Is Salmonella enterica shared between wildlife and cattle in cattle farming areas? An 11-year retrospective study in Tokachi district, Hokkaido, Japan.

BACKGROUND: Salmonella enterica in cattle has long been problematic and suspected to be transmitted by wildlife in Tokachi, Hokkaido, a major cattle farming area in Japan. Understanding the role of wildlife in S. enterica transmission would be helpful for developing control strategies of bovine salmonellosis. OBJECTIVES: We aimed to elucidate the possibility of S. enterica transmission between sympatric wildlife, including raccoons and crows and cattle, in Tokachi from 2008 to 2018 by analysing S. enterica detection records, and the genetic relatedness of serotypes shared between wildlife and cattle. METHODS: S. enterica detection records were based on the results of a field survey and existing cattle records at relevant organisations, including clinical reports, a monitoring survey and quarantine for introduced calves at growing farms and public calving farms. S. enterica was identified by polymerase chain reaction assay and serotyped by agglutination assay. The detection records were organised chronologically to investigate whether common serotypes in wildlife and cattle were detected in the same year. The isolates corresponding to detection records were assessed for their genetic patterns by pulsed-field gel electrophoresis. RESULTS: The prevalence of S. enterica in raccoons and crows was 10.7% (17/159) and 5.7% (55/967), respectively. The following serotypes were detected from both wildlife and cattle: Braenderup, Dublin, Infantis, Mbandaka, Montevideo, 4,[5],12:i:- and Typhimurium. Genetically similar isolates for S. Braenderup, S. Dublin, S. Montevideo and S. 4,[5],12:i:- were detected from both species in the same year. CONCLUSIONS: Our long-term retrospective observations supported that S. enterica was shared between wildlife and cattle. Wildlife invasions should be controlled at farms to prevent inter-species transmission of S. enterica from livestock farms.

Genetic population structure of invasive raccoons (Procyon lotor) in Hokkaido, Japan: Unique phenomenon caused by pet escape or abandonment.

Phylogeographic studies can resolve relationships between genetic population structure of organisms and geographical distributions. Raccoons have become feral in Japan, and in Hokkaido island, they have been rapidly increasing in number and spreading since the 1970s. We analyzed mitochondrial (mtDNA) and microsatellite DNA to understand the current phylogenetic distribution and invasive founder events. Overall, Hokkaido raccoons maintained high genetic diversity (i.e., the level of heterozygosity was comparable to the original habitat, North America). Based on mtDNA distribution and microsatellite diversity, Hokkaido raccoons were divided into six management units. However, mtDNA haplotype distributions and genetic structures based on microsatellites did not always correspond to each other (e.g., two geographically and genetically separated populations showed similar mtDNA distributions). In addition, a high degree of genetic admixture was observed in every unit, and the degree of genetic differentiation was low even between regions separated by long distances. Compared with other countries in Europe where genetic distribution of introduced raccoons is more clearly structured, the current results represent a unique and complex phenomenon of pet escape/abandonment in Hokkaido: i.e., genetically related colonies were introduced into multiple regions as founder events, resulting in the current state in which raccoons are not clearly genetically differentiated even 40 years after introduction.

First detection of influenza A virus genes from wild raccoons in Japan.

Serological surveys have shown that wild raccoons are exposed to influenza A viruses (IAVs); however, no genetic evidence for this IAV infection has been found. In the present study, we first detected IAV genes in wild raccoons captured during periods other than the wintering season of migratory waterfowl and epidemic season of influenza in Japan. Viral matrix (M) and nucleoprotein (NP) genes were detected by a conventional reverse transcription-polymerase chain reaction assay from three suckling siblings and one juvenile without any noticeable clinical signs, although the NP gene could not be detected from one sibling. The sequences of M gene fragments detected from the rectal swabs of three suckling siblings were comparable with each other but different from those detected from the nasal swab of the juvenile raccoon caught from a different site. The sequences of NP gene fragments detected from two suckling siblings were also comparable. These genetic evidences suggest that IAV is maintained among raccoon populations in the northern part of Japan. Further genetic and virological investigation of IAV infection in wild raccoons is needed to better understand the IAV ecology in the field.

Serologic evidence of Brucella infection in pinnipeds along the coast of Hokkaido, the northernmost main island of Japan.

