Prediction and causal inference of cardiovascular and cerebrovascular diseases based on lifestyle questionnaires.

Cardiovascular and cerebrovascular diseases (CCVD) are prominent mortality causes in Japan, necessitating effective preventative measures, early diagnosis, and treatment to mitigate their impact. A diagnostic model was developed to identify patients with ischemic heart disease (IHD), stroke, or both, using specific health examination data. Lifestyle habits affecting CCVD development were analyzed using five causal inference methods. This study included 473,734 patients aged ≥ 40 years who underwent specific health examinations in Kanazawa, Japan between 2009 and 2018 to collect data on basic physical information, lifestyle habits, and laboratory parameters such as diabetes, lipid metabolism, renal function, and liver function. Four machine learning algorithms were used: Random Forest, Logistic regression, Light Gradient Boosting Machine, and eXtreme-Gradient-Boosting (XGBoost). The XGBoost model exhibited superior area under the curve (AUC), with mean values of 0.770 (± 0.003), 0.758 (± 0.003), and 0.845 (± 0.005) for stroke, IHD, and CCVD, respectively. The results of the five causal inference analyses were summarized, and lifestyle behavior changes were observed after the onset of CCVD. A causal relationship from 'reduced mastication' to 'weight gain' was found for all causal species theory methods. This prediction algorithm can screen for asymptomatic myocardial ischemia and stroke. By selecting high-risk patients suspected of having CCVD, resources can be used more efficiently for secondary testing.

Genetic parameters for novel mastitis traits defined by combining test-day somatic cell score and differential somatic cell count in the first lactation of Japanese Holsteins.

In this study, we aimed to improve current udder health genetic evaluations by addressing the limitations of monthly sampled somatic cell score (SCS) for distinguishing cows with robust innate immunity from those susceptible to chronic infections. The objectives were to (1) establish novel somatic cell traits by integrating SCS and the differential somatic cell count (DSCC), which represents the combined proportion of polymorphonuclear leukocytes and lymphocytes in somatic cells and (2) estimate genetic parameters for the new traits, including their daily heritability and genetic correlations with milk production traits and SCS, using a random regression test-day model (RRTDM). We derived 3 traits, namely ML_SCS_DSCC, SCS_4_DSCC_65_binary, and ML_SCS_DSCC_binary, by using milk loss estimates at corresponding SCS and DSCC levels, thresholds established in previous studies, and a threshold established from milk loss estimates, respectively. Data consisted of test-day records collected during January 2021 through March 2022 from 265 herds in Hokkaido, Japan. From these records, we extracted records between 7 to 305 d in milk (DIM) in the first lactation to fit the RRTDM. The model included the random effect of herd-test-day, the fixed effect of year-month, fixed lactation curves nested with calving age groups, and random regressions with Legendre polynomials of order 3 for additive genetic and permanent environmental effects. The analysis was performed using Gibbs sampling with Gibbsf90+ software. The averages (ranges) of daily heritability estimates over lactation were 0.086 (0.075 to 0.095) for SCS, 0.104 (0.073 to 0.127) for ML_SCS_DSCC, 0.137 (0.014 to 0.297) for SCS_4_DSCC_65_binary, and 0.138 (0.115 to 0.185) for ML_SCS_DSCC_binary; the heritability curve for SCS_4_DSCC_65_binary was erratic. Genetic correlations within the trait decreased as the DIM interval widened, especially for those integrating DSCC, indicating that these traits should be analyzed using RRTDM rather than repeatability models. The averages (ranges) of genetic correlations with milk yield over lactation were 0.01 (-0.22 to 0.28) for SCS, -0.05 (-0.40 to 0.13) for ML_SCS_DSCC, -0.08 (-0.17 to 0.09) for SCS_4_DSCC_65_binary, and -0.08 (-0.22 to 0.27) for ML_SCS_DSCC_binary. Compared with SCS, the newly defined traits exhibited slightly stronger negative genetic correlations with milk yield. Especially in late lactation stages, the genetic correlation between ML_SCS_DSCC and milk yield was significantly below zero, with a posterior median of -0.40. Furthermore, the new traits showed positive correlations with SCS, having estimates varying from 0.68 to 0.85 for ML_SCS_DSCC, 0.14 to 0.47 for SCS_4_DSCC_65_binary, and 0.61 to 0.66 for ML_SCS_DSCC_binary, depending on DIM. Considering that ML_SCS_DSCC and ML_SCS_DSCC_binary have relatively high heritability (compared with SCS) and favorable genetic correlations with milk production traits and SCS, their incorporation into breeding programs appears promising. Nevertheless, their genetic relationships with (sub)clinical mastitis require further investigation.

