will be discussed as well as the remarkable absence of clinical symptoms in this particular patient.

Excitation of NH Stretching Modes in Aromatic Molecules: o-Toluidine and α-Methylbenzylamine.

Selectively excited o-toluidine and α-methylbenzylamine have been studied with quasi-classical trajectory procedures to determine the extent and timescales of intramolecular energy flow. The initial excitation is in the stretching mode of the para-CH bond, and its flow is initiated by interaction with an argon atom. Energy flow to the NH stretching mode is the dominant relaxation pathway, and its effectiveness is enhanced strongly by the methyl-NH interaction. Energy flow characteristics in both molecules are similar, but the flow is more effective in o-toluidine than in α-methylbenzylamine because the methyl group bonded to the benzene ring exerts stronger perturbation on the energy-flow pathway than the group bonded to the side chain. The relaxation of the initially excited CH completes on a timescale of several picoseconds, but the main part of energy flow to the NH occurs on a subpicosecond scale. In o-toluidine, carbon-carbon overtone modes lead to ring-CC bonds gaining and transporting more energy than high-frequency CH bonds, but they all gain far less energy than the NH stretching mode.

Artificial intelligence for detection of intracranial haemorrhage on head computed tomography scans: diagnostic accuracy in Hong Kong.

INTRODUCTION: The use of artificial intelligence (AI) to identify acute intracranial haemorrhage (ICH) on computed tomography (CT) scans may facilitate initial imaging interpretation in the accident and emergency department. However, AI model construction requires a large amount of annotated data for training, and validation with real-world data has been limited. We developed an algorithm using an open-access dataset of CT slices, then assessed its utility in clinical practice by validating its performance on CT scans from our institution. METHODS: Using a publicly available international dataset of >750 000 expert-labelled CT slices, we developed an AI model which determines ICH probability for each CT scan and nominates five potential ICH-positive CT slices for review. We validated the model using retrospective data from 1372 non-contrast head CT scans (84 [6.1%] with ICH) collected at our institution. RESULTS: The model achieved an area under the curve of 0.842 (95% confidence interval=0.791-0.894; P<0.001) for scan-based detection of ICH. A pre-specified probability threshold of ≥50% for the presence of ICH yielded 78.6% accuracy, 73% sensitivity, 79% specificity, 18.6% positive predictive value, and 97.8% negative predictive value. There were 62 true-positive scans and 22 false-negative scans, which could be reduced to six false-negative scans by manual review of model-nominated CT slices. CONCLUSION: Our model exhibited good accuracy in the CT scan-based detection of ICH, considering the low prevalence of ICH in Hong Kong. Model refinement to allow direct localisation of ICH will facilitate the use of AI solutions in clinical practice.

[Assessment of exo- and endocrine function of pancreas following distal pancreatectomy].

AIM: The assessment of pancreatic resection volume influence on exo- and endocrine pancreatic functions. MATERIALS AND METHODS: The resected pancreatic volume influence was assessed in 47 patients: 31 (66%) patients after resections of pancreatic body and tail, and 16 (34%) patients after distal resections. The exocrine pancreatic function was assessed by pancreatic fecal elastase 1 as well as endocrine pancreatic function was assessed by C-peptide level measurement. Computed tomography with intravenous contrast enhancement and postprocessing was used for pre- and postoperative pancreatic volume assessment. All tests were performed before and 1, 3, and 6 months after surgery. RESULTS: Type of surgery had no influence on C-peptide and pancreatic fecal elastase 1 levels (p>0.05). Exo- and endocrine pancreatic functions markers tended to decrease in 1st month after surgery with consequent functions restoration towards 6 months after surgery. There were 15 (35.7%) patients from 42 patients with normal exocrine pancreatic function with a fecal elastase 1 level decrease to 114.7±61.8 µg/g; exocrine insuficiency remained only in 2 (4.8%) patients after 6 months after surgery. C-peptide concentration decrease before surgery to less than 1.1 ng/ml was noticed only in 8 (17%) patients. C-peptide concentration decreased in 30 (63.8%) patients in 1st month after surgery, but after 6 months after surgery, C-peptide level decrease was only in 7 (14.9%) patients. CONCLUSION: The exo- and endocrine function of the pancreas is restored in more than 80% of patients after DR. Probably it could be associated with the activation of the pancreatic compensatory abilities.

Characterizing Determinants of Near-Road Ambient Air Quality for an Urban Intersection and a Freeway Site.

INTRODUCTION: Near-road ambient air pollution concentrations that are affected by vehicle emissions are typically characterized by substantial spatial variability with respect to distance from the roadway and temporal variability based on the time of day, day of week, and season. The goal of this work is to identify variables that explain either temporal or spatial variability based on case studies for a freeway site and an urban intersection site. The key hypothesis is that dispersion modeling of near-road pollutant concentrations could be improved by adding estimates or indices for site-specific explanatory variables, particularly related to traffic. Based on case studies for a freeway site and an urban intersection site, the specific aims of this project are to (1) develop and test regression models that explain variability in traffic-related air pollutant (TRAP) ambient concentration at two near-roadway locations; (2) develop and test refined proxies for land use, traffic, emissions and dispersion; and (3) prioritize inputs according to their ability to explain variability in ambient concentrations to help focus efforts for future data collection and model development.The key pollutants that are the key focus of this work include nitrogen oxides (NOx), carbon monoxide (CO), black carbon (BC), fine particulate matter (PM2.5; PM ≤ 2.5 µm in aerodynamic diameter), ultrafine particles (UFPs; PM ≤ 0.1 µm in aerodynamic diameter), and ozone (O3). NOx, CO, and BC are tracers of vehicle emissions and dispersion. PM2.5 is influenced by vehicle table emissions and regional sources. UFPs are sensitive to primary vehicle emissions. Secondary particles can form near roadways and on regional scales, influencing both PM2.5 and UFP concentrations. O3 concentrations are influenced by interaction with NOx near the roadway. Nitrogen dioxide (NO2), CO, PM2.5, and O3 are regulated under the National Ambient Air Quality Standards (NAAQS) because of demonstrated health effects. BC and UFPs are of concern for their potential health effects. Therefore, these pollutants are the focus of this work. METHODS: The methodological approach includes case studies for which variables are identified and assesses their ability to explain either temporal or spatial variability in pollutant ambient concentrations. The case studies include one freeway location and one urban intersection. The case studies address (1) temporal variability at a fixed monitor 10 meters from a freeway; (2) downwind concentrations perpendicular to the same location; (3) variability in 24-hour average pollutant concentrations at five sites near an urban intersection; and (4) spatiotemporal variability along a walking path near that same intersection.The study boundary encompasses key factors in the continuum from vehicle emissions to near-road exposure concentrations. These factors include land use, transportation infrastructure and traffic control, vehicle mix, vehicle (traffic) flow, on-road emissions, meteorology, transport and evolution (transformation) of primary emissions, and production of secondary pollutants, and their resulting impact on measured concentrations in the near-road environment. We conducted field measurements of land use, traffic, vehicle emissions, and near-road ambient concentrations in the vicinity of two newly installed fixed-site monitors. One is a monitoring station jointly operated by the U.S. Environmental Protection Agency (U.S. EPA) and the North Carolina Department of Environmental Quality (NC DEQ) on I-40 between Airport Boulevard and I-540 in Wake County, North Carolina. The other is a fixed-site monitor for measuring PM2.5 at the North Carolina Central University (NCCU) campus on E. Lawson Street in Durham, North Carolina. We refer to these two locations as the freeway site and the urban site, respectively. We developed statistical