Brucella infection in Hokkaido was serologically surveyed in four species of pinnipeds inhabiting Cape Erimo during 2008-2013 and the Shiretoko Peninsula in 1999 by ELISA using Brucella abortus and B. canis as antigens. Anti-Brucella positive sera showed higher absorbance to B. abortus than B. canis in almost all samples. Anti-B. abortus antibodies were detected in serum samples from 24% (n = 55) of Western Pacific harbor seals (Phoca vitulina stejnegeri) in Cape Erimo and from 66% (n = 41) of spotted seals (P. largha), 15% (n = 20) of ribbon seals (Histriophoca fasciata) and 18% (n = 17) of Western Steller's sea lions (Eumetopias jubatus jubatus) in the Shiretoko Peninsula. Anti-Brucella antibodies were detected at higher absorbance in 1- to 4-year-old harbor seals than in the pups and mature animals, suggesting either that Brucella infection mainly occurs after weaning or that it is maternally transmitted to pups with premature or suppressed immunity. Anti-Brucella antibodies were detected in both immature and mature spotted seals and ribbon seals, with higher absorbance in the former. The antibodies were detected only in mature Western Steller's sea lions. Western blot analysis of the serum samples showed some differences in band appearances, namely discrete versus smeary, and in the number of bands, indicating that multiple different Brucella may be prevalent in pinnipeds in Hokkaido. Alternatively, the Brucella of pinnipeds may have some intra-species diversity.

A specific mode of microsatellite instability is a crucial biomarker in adult T-cell leukaemia/lymphoma patients.

PURPOSE: Microsatellite instability (MSI) has been a long-standing biomarker candidate for drug resistance in tumour cells. Despite numerous clinical studies, the data in the literature are not conclusive. The complexity of the MSI phenomenon in some malignancies may, at least partly, account for the discrepancy. In addition, methodological problems are also pointed out in the assay techniques. We previously established a unique fluorescent technique in which the major methodological problems in conventional assays are overcome. Application of this technique has revealed two distinct modes of microsatellite alterations, i.e. Type A and Type B. More importantly, we demonstrated that Type A MSI is the direct consequence of defective DNA mismatch repair (MMR) that causes cellular resistance against antineoplastic agents. METHOD: We first applied this technique to adult T-cell leukaemia/lymphoma (ATLL). RESULTS: The MSI phenomenon was indeed observed in ATLLs (4/20, 20%). Intriguingly, the observed microsatellite alterations were invariably Type A, which implies that the tumours were MMR-defective. Indeed, clinical outcomes of patients with these MSI+ tumours were significantly worse. Furthermore, multivariate analysis revealed that Type A MSI is an independent prognostic factor. CONCLUSION: These observations strongly suggest the possibility of Type A MSI as a prognostic and potentially predictive biomarker in ATLL.

Superior mesenteric artery plasty for type A acute aortic dissection with visceral ischemia.

Treatment of visceral ischemia complicated with acute type A aortic dissection is controversial. We had two cases of acute type A aortic dissection complicated by superior mesenteric artery (SMA) ischemia and successfully treated them with direct SMA perfusion during central aortic repair followed by SMA plasty. The presented procedures can be an option to treat visceral ischemia with a standard operative theater and equipment.

Valve selection for the aortic position in dialysis patients.

BACKGROUND: Prosthetic valve selection in dialysis patients remains controversial because of the limited data available. This study aimed to clarify late clinical outcomes and discuss strategies for optimal valve selection in dialysis patients. METHODS: We retrospectively analyzed the data obtained from 406 consecutive patients who underwent aortic valve replacement between 1995 and 2010. We compared valve-related outcomes among 89 dialysis and 317 nondialysis patients. We selected bioprostheses for all patients older than 65 to 70 years, irrespective of the renal function. RESULTS: Dialysis was found to be a significant risk factor for bleeding events (hazard ratio, 3.98; 95% confidence interval, 2.51 to 6.30; p < 0.001), however, no significant differences were observed according to the type of prosthesis. The overall survival was significantly worse in the dialysis patients (63% versus 85% at 5 years; p < 0.001), and freedom from structural valve deterioration was also lower in the dialysis patients (82% versus 100% at 5 years; p < 0.001). Among the dialysis patients, an advanced age (≥ 70 years; hazard ratio, 3.53; p = 0.011), diabetes mellitus (hazard ratio, 2.48; p = 0.041), and concomitant coronary artery bypass grafting (hazard ratio, 1.99; p = 0.071) were independent predictors for late death based on a multivariate analysis. CONCLUSIONS: Our valve selection criteria in dialysis patients, which are the same as the current practice guidelines for nondialysis patients, are acceptable. Bioprostheses can be considered in all dialysis patients with diabetes or coronary artery disease.