Estimating the nonlinear interaction between somatic cell score and differential somatic cell count on milk production by parity using generalized additive models.

This observational study aimed to use somatic cell score (SCS) and differential somatic cell count (DSCC), the combined proportion of polymorphonuclear leukocytes and lymphocytes in somatic cells, to investigate how mastitis affected milk production. Using generalized additive models, we analyzed 50,618 test-day records from 8,081 lactations from 7,912 cows in 197 herds between January 2021 and March 2022 to estimate the nonlinear interaction between SCS and DSCC, and the effects of lactation stages and seasons on milk yield, milk component percentages, and milk component yields by parity of cows. The results show that the interaction between SCS and DSCC on these traits was significant, nonlinear, and complex. When DSCC was high, the negative effects of SCS were minimal, even when SCS reached 8 (i.e., 3,200,000 somatic cells/mL). Cows with high DSCC could have milk yields similar to healthy cows, implying that these cows may have been in the early stages of mastitis and that the milk yield had yet to be affected. Contrastingly, when DSCC was low, milk loss due to high SCS was drastic, especially for cows in third or later lactations, whose milk yield could reduce from more than 35 kg/d to less than 15 kg/d (-59.9%). This tremendous milk loss in high-parity cows was likely due to their higher milk yield and higher risks of chronic mastitis. High SCS and low DSCC also led to a pronounced change in milk composition. The decrease in the percentage of lactose can be directly related to the damage of inflammation to the mammary gland, while the increase in fat and protein percentages was more attributable to the concentration effect resulting from the reduced milk yield. Compared with analyses based on categorized SCS and DSCC values, modeling these 2 indices directly helps us more precisely assess mastitis effects on milk yield and milk composition. For efficient milk production, our results indicate that we should prevent high-parity cows from entering a state of high SCS and low DSCC.

[A case of bilingual aphasia with language mixing between Japanese and English caused by superior longitudinal fasciculus lesion-a study using functional MRI and diffusion tensor imaging].

We report a case of left-handed bilingual aphasia with phonemic paraphasia and language mixing from Japanese as a first language to English as a second language. The lesion caused by cerebral infarction was mainly localized in the left parietal lobe white matter. The patient was a 46-year-old, left-handed woman who was bilingual in Japanese and English. Both auditory and visual comprehensions were well maintained after the acute phase of the disease; however, language mixing between Japanese and English was observed during Japanese speech. A pathophysiological interpretation of this case required a focus on the brain network. Our findings suggest that lesions of the superior longitudinal fasciculus and arcuate fasciculus of the white matter fibers just below the left inferior parietal lobule are associated with bilingual aphasia.

Explainable Machine Learning for Atrial Fibrillation in the General Population Using a Generalized Additive Model　- A Cross-Sectional Study.

Background: Atrial fibrillation (AF) is the most common arrhythmia and is associated with increased thromboembolic stroke risk and heart failure. Although various prediction models for AF risk have been developed using machine learning, their output cannot be accurately explained to doctors and patients. Therefore, we developed an explainable model with high interpretability and accuracy accounting for the non-linear effects of clinical characteristics on AF incidence. Methods and Results: Of the 489,073 residents who underwent specific health checkups between 2009 and 2018 and were registered in the Kanazawa Medical Association database, data were used for 5,378 subjects with AF and 167,950 subjects with normal electrocardiogram readings. Forty-seven clinical parameters were combined using a generalized additive model algorithm. We validated the model and found that the area under the curve, sensitivity, and specificity were 0.964, 0.879, and 0.920, respectively. The 9 most important variables were the physical examination of arrhythmia, a medical history of coronary artery disease, age, hematocrit, γ-glutamyl transpeptidase, creatinine, hemoglobin, systolic blood pressure, and HbA1c. Further, non-linear relationships of clinical variables to the probability of AF diagnosis were visualized. Conclusions: We established a novel AF risk explanation model with high interpretability and accuracy accounting for non-linear information obtained at general health checkups. This model contributes not only to more accurate AF risk prediction, but also to a greater understanding of the effects of each characteristic.

Impact of salt intake on urinary albumin excretion in patients with type 2 diabetic nephropathy: a retrospective cohort study based on a generalized additive model.

Diabetic kidney disease is an important and common cause of end-stage renal disease. Measurement of urinary albumin excretion (UAE) requires the diagnosis of the stage of diabetic nephropathy and the prognosis of renal function. We aimed to analyze the impact of lifestyle modification on UAE in patients with stage 2 and 3 type 2 diabetic nephropathy who received comprehensive medical care, using a generalized additive model (GAM), an explanatory machine learning model. In this retrospective observational study, we used changes in HbA1c, systolic blood pressure (SBP), and diastolic blood pressure (DBP) levels; body mass index (BMI); and daily salt intake as factors contributing to changes in UAE. In total, 269 patients with type 2 diabetic nephropathy were enrolled (stage 2, 217 patients; stage 3, 52 patients). The rankings that contributed to changes in UAE over 6 months by permutation importance were the changes in daily salt intake, HbA1c, SBP, DBP, and BMI. GAM, which predicts the change in UAE, showed that with increase in the changes in salt intake, SBP, and HbA1c, the delta UAE tended to increase. Salt intake was the most contributory factor for the changes in UAE, and daily salt intake was the best lifestyle factor to explain the changes in UAE. Strict control of salt intake may have beneficial effects on improving UAE in patients with stage 2 and 3 diabetic nephropathy.

Artificial Intelligence in Current Diabetes Management and Prediction.

PURPOSE OF REVIEW: Artificial intelligence (AI) can make advanced inferences based on a large amount of data. The mainstream technologies of the AI boom in 2021 are machine learning (ML) and deep learning, which have made significant progress due to the increase in computational resources accompanied by the dramatic improvement in computer performance. In this review, we introduce AI/ML-based medical devices and prediction models regarding diabetes. RECENT FINDINGS: In the field of diabetes, several AI-/ML-based medical devices and regarding automatic retinal screening, clinical diagnosis support, and patient self-management tool have already been approved by the US Food and Drug Administration. As for new-onset diabetes prediction using ML methods, its performance is not superior to conventional risk stratification models that use statistical approaches so far. Despite the current situation, it is expected that the predictive performance of AI will soon be maximized by a large amount of organized data and abundant computational resources, which will contribute to a dramatic improvement in the accuracy of disease prediction models for diabetes.

Early Detection of Symptom Exacerbation in Patients With SARS-CoV-2 Infection Using the Fitbit Charge 3 (DEXTERITY): Pilot Evaluation.

BACKGROUND: Some patients with COVID-19 experienced sudden death due to rapid symptom deterioration. Thus, it is important to predict COVID-19 symptom exacerbation at an early stage prior to increasing severity in patients. Patients with COVID-19 could experience a unique "silent hypoxia" at an early stage of the infection when they are apparently asymptomatic, but with rather low SpO2 (oxygen saturation) levels. In order to continuously monitor SpO2 in daily life, a high-performance wearable device, such as the Apple Watch or Fitbit, has become commercially available to monitor several biometric data including steps, resting heart rate (RHR), physical activity, sleep quality, and estimated oxygen variation (EOV). OBJECTIVE: This study aimed to test whether EOV measured by the wearable device Fitbit can predict COVID-19 symptom exacerbation. METHODS: We recruited patients with COVID-19 from August to November 2020. Patients were asked to wear the Fitbit for 30 days, and biometric data including EOV and RHR were extracted. EOV is a relative physiological measure that reflects users' SpO2 levels during sleep. We defined a high EOV signal as a patient's oxygen level exhibiting a significant dip and recovery within the index period, and a high RHR signal as daily RHR exceeding 5 beats per day compared with the minimum RHR of each patient in the study period. We defined successful prediction as the appearance of those signals within 2 days before the onset of the primary outcome. The primary outcome was the composite of deaths of all causes, use of extracorporeal membrane oxygenation, use of mechanical ventilation, oxygenation, and exacerbation of COVID-19 symptoms, irrespective of readmission. We also assessed each outcome individually as secondary outcomes. We made weekly phone calls to discharged patients to check on their symptoms. RESULTS: We enrolled 23 patients with COVID-19 diagnosed by a positive SARS-CoV-2 polymerase chain reaction test. The patients had a mean age of 50.9 (SD 20) years, and 70% (n=16) were female. Each patient wore the Fitbit for 30 days. COVID-19 symptom exacerbation occurred in 6 (26%) patients. We were successful in predicting exacerbation using EOV signals in 4 out of 5 cases (sensitivity=80%, specificity=90%), whereas the sensitivity and specificity of high RHR signals were 50% and 80%, respectively, both lower than those of high EOV signals. Coincidental obstructive sleep apnea syndrome confirmed by polysomnography was detected in 1 patient via consistently high EOV signals. CONCLUSIONS: This pilot study successfully detected early COVID-19 symptom exacerbation by measuring EOV, which may help to identify the early signs of COVID-19 exacerbation. TRIAL REGISTRATION: University Hospital Medical Information Network Clinical Trials Registry UMIN000041421; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000047290.

Startup of pilot-scale single-stage nitrogen removal using anammox and partial nitritation (SNAP) reactor for waste brine treatment using marine anammox bacteria.

This study is the first to demonstrate the startup of a pilot-scale single-stage nitrogen removal using anammox and partial nitritation (SNAP) reactor utilizing marine anammox bacteria. A complete mixing type reactor, continuously fed with waste brine obtained from a natural gas plant (salinity 3%, NH4+-N 130-180 mg/L) and having an effective volume of 2 m3, achieved stable operation at temperatures of 20-30°C with a maximum nitrogen removal rate of 1.43 kg-N/m3/day. During the startup process, along with a small amount of seed sludge, granular sludge was additionally inoculated as a biomass carrier for the enrichment of ammonia oxidizing bacteria (AOB), followed by the enrichment of anammox bacteria. A mesh screen equipped at the outlet of the reactor facilitated the successful sludge retention in the reactor. Analysis of bacterial community composition indicated that Candidatus Scalindua was successfully enriched in the pilot SNAP reactor. These methods for stable sludge retention in the reactor greatly contributed to the startup of the first pilot-scale SNAP reactor using marine anammox bacteria.

A phase I study of high dose camostat mesylate in healthy adults provides a rationale to repurpose the TMPRSS2 inhibitor for the treatment of COVID-19.

Camostat mesylate, an oral serine protease inhibitor, is used to treat chronic pancreatitis and reflux esophagitis. Recently, camostat mesylate and its active metabolite 4-(4-guanidinobenzoyloxy)phenylacetic acid (GBPA) were reported to inhibit the infection of cells by severe acute respiratory syndrome coronavirus 2 by inhibiting type II transmembrane serine protease. We conducted a phase I study to investigate high-dose camostat mesylate as a treatment for coronavirus disease 2019. Camostat mesylate was orally administered to healthy adults at 600 mg 4 times daily under either of the following conditions: fasted state, after a meal, 30 min before a meal, or 1 h before a meal, and the pharmacokinetics and safety profiles were evaluated. In addition, the time of plasma GBPA concentration exceeding the effective concentration was estimated as the time above half-maximal effective concentration (EC50 ) by using pharmacokinetic/pharmacodynamic modeling and simulation. Camostat mesylate was safe and tolerated at all dosages. Compared with the fasted state, the exposure of GBPA after a meal and 30 min before a meal was significantly lower; however, no significant difference was observed at 1 h before a meal. The time above EC50 was 11.5 h when camostat mesylate 600 mg was administered 4 times daily in the fasted state or 1 h before a meal. Based on the results of this phase I study, we are currently conducting a phase III study.

Effect of sodium-glucose cotransporter-2 inhibitors on aldosterone-to-renin ratio in diabetic patients with hypertension: a retrospective observational study.

BACKGROUND: Plasma aldosterone-to-renin ratio (ARR) is popularly used for screening primary aldosteronism (PA). Some medications, including diuretics, are known to have an effect on ARR and cause false-negative and false-positive results in PA screening. Currently, there are no studies on the effects of sodium-glucose cotransporter-2 (SGLT2) inhibitors, which are known to have diuretic effects, on ARR. We aimed to investigate the effects of SGLT2 inhibitors on ARR. METHODS: We employed a retrospective design; the study was conducted from April 2016 to December 2018 and carried out in three hospitals. Forty patients with diabetes and hypertension were administered SGLT2 inhibitors. ARR was evaluated before 2 to 6 months after the administration of SGLT2 inhibitors to determine their effects on ARR. RESULTS: No significant changes in the levels of ARR (90.9 ± 51.6 vs. 81.4 ± 62.9) were found. Body mass index, diastolic blood pressure, heart rate, fasting plasma glucose, and hemoglobin A1c were significantly decreased by SGLT2 inhibitors. Serum creatinine was significantly increased. CONCLUSION: SGLT2 inhibitor administration yielded minimal effects on ARR and did not increase false-negative results in PA screening in patients with diabetes and hypertension more than 2 months after administration.

Unique hexameric structure of copper-containing nitrite reductase of an anammox bacterium KSU-1.

Anaerobic ammonium oxidation (anammox) and denitrification are two different microbial reactions that form nitrogen gas. The initial step in the anammox reaction-reduction of nitrite to nitric oxide-is thought to be catalyzed by homologs of dissimilatory nitrite reductase, which is known to be involved in denitrification. Here, we reveal the crystal structure of the copper-containing nitrite reductase (CuNIR) of strain KSU-1, an anammox bacterium. CuNIR had a unique homohexameric structure with three disulfide bridges between homotrimers, although the trimer was similar to that of known CuNIRs. Kinetic and mutagenesis analyses suggested that the hexameric structure is important for the electron transfer reaction.

A case of renovascular hypertension with incidental primary bilateral macronodular adrenocortical hyperplasia.

SUMMARY: Renovascular hypertension (RVHT) is an important and potentially treatable form of resistant hypertension. Hypercortisolemia could also cause hypertension and diabetes mellitus. We experienced a case wherein adrenalectomy markedly improved blood pressure and plasma glucose levels in a patient with RVHT and low-level autonomous cortisol secretion. A 62-year-old Japanese man had been treated for hypertension and diabetes mellitus for 10 years. He was hospitalized because of a disturbance in consciousness. His blood pressure (BP) was 236/118 mmHg, pulse rate was 132 beats/min, and plasma glucose level was 712 mg/dL. Abdominal CT scanning revealed the presence of bilateral adrenal masses and left atrophic kidney. Abdominal magnetic resonance angiography demonstrated marked stenosis of the left main renal artery. The patient was subsequently diagnosed with atherosclerotic RVHT with left renal artery stenosis. His left adrenal lobular mass was over 40 mm and it was clinically suspected the potential for cortisol overproduction. Therefore, laparoscopic left nephrectomy and adrenalectomy were simultaneously performed, resulting in improved BP and glucose levels. Pathological studies revealed the presence of multiple cortisol-producing adrenal nodules and aldosterone-producing cell clusters in the adjacent left adrenal cortex. In the present case, the activated renin-angiotensin-aldosterone system and cortisol overproduction resulted in severe hypertension, which was managed with simultaneous unilateral nephrectomy and adrenalectomy. LEARNING POINTS: Concomitant activation of the renin-angiotensin-aldosterone system and cortisol overproduction may contribute to the development of severe hypertension and lead to lethal cardiovascular complications. Treatment with simultaneous unilateral nephrectomy and adrenalectomy markedly improves BP and blood glucose levels. CYP11B2 immunohistochemistry staining revealed the existence of aldosterone-producing cell clusters (APCCs) in the adjacent non-nodular adrenal gland, suggesting that APCCs may contribute to aldosterone overproduction in patients with RVHT.

Primary aldosteronism subtype discordance between computed tomography and adrenal venous sampling.

The primary aldosteronism (PA) subtype is usually confirmed by CT and adrenal venous sampling (AVS). However, the subtype diagnosis by AVS is not necessarily consistent with the subtype diagnosis by CT. Patients with PA who show bilateral lesions (normal-appearing adrenals or bilateral adrenal nodules) on CT but unilateral disease on AVS are often found. The aim of this study was to evaluate whether patients with PA subtype discordance between CT and AVS obtain benefits from unilateral adrenalectomy. We retrospectively analyzed 362 consecutive patients with PA who underwent both CT and adrenocorticotropic hormone-unstimulated AVS at Kanazawa University Hospital. Surgical outcomes for unilateral PA were evaluated according to the criteria of the Primary Aldosteronism Surgical Outcome study. In our study, the success rate of AVS in patients with bilateral lesions on CT was 89% (191/214). Furthermore, the discordance rate between CT and AVS in patients with bilateral lesions on CT was 39% (74/191). After surgery, patients with bilateral lesions on CT but unilateral disease on AVS (n = 17) had a lower complete biochemical success rate than those with unilateral lesions on CT and ipsilateral disease on AVS (n = 30) (41% vs. 80%, p = 0.01), but clinical and biochemical benefits (the complete and partial success combined) were not significantly different between them (76% vs. 93% (p = 0.11) and 70% vs. 90% (p = 0.10), respectively). In conclusion, patients with bilateral lesions on CT but unilateral disease on AVS benefited from surgery, and AVS should be performed for patients who pursue surgical management when the CT findings suggest bilateral lesions.

Effects of vibration on anammox-enriched biofilm in a high-loaded upflow reactor.

An upflow biofilm reactor was operated for 211 days to investigate the effects of vibration on anammox treatment performance. With vibration, the highest nitrogen removal rates (20 kg-N·m-3·d-1) were obtained on day 180. Since the vibration could directly applied on the biofilm, it could release the dinitrogen gas accumulated in the biofilm timely and reduce the internal mass transfer resistance sharply. The specific anammox activity increased by more than 3 times with a higher vibration intensity. Meanwhile, the unique random motion caused by mechanical vibration promotes the production of extracellular proteins. Moreover, the VSS reached 20.97 g·L-1 which was 1.6 times higher than the control reactor. Such enrichment method resulted in a hard and thick anammox biofilm with a special granular morphology, and the nitrite tolerance concentration could reach 500 mg-N·L-1. Operated with an adequate vibration intensity could maintain the biofilm thickness and conducive to improve the stability of the reactor. In addition, this technique also allowed the microorganisms inside the biofilm and those on the surface to reach the same culture conditions. Base on the batch experiments, intermittent vibration caused a decrease in energy consumption from about 7.757 (kW·h)·(kg-N)-1 in group 0-Lv7(60-60) to 0.912 (kW·h)·(kg-N)-1 in group 0-Lv7(5-60). Compared to the internal recycle without vibration, the energy consumption fell by a slice over 65%. Furthermore, the high-throughput sequencing results showed that the relative abundance of Candidatus Kuenenia in reactor 1 increased from 13.2% to 43.9%.

Anammox Organism KSU-1 Expresses a Novel His/DOPA Ligated Cytochrome c.

Anammox is a bacterial energy metabolic process that forms N2 gas from nitrite and ammonium ions. The enzymatic mechanisms of anammox have been gradually revealed; however, the electron transport chain in anammox bacteria remains poorly understood. In the present study, we purified and characterized two low-molecular-weight c-type cytochromes from an enriched culture of the anammox bacterium strain, KSU-1. Their genes, KSU1_B0428 and KSU1_C0855, were identified in the KSU-1 genome, and their recombinant proteins were characterized. KSU1_B0428 is a typical c-type cytochrome with a His/Met coordinated heme, acting as an electron transfer protein. In contrast, KSU1_C0855 could not be assigned as a known cytochrome and its heme was suggested to have an uncommon axial ligand set. Crystal structural analyses of C0855 clearly showed that its heme iron is coordinated by His15 as a fifth ligand. Moreover, the sixth coordination site is occupied by the aromatic ring of Tyr60, and an unassignable electron density that is inseparable with that of aromatic carbon of Tyr60 was found. The additional electron density was assigned to an O atom by molecular mass analyses. Therefore, Tyr60 would be chemically modified to 3,4-dihydroxyphenylalanine and bound to the Fe atom. We revealed that an anammox bacterium strain KSU-1 expresses a novel cytochrome c having an unprecedented His/3,4-dihydroxyphenylalanine coordinating heme. The expression of the novel c-type cytochrome might be required for the redox reaction of the anammox process.

Temperature dependence of nitrogen removal activity by anammox bacteria enriched at low temperatures.

The anaerobic ammonium oxidation (anammox) process, which is applicable at ambient temperature, is necessary to develop more versatile nitrogen removal technologies. In this study, two anammox reactors, Low-R1 and Low-R2 inoculated with activated sludge respectively in Kumamoto and Hokkaido, Japan, achieved nitrogen removal rates (NRRs) of 1.5 kg-N/m3/day at 20°C. The specific anammox activity (SAA) of the Low-R1 and Low-R2 sludge samples had peaks, respectively, of 2.8±0.3 mg-N/g-VSS/h at 25°C and 4.2±0.3 mg-N/g-VSS/h at 30°C and dropped over the optimum temperature. Moreover, the SAA values of the Low-R1 and Low-R2 were higher at 10-25°C and 10-35°C, respectively, than that of an anammox reactor inoculated with activated sludge in Kumamoto operated at 35°C (Mod-R). The apparent activation energy for anammox of Low-R1, Low-R2, and Mod-R were 108 kJ/mol (10-25°C), 73 kJ/mol (10-30°C), and 89 kJ/mol (10-35°C), respectively. Candidatus Kuenenia stuttgartiensis dominated in the Mod-R sludge. The Low-R1 sludge was comprised of Ca. K. stuttgartiensis, Ca. Brocadia caroliniensis and Ca. B. fulgida and uncultured anammox-like or planctomycete-like bacteria. The Low-R2 sludge was comprised of various uncultured anammox-like or planctomycete-like bacteria. As Low-R2 was constructed, enrichment of freshwater anammox bacteria at low temperature with seed sludge collected from cold regions is expected to be an effective strategy for anammox applications under a wide temperature range.

Angiotensin II receptor blocker combined with eplerenone or hydrochlorothiazide for hypertensive patients with diabetes mellitus.

Experimental models recently suggested an interaction between aldosterone and adipose tissue, but clinical investigation has been limited. We studied the effects of eplerenone compared to hydrochlorothiazide (HCTZ) on blood pressure (BP), glucose, and lipid levels in 50 patients with essential hypertension (EHT) and type 2 diabetes mellitus whose BP failed to reach target levels with 8 mg of candesartan alone. BP improved similarly in both groups over the 12-month study period, but BMI, waist circumference, and LDL-cholesterol were decreased in the eplerenone group, while glycohemoglobin was elevated in the HCTZ group.

Granulocyte-colony stimulating factor-producing gallbladder carcinoma-include analysis all case reports: A case report.

INTRODUCTION: It is extremely rare for gallbladder carcinoma to produce granulocyte-colony stimulating factor (G-CSF) and such tumors have a poor prognosis. PRESENTATION OF CASE: A 67-year-old man was admitted with continuous fever. Laboratory tests showed a leukocyte count of 27,980/µL, serum C-reactive protein (CRP) of 9.2mg/dL and serum G-CSF of 225pg/mL. Imaging revealed an irregular gallbladder mass about 90mm in diameter with peripheral enhancement that also involved the liver and transverse colon. G-CSF producing gallbladder carcinoma was diagnosed. We performed cholecystectomy, partial resection of segments 4 and 5 of the liver, partial resection of the transverse colon, and gastrostomy. Histopathological examination showed gallbladder carcinoma (pT3, pN0, M0, G2, and pStage IIIA by the UICC classification, version 7). On immunohistochemical staining, tumor cells were positive for G-CSF. The leukocyte count was normalized postoperatively and fever subsided immediately after surgery. Two months later, the leukocyte count rose to 56,820/µL and metastases to the liver and lymph nodes were detected by CT. Chemotherapy (gemcitabine plus cisplatin) was started and the leukocyte count was normalized after the first course. The patient has continued chemotherapy and has survived for 16 months postoperatively. DISCUSSION: G-CSF producing gallbladder carcinoma has a poor prognosis and most patients die within 12 months of starting therapy. It is rare for patients with recurrence to survive for 16 months after surgery, as in the present case. CONCLUSION: Multidisciplinary therapy (surgery and chemotherapy) may prolong the survival of patients with G-CSF producing gallbladder carcinoma, especially those with recurrence.