models for the freeway and urban sites. RESULTS: We quantified land use metrics at each site, such as distances to the nearest bus stop. For the freeway site, we quantified lane-by-lane total vehicle count, heavy vehicle (HV) count, and several vehicle-activity indices that account for distance from each lane to the roadside monitor. For the urban site, we quantified vehicle counts for all 12 turning movements through the intersection. At each site, we measured microscale vehicle tailpipe emissions using a portable emission measurement system.At the freeway site, we measured the spatial gradient of NOx, BC, UFPs, and PM, quantified particle size distributions at selected distances from the roadway and assessed partitioning of particles as a function of evolving volatility. We also quantified fleet-average emission factors for several pollutants.At the urban site, we measured daily average concentrations of nitric oxide (NO), NOx, O3, and PM2.5 at five sites surrounding the intersection of interest; we also measured high resolution (1-second to 10-second averages) concentrations of O3, PM2.5, and UFPs along a pedestrian transect. At both sites, the Research LINE-source (R-LINE) dispersion model was applied to predict concentration gradients based on the physical dispersion of pollution.Statistical models were developed for each site for selected pollutants. With variables for local wind direction, heavy-vehicle index, temperature, and day type, the multiple coefficient of determination (R2) was 0.61 for hourly NOx concentrations at the freeway site. An interaction effect of the dispersion model and a real-time traffic index contributed only 24% of the response variance for NOx at the freeway site. Local wind direction, measured near the road, was typically more important than wind direction measured some distance away, and vehicle-activity metrics directly related to actual real-time traffic were important. At the urban site, variability in pollutant concentrations measured for a pedestrian walk-along route was explained primarily by real-time traffic metrics, meteorology, time of day, season, and real-world vehicle tailpipe emissions, depending on the pollutant. The regression models explained most of the variance in measured concentrations for BC, PM, UFPs, NO, and NOx at the freeway site and for UFPs and O3 at the urban site pedestrian transect. CONCLUSIONS: Among the set of candidate explanatory variables, typically only a few were needed to explain most of the variability in observed ambient concentrations. At the freeway site, the concentration gradients perpendicular to the road were influenced by dilution, season, time of day, and whether the pollutant underwent chemical or physical transformations. The explanatory variables that were useful in explaining temporal variability in measured ambient concentrations, as well as spatial variability at the urban site, were typically localized real-time traffic-volume indices and local wind direction. However, the specific set of useful explanatory variables was site, context (e.g., next to road, quadrants around an intersection, pedestrian transects), and pollutant specific. Among the most novel of the indicators, variability in real-time measured tailpipe exhaust emissions was found to help explain variability in pedestrian transect UFP concentrations. UFP particle counts were very sensitive to real-time traffic indicators at both the freeway and urban sites. Localized site-specific data on traffic and meteorology contributed to explaining variability in ambient concentrations. HV traffic influenced near-road air quality at the freeway site more so than at the urban site. The statistical models typically explained most of the observed variability but were relatively simple. The results here are site-specific and not generalizable, but they are illustrative that near-road air quality can be highly sensitive to localized real-time indicators of traffic and meteorology.

Viral Safety Issues in the Production and Manufacturing of Human Immunoglobulin Preparations from Equine Plasma/Serum.

The current Russian and foreign pharmacopoeias either do not provide any information about existing types of viral diseases in horses or do not present it in full. Data of modern domestic and foreign literature was used to prepare the most complete list of viruses that cause equine diseases including 36 infectious agents, 25 of which are pathogenic for humans, 13 of the 25 of which are widespread throughout Russia. Information is provided on the magnitudes of the disease incubation periods (which are most often within one month), the external clinical signs of these diseases (which can also be asymptomatic), and the maximum possible concentrations of viruses in the blood of horses with these diseases (which can reach 8 log conventional units/mL of blood). This information is offered for use in critical production stages of heterologous immunoglobulin drugs for medical use to assure viral safety.

Evaluation of Various Polishing Systems for Lithium Disilicate Glass-Ceramics.

OBJECTIVE: The aim of this study was to investigate the surface roughness of lithium disilicates (LS2s) polished using various polishing systems. MATERIALS AND METHODS: Two types of LS2 (A, Amber Mill and E, IPS e.max CAD) were polished using LS2-specific polishing systems (L-Edenta, L-Jota), a zirconia-specific polishing system (Z-Jota), and a conventional ceramic polishing system (P-Shofu) (n = 8 per group). The compositions of different polishing systems were analyzed using EDS. Surface roughness was measured using confocal laser scanning microscopy and analyzed using EDS and SEM. ANOVA and Tukey's tests were used for the statistical analyses (p = 0.05). RESULTS: The polishing systems were mainly composed of C, O, and Si. The L-Jota group exhibited rougher surfaces than the other groups. Amber Mill exhibited higher surface roughness than IPS e.max CAD (p⟨0.001). Among the polishing systems, the L-Jota group presented the highest roughness value (pp⟨0.001). The surface roughness of the AL-Jota group was higher than that of the other groups. CONCLUSIONS: A sufficiently smooth surface can be achieved without a LS2-specific polishing system. Further, the same polishing system can have different effects depending on the type of LS2.

The white coat public art project: using the white coat as a canvas for reflection for women in medicine.

OBJECTIVES: Burnout and low job satisfaction have disproportionately impacted female physicians compared with their male counterparts, with gender-specific oppression and bias in the workforce. This project aims to address the relationship of women in medicine to their chosen field through public art. STUDY DESIGN: A call for using the white coat as a canvas to describe positive attributes and self-reflection was shared with all American Medical Women's Association (AMWA) branches at medical schools. METHODS: Students in AMWA branches created white coats, designing them to answer the posed question. RESULTS: White coats were sent to the national conference for display, revealing certain themes, challenges, resilience, and humanization of the training and working experience for women in medicine. CONCLUSION: This white coat public art project directly and indirectly addresses causes of burnout and serves as a way to create community, address isolation, and empower women in medicine.

Performance and reading time of lung nodule identification on multidetector CT with or without an artificial intelligence-powered computer-aided detection system.

AIM: To compare the performance and reading time of different readers using automatic artificial intelligence (AI)-powered computer-aided detection (CAD) to detect lung nodules in different reading modes. MATERIALS AND METHODS: One hundred and fifty multidetector computed tomography (CT) datasets containing 340 nodules ≤10 mm in diameter were collected retrospectively. A CAD with vessel-suppressed function was used to interpret the images. Three junior and three senior readers were assigned to read (1) CT images without CAD, (2) second-read using CAD in which CAD was applied only after initial unassisted assessment, and (3) a concurrent read with CAD in which CAD was applied at the start of assessment. Diagnostic performances and reading times were compared using analysis of variance. RESULTS: For all readers, the mean sensitivity improved from 64% (95% confidence interval [CI]: 62%, 66%) for the without-CAD mode to 82% (95% CI: 80%, 84%) for the second-reading mode and to 80% (95% CI: 79%, 82%) for the concurrent-reading mode (p<0.001). There was no significant difference between the two modes in terms of the mean sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) for both junior and senior readers and all readers (p>0.05). The reading time of all readers was significantly shorter for the concurrent-reading mode (124 ± 25 seconds) compared to without CAD (156 ± 34 seconds; p<0.001) and the second-reading mode (197 ± 46 seconds; p<0.001). CONCLUSION: In CAD for lung nodules at CT, the second-reading mode and concurrent-reading mode may improve detection performance for all readers in both screening and clinical routine practice. Concurrent use of CAD is more efficient for both junior and senior readers.

Imaging of head and neck mucosa-associated lymphoid tissue lymphoma (MALToma).

Marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALToma) arises in extranodal sites in the head and neck. Chronic inflammatory, infectious or autoimmune conditions are implicated in its pathogenesis. Within the head and neck, MALToma is often multifocal and indolent and the imaging appearances may be mistaken for non-malignant disease in the head and neck. The aim of this article is to illustrate the varied radiological and clinical features of MALToma in the head and neck, an awareness of which is needed for timely and correct diagnosis to guide subsequent disease management.

Phase I dose escalation study of naive T-cell depleted donor lymphocyte infusion following allogeneic stem cell transplantation.

Prophylactic donor lymphocyte infusions (DLI) are used to augment post-transplant immune recovery to reduce both infectious complications and disease recurrence. Preclinical studies implicate the naive T-cell subset as the primary driver of graft-versus-host disease (GvHD). In this phase I dose escalation study, we assessed the safety of a DLI that was depleted of CD45RA+ naive T cells. Sixteen adult patients received a prophylactic DLI at a median of 113 days (range 76-280 days) following an HLA-identical, non-myeloablative allogeneic hematopoietic stem cell transplantation. Three patients each received the naive T-cell depleted DLI with a CD3+ dose of 1 × 105/kg, 1 × 106/kg, and 5 × 106/kg. The maximum dose of 1 × 107/kg was expanded to 7 patients. No dose-limiting grade III/IV acute GvHD or adverse events attributable to the DLI were observed at any dose level. One patient developed grade 2 acute GvHD of skin and upper intestines, and another developed moderate chronic GvHD of the lungs following the DLI. With a median follow-up of 2.8 years, 2-year progression-free and overall survival is 50.0% and 68.8%, respectively. In conclusion, these data suggest that a DLI that has been depleted of CD45RA+ naive T cells is feasible and carries a low risk of acute or chronic GvHD.

Current and future perspectives on allogeneic transplantation using ex vivo expansion or manipulation of umbilical cord blood cells.

In patients with hematologic malignancies, the outcome of umbilical cord blood transplantation has improved and is now comparable to that of matched unrelated donor transplantation. However, the limitation of using umbilical cord blood has been a delay in both hematopoietic and immunologic recovery. Strategies have been proposed to overcome these limitations. One strategy involves ex vivo expansion of the umbilical cord blood unit prior to transplantation. A second strategy involves exposure of the umbilical cord blood graft to compounds aimed at improving homing and engraftment following transplantation. Many of these strategies are now being tested in late phase multi-center clinical trials. If proven cost effective and efficacious, they may alter the landscape of donor options for allogeneic stem cell transplantation.

Lytic transglycosylase contributes to the survival of lipooligosaccharide-deficient, colistin-dependent Acinetobacter baumannii.

OBJECTIVES: The phenomenon of colistin dependence in Acinetobacter baumannii has been described in a situation in which colistin is now considered as the last resort for the treatment of infections caused by multidrug-resistant Gram-negative bacteria. In this study, we aimed to reveal a gene associated with colistin dependence in A. baumannii. METHODS: The colistin-dependent A. baumannii H08-391D strain was isolated from a patient, and target gene-inactivation mutants were constructed. We investigated the effects of target gene on colistin dependence with quantitative real-time PCR and endotoxin assay. Also, we observed the change of cell morphology by electron microscopy. RESULTS: The expression of ACICU_02898, encoding a soluble lytic transglycosylase associated with cell-wall degradation and recycling, was increased by eight-to 42-fold in colistin-dependent mutants, and deletion of ACICU_02898 in a colistin-dependent strain led to colistin susceptibility (MIC = 8 mg/L). Endotoxin activity was significantly low in a colistin-dependent derivative ACICU_02898-inactivated mutant and a complemented mutant. In addition, the ACICU_02898-inactivated mutant showed a highly reduced growth rate. The colistin-dependent derivative and ACICU_02898-inactivated mutant showed clearly distinguished absorption profiles in the red/green fluorescence dot blot with regard to their membrane potential. Electron microscopy revealed that the deletion mutant cells were elongated compared to the colistin-susceptible wild-type strain and colistin-dependent strain. CONCLUSIONS: A colistin-dependent A. baumannii strain exhibited a deficiency in its outer membrane integrity and high expression of lytic transglycosylase was required for survival. This study reveals why the colistin-dependent mutant can tolerate high antibiotic concentrations.

Perception of the risk of tobacco use in pregnancy and factors associated with tobacco use in rural areas of Myanmar.

INTRODUCTION: Tobacco use is recognized as the most important preventable risk factor for pregnancy complications and undesirable fetal outcomes. This study examined the reported prevalence of tobacco use among married men and women residing in rural areas, and their knowledge on the risks of tobacco use during pregnancy and the factors associated with tobacco use. METHODS: A cross-sectional study was conducted within 32 villages in the delta region of Myanmar, randomly selected through multistage sampling procedure by using a pre-tested structured questionnaire during 2016. In all, 617 people participated in the household survey. RESULTS: About 80% of current smokers (109/128) smoked at home, of whom 16% reported the presence of a pregnant woman in their smoking area. Less than 25% of the respondents were aware of the negative impacts of tobacco use on pregnancy outcomes. Men had significantly lower perceived risk towards smoking on some pregnancy outcomes. Multivariate analysis confirmed the significant influence of male gender (adjusted OR, AOR=12.62; 95% CI: 6.30-25.29) and the age of women <35 years (AOR=3.51; 95% CI: 1.97-6.26) on current tobacco use, when controlling for other variables. CONCLUSIONS: Men in the study villages and those with a low level of education had poor knowledge on the risks of tobacco on pregnancy outcomes. However, good knowledge and perceived risk of undesirable impacts on pregnancy did not have any influence on tobacco use.

Kidney Transplantation Using Expanded-Criteria Deceased Donors: A Comparison With Ideal Deceased Donors and Non-Expanded-Criteria Deceased Donors.

PURPOSE: The use of expanded-criteria deceased-donor (ECD) kidneys must be evaluated within the objective perspective of critical organ shortage and graft function and survival. In this study, we aimed to compare the clinical outcomes of ECD reliance with concurrent use of ideal-criteria deceased donors (IDDs) and non-ECDs in adult renal transplantation. METHODS: Between February 2000 and December 2015, we analyzed 405 deceased-donor renal transplants, specifically 129 grafts (31.9%) from ECDs, 233 grafts (57.5%) from non-ECDs, and 43 grafts (10.6%) from IDDs. ECDs were classified according to the United Network for Organ Sharing guidelines, while an IDD was defined as a younger person (10-39 years of age) with no medical risk factors who died from a traumatic head injury. Donor and recipient risk factors were separately analyzed and correlated with recipient graft function, and survival was evaluated. RESULTS: ECDs were older (56.8 ± 6.3 years); showed increased incidence of hypertension, diabetes, and cerebrovascular brain death; and had a higher pre-retrieval serum creatinine level than the other groups. ECD kidney recipients were also older (50.6 ± 9.8 years), had a shorter waiting time (P = .031), and demonstrated a low frequency of re-transplantation (P = .028). Long-term renal function followed longitudinally was lower in ECD kidney recipients until five years after transplantation, while the glomerular filtration rate (GFR) level at 7 and 10 years did not differ significantly among the groups (P = .074 and .262, respectively). There were no significant differences in terms of graft survival (P = .394) or patient survival (P = .737) among the groups. CONCLUSIONS: Although the long-term renal function followed longitudinally was lower in ECD kidney recipients, the use of renal grafts from ECDs is an acceptable method to resolve the disparity of critical organ shortage. However, the classification of the high-risk group should be updated with consideration given to differences in regional characteristics.

Large anomalous Hall current induced by topological nodal lines in a ferromagnetic van der Waals semimetal.

Topological semimetals host electronic structures with several band-contact points or lines and are generally expected to exhibit strong topological responses. Up to now, most work has been limited to non-magnetic materials and the interplay between topology and magnetism in this class of quantum materials has been largely unexplored. Here we utilize theoretical calculations, magnetotransport and angle-resolved photoemission spectroscopy to propose Fe3GeTe2, a van der Waals material, as a candidate ferromagnetic (FM) nodal line semimetal. We find that the spin degree of freedom is fully quenched by the large FM polarization, but the line degeneracy is protected by crystalline symmetries that connect two orbitals in adjacent layers. This orbital-driven nodal line is tunable by spin orientation due to spin-orbit coupling and produces a large Berry curvature, which leads to a large anomalous Hall current, angle and factor. These results demonstrate that FM topological semimetals hold significant potential for spin- and orbital-dependent electronic functionalities.

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.