Prevalence of multiple subtypes of influenza A virus in Japanese wild raccoons.

Raccoons (Procyon lotor), which are not native to Japan, have been suspected to transmit various pathogens by frequent intrusion into agricultural and residential areas. To determine influenza A virus seropositivity in raccoons in Japan, we examined a total of 634 raccoons captured in 19 towns (A-S) from 2009 to 2012. Agar gel precipitation tests showed that the antibody prevalence was 1.89% (12/634). All positive raccoons were captured in three towns (A-C) located within a radius of approximately 30km, and 75% had antibodies to multiple subtypes (H1, H3-5, N1, N6, and N8). H3 and N8 antibodies were most frequently detected (75%). Among all the raccoons captured, 67% (8/12) were found in town A in 2009 and 2010, and all five raccoons captured in 2010 had H3 and N8 antibodies, suggesting that transmission of the subtype might occur. H5 and N1 antibodies were also detected in two raccoons captured in town A. Virus neutralization tests examining the highly pathogenic avian influenza virus (HPAIV) H5N1 subtype (four isolates of which have been detected in Japan to date) and the low PAIV (LPAIV) H5N3 subtype showed that raccoon sera highly cross-reacted with three H5N1 strains (clade 2.5: Ck/Yamaguchi/7/04; clade 2.3.2.1: Whooper swan/Hokkaido/1/08 and Whooper swan/Hamanaka/11), while they displayed a low cross-reactivity with the antisera to the clade 2.2 virus (Ck/Miyazaki/K11/07) and H5N3 LPAIV (Whistling swan/Shimane/499/83). Thus, the origin of the H5N1 virus was not clearly defined. The viral M gene was detected in four antibody-negative raccoons captured in three towns by real-time reverse transcription-polymerase chain reaction (rRT-PCR) with high Ct values, although no virus was isolated. This study is the first report showing that raccoons of Japan were infected with multiple subtypes of influenza A virus, including H5N1. It remains to be elucidated how raccoons play a role in persistence of influenza A virus in nature and if they could pose risks to animal and human health, for example, by playing a role as "mixing vessel" to generate novel strains of influenza A virus.

The presence of disease-associated prion protein in skeletal muscle of cattle infected with classical bovine spongiform encephalopathy.

The aim of this study was to investigate the presence of disease-associated prion protein (PrP(Sc)) in the skeletal muscle of cattle infected with classical bovine spongiform encephalopathy (C-BSE). The study was carried out systematically in 12 different muscle samples from 43 (3 field and 40 experimental) cases of C-BSE; however, muscle spindles were not available in many of these cases. Therefore, analysis became restricted to a total of 31 muscles in 23 cattle. Even after this restriction, low levels of PrP(Sc) were detected in the muscle spindles of the masseter, intercostal, triceps brachii, psoas major, quadriceps femoris and semitendinosus muscles from 3 field and 6 experimental clinical-stage cases. The present data indicate that small amounts of PrP(Sc) are detectable by immunohistochemistry in the skeletal muscles of animals terminally affected with C-BSE.

Clinical validation of coronary artery flow through an intracoronary shunt during off-pump coronary artery bypass grafting.

OBJECTIVES: Intracoronary shunts have been developed for a bloodless field and preserved forward flow preventing ischemia during off-pump coronary artery bypass (OPCAB) surgery. However, reports directly measuring the forward flow through the shunt in clinical settings are lacking. METHODS: Using a 7.5-MHz Doppler probe, we investigated the coronary flow through a 1.5-mm shunt inserted into the left anterior descending artery (LAD) for anastomosis with the internal thoracic artery during OPCAB in 30 consecutive patients. The following Doppler flow parameters were obtained before and after shunting: peak velocity, mean velocity, time-velocity integral, and flow. RESULTS: No patients developed significant electrocardiographic changes and the peak value of postoperative myocardial band of creatine kinase was 17 ± 16 IU/L. All Doppler flow parameters of the LAD decreased significantly after shunting; peal velocity: 71.3 ± 34.6 cm/second to 54.5 ± 25.3 cm/second (-24% ± 27%), mean velocity: 33.3 ± 18.3 cm/second to 26.3 ± 14.0 cm/second (-21% ± 23%), and time-velocity integral: 28.7 ± 12.1 cm to 19.0 ± 7.1 cm (-28% ± 14%), and flow: 38.7 ± 16.8 mL/minute to 25.0 ± 9.5 mL/minute (-31% ± 13%) (P < .01). CONCLUSIONS: The LAD flow is preserved at least 50% through a 1.5-mm intracoronary shunt, although the flow pattern was attenuated, during OPCAB anastomosis. The Doppler evaluation of the coronary artery flow before and after shunting is useful to justify the protective use of the shunt on myocardial perfusion during OPCAB.

Effects of the side of arteriovenous fistula on outcomes after coronary artery bypass surgery in hemodialysis-dependent patients.

OBJECTIVE: The aim of the study was to determine whether using the in situ internal thoracic artery (ITA) graft ipsilateral to the arteriovenous fistula adversely affects the outcomes after isolated coronary artery bypass grafting (CABG) in the dialysis-dependent patients to answer the concerns of a possible steal and consequent myocardial ischemia. METHODS: We categorized 155 dialysis patients undergoing isolated CABG between January 1993 and December 2011 into 108 patients (70%, ipsilateral group) whose left anterior descending artery (LAD) was revascularized with the ITA ipsilateral to the arteriovenous fistula and 47 patients (contralateral group) whose LAD was grafted with the ITA opposite to the fistula, to compare their early and late outcomes. RESULTS: While 94% of the ipsilateral group had left fistula, 55% of the contralateral group had left fistulas. The LAD was grafted with the left ITA in 94% of the ipsilateral group, whereas it was grafted with left (49%) or right (51%) ITAs in the contralateral group. There was no significant difference in hospital mortality between the groups (ipsilateral 10.2% vs contralateral 10.6%). After follow-up for 55 ± 42 months, the overall survival (ipsilateral 58% vs contralateral 65% at 5 years) and cardiac event-free rates (ipsilateral 74% vs contralateral 68% at 5 years) were also similar between the groups by log-rank tests (P = .90 and P = .07). CONCLUSIONS: Revascularization of the LAD using the in situ ITA graft ipsilateral to the arteriovenous fistula increases neither the operative mortality nor the risks of late death and cardiac events after isolated CABG in dialysis patients.

Recent risk factors for open surgical mortality in patients with ruptured abdominal aortic aneurysm.

AIM: We examined recent relevant prognostic factors for the outcome of open surgical treatment of ruptured abdominal aortic aneurysm. METHODS: Between 2006 and 2012, 35 patients received emergency open surgical treatment for ruptured abdominal aortic aneurysm at our institute. We reviewed ambulance activity logs and clinical records of 34 infrarenal ruptured abdominal aortic aneurysm patients retrospectively. Univariate and multivariate logistic regression analyses were carried out to identify risk factors for surgical outcomes. RESULTS: Eight patients died during surgery or within a few hours following surgery completion. Through univariate analysis, body mass index, serum lactate level, arterial blood pH, base excess, platelet count, prothrombin time-international normalized ratio, activated partial thromboplastin time, type of ruptured aneurysm, response to i.v. fluid resuscitation within 2,000 mL in the initial therapy, and volume of blood loss during surgery were detected to be significant variants. Multivariate logistic regression analysis revealed the patients who were hemodynamically stabilized after primary volume loading had a 13.2 times higher possibility of survival. Body mass index, high serum lactate level, and volume of blood loss were also found to be independent risk factors of mortality. CONCLUSION: The risk factors of open surgical ruptured abdominal aortic aneurysm repair, body mass index, lactate level, volume of intraoperative blood loss, and response to initial 2,000 mL fluid resuscitation were correlated to survival.

Predictors for early and late outcomes after coronary artery bypass grafting in hemodialysis patients.

BACKGROUND: Markedly higher hospital and long-term mortality after coronary artery bypass grafting (CABG) have been reported in hemodialysis (HD)-dependent patients. We tried to identify the predictors for short-term and long-term outcomes after CABG, which have not been well studied. METHODS: Between 1993 and 2010, 152 patients undergoing HD (117 men; HD duration of 8.7±8.0 years) underwent isolated CABG. Our strategies included use of a single internal thoracic artery (ITA) in patients with diabetes mellitus (DM), bilateral ITAs in patients without DM, and possible avoidance of cardiopulmonary bypass (CPB) after 2003. RESULTS: Thirty-six percent of patients underwent conventional CABG: 20% had on-pump beating heart procedures and 44% had off-pump procedures, with 2.8±1.0 anastomoses. Hospital mortality was 10.6% with improvement to 6.8% after 2003. Predictors for hospital death were left ventricular ