Directional and amplitude characteristics of pulsed call sequences in captive free-swimming Pacific white-sided dolphins (Lagenorhynchus obliquidens).

We investigated the directional properties and gain control of a pulsed call sequence that functions as a contact call in Pacific white-sided dolphins (Lagenorhynchus obliquidens). The pulsed call sequences were stereotyped patterns composed of three or more pulsed call elements and were collected from two dolphins, separated into adjacent pools, and allowed to swim freely. Eight hydrophones and an overhead camera were used to determine the positions and directions of the participants. The mean peak frequency and source levels were 8.4 ± 4.4 (standard deviation)-18.7 ± 12.7 kHz and 160.8 ± 3.8 to 176.4 ± 7.9 dB re 1 µPa (peak-to-peak), respectively, depending on the element types. The elements were omnidirectional, with mean directivity index of 0.9 ± 3.4 dB. The dolphins produced sequences, regardless of their relative position and direction to the lattice, leading to the adjacent pool where the conspecific was housed. They increased the amplitude by 6.5 ± 4.6 dB as the distance from the caller to an arbitrary point in the adjacent pool doubled. These results suggest that callers broadcast pulsed call sequences in a wide direction to reach dispersed conspecifics. However, they can adjust the acoustic active space by controlling the source levels.

An anthropometric evidence against the use of age-based estimation of bodyweight in pediatric patients admitted to intensive care units.

Age-based bodyweight estimation is commonly used in pediatric settings, but pediatric ICU patients often have preexisting comorbidity and resulting failure to thrive, hence their anthropometric measures may be small-for-age. Accordingly, age-based methods could overestimate bodyweight in such settings, resulting in iatrogenic complications. We performed a retrospective cohort study using pediatric data (aged < 16 years) registered in the Japanese Intensive Care Patient Database from April 2015 to March 2020. All the anthropometric data were overlaid on the growth charts. The estimation accuracy of 4 age-based and 2 height-based bodyweight estimations was evaluated by the Bland-Altman plot analysis and the proportion of estimates within 10% of the measured weight (ρ10%). We analyzed 6616 records. The distributions of both bodyweight and height were drifted to the lower values throughout the childhood while the distribution of BMI was similar to the general healthy children. The accuracy in bodyweight estimation with age-based formulae was inferior to that with height-based methods. These data demonstrated that the pediatric patients in the Japanese ICU were proportionally small-for-age, suggesting a special risk of using the conventional age-based estimation but supporting the use of height-based estimation of the bodyweight in the pediatric ICU.

Impact of Antibiotic Time-Outs in Multidisciplinary ICU Rounds for Antimicrobial Stewardship Program on Patient Survival: A Controlled Before-and-After Study.

The antimicrobial stewardship program (ASP) is an important quality improvement initiative that is recommended in the ICU. However, the shortage of infectious disease physicians in Japan has led to the need for simpler methods for implementing ASPs. We investigated whether antibiotic time-outs (ATOs) during multidisciplinary rounds as part of an ASP can improve patient survival and reduce the number of days of therapy (DOT) with antibiotics. DESIGN: Single-center controlled before-and-after study. SETTING: Medical/surgical ICU in a tertiary university medical center in Tokyo, Japan. PATIENTS: All patients 16 years old or older admitted consecutively in the ICU between October 2016 and March 2020. INTERVENTIONS: An intensivist-driven ICU multidisciplinary round was introduced in October 2016, and ATOs with ICU rounds were implemented in June 2018. ATOs were conducted 3, 7, and 14 days after initiation of antibiotics. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the subdistribution hazard ratio (SHR) of survival to hospital discharge compared between multidisciplinary rounds (phase 1) and ATO during multidisciplinary rounds (phase 2) using the multivariable Fine-Gray model. The secondary outcomes were the SHR of survival to ICU discharge and the trends in the DOT with IV antibiotics per 1,000 patient-days between October 2016 and March 2020 by using interrupted time-series analysis. The number of patients in phases 1 and 2 was 777 and 796, respectively. The group that underwent ATO during multidisciplinary rounds showed a significant increase in the survival to hospital discharge in comparison with the multidisciplinary round-only group (SHR, 1.13; 95% CI, 1.02-1.25); however, the SHR of survival to ICU discharge showed no significant intergroup difference. The DOT with total IV antibiotics decreased after ATO implementation (change in intercept, -178.26; 95% CI, -317.74 to -38.78; change in slope, -7.00; 95% CI, -15.77 to 1.78). CONCLUSIONS: ATOs during multidisciplinary rounds are associated with improved patient survival and reduced DOT.

Tracheobronchial aspergillosis presenting with black mucus plugs and tracheal ulcers.

Tracheobronchial aspergillosis is a rare but lethal disease with characteristic findings of tracheal plaques and ulcers. It requires appropriate airway management for possible tracheal obstruction with the black mucus plug.

COVID-19 case of ventilator-induced lung injury on extracorporeal membrane oxygenation: Physicians' clinical struggle and ethical conflict in a novel pandemic.

Resource scarcity was concerned in the initial surge of the COVID-19 pandemic. To open slots for Extracorporeal Membrane Oxygenation (ECMO), we tried ECMO weaning allowing invasive ventilation in a 66-year-old male with severe COVID-19, backfiring as ventilator-induced lung injury. We will discuss ethical conflict in pandemics in this report.

Pulsed call sequences as contact calls in Pacific white-sided dolphins (Lagenorhynchus obliquidens).

Pacific white-sided dolphins are a group-living species and appear to exchange "contact calls" to maintain group cohesion. The aim of this study was to find and characterize their contact calls. Calls were recorded from two females at Osaka Aquarium KAIYUKAN (OAK) and three females at Izu-Mito Sea Paradise (IMSP). Because they often produced pulsed calls consecutively, a "pulsed call sequence" was defined as three or more successive pulsed calls occurring within 325 ms, which was calculated using a bout analysis. The pulsed call sequences increased during separation periods and decreased during reunions and were used for vocal exchange, suggesting that the sequences are contact calls in Pacific white-sided dolphins. Most of the pulsed call sequences were classified into unique types; several stereotyped, repeated patterns were found. One sequence type was found at OAK and the two dolphins shared the type; they exchanged sequences with type matching. On the other hand, three sequence types were found in IMSP and the three dolphins shared all of the types; however, each dolphin preferentially used different types and frequently exchanged with their own favorite types but not with type matching. These results suggest that the sequence type may function as an individual and/or group identity.

Nivolumab-induced Hypophysitis, Secondary Adrenal Insufficiency and Destructive Thyroiditis in a Patient with Lung Adenocarcinoma.

Nivolumab-induced multiple organ immune-related adverse events (irAEs) have been described in some case reports. The symptoms of endocrinological irAEs are especially nonspecific. A 63-year-old man with a postoperative recurrence of pulmonary adenocarcinoma who was treated with nivolumab presented fever, anorexia and fatigue after the 7th cycle. He underwent a rapid adrenocorticotrophic hormone test, four-hormone tolerance test and thyroid gland scintigraphy. The results were consistent with destructive thyroiditis, hypophysitis and secondary adrenal insufficiency. Nivolumab was restarted following glucocorticoid and thyroid hormone replacement treatment. When a patient presents nonspecific symptoms, the possibility of endocrinological irAEs should be considered as it may enable their early detection.

Treatment of asthma in smokers: A questionnaire survey in Japanese clinical practice.

BACKGROUND: Cigarette smoking in patients with asthma leads to poor symptom control. As patients who are current smokers have been excluded from enrollment in many clinical trials on asthma, there are few reports on the treatment in current smokers with asthma. In this study, we aimed to assess how respiratory physicians manage asthma in current smokers in Japan. METHODS: Respiratory physicians in 16 Japanese hospitals answered a questionnaire on treatment for patients with asthma between December 2014 and February 2015. Medical records were reviewed for 1756 patients with asthma. RESULTS: The mean patient age was 61.1 years, and 62.9% of the patients were female. A total of 102 patients (5.8%) were current smokers, and 546 patients (31.1%) were former smokers. Long-acting muscarinic antagonists (LAMA) were prescribed more frequently for current smokers with asthma than for former smokers and never smokers with asthma (10.8% vs 4.6%, p = 0.01, 10.8% vs 3.8%, p < 0.01). In contrast, macrolides were prescribed more frequently for former smokers and never smokers with asthma than for current smokers with asthma (7.7% vs 1.0%, p = 0.01, 6.4% vs 1.0%, p = 0.03). Triple therapy, i.e., inhaled corticosteroids, long-acting beta agonists, and LAMA concomitantly, was prescribed for current smokers with asthma more frequently than for former smokers and never smokers with asthma (9.8% vs 4.0%, p = 0.01, 9.8% vs 3.3%, p < 0.01). CONCLUSIONS: According to this survey, current smokers with asthma received more intensive therapy, including LAMA, than did former smokers with asthma.

Individuality embedded in the isolation calls of captive beluga whales (Delphinapterus leucas).

INTRODUCTION: Species with fission-fusion social systems tend to exchange individualized contact calls to maintain group cohesion. Signature whistles by bottlenose dolphins are unique compared to the contact calls of other non-human animals in that they include identity information independent of voice cues. Further, dolphins copy the signatures of conspecifics and use them to label specific individuals. Increasing our knowledge of the contact calls of other cetaceans that have a fluid social structure may thus help us better understand the evolutionary and adaptive significance of all forms of individually distinctive calls. It was recently reported that one type of broadband pulsed sounds (PS1), rather than whistles, may function as individualized contact calls in captive belugas. The objective of this study was to assess the function and individual distinctiveness of PS1 calls in an isolation context. Recordings were made from five captive belugas, including both sexes and various ages. RESULTS: PS1 was the predominant call type (38 % in total) out of five broader sound categories. One sub-adult and three adults had individually distinctive and stereotyped pulse repetition pattern in PS1; one calf showed no clear stereotyped pulse repetition pattern. While visual inspection of the PS1 power spectra uncovered no apparent individual specificity, statistical analyses revealed that both temporal and spectral parameters had inter-individual differences and that there was greater inter-individual than intra-individual variability. Discriminant function analysis based on five temporal and spectral parameters classified PS1 calls into individuals with an overall correct classification rate of 80.5 %, and the most informative parameter was the average Inter-pulse interval, followed by peak frequency. CONCLUSION: These results suggest that belugas use individually distinctive contact calls in an isolation context. If belugas encode signature information in PS1 calls, as seen in bottlenose dolphins, the pulse repetition pattern may be the carrier, as it is individually stereotyped and appears to require vocal development. This idea is supported by the finding that the average inter-pulse interval is the most powerful discriminator in discriminant analysis. Playback experiments will elucidate which parameters are perceived as individual characteristics, and whether one of the parameters functions as a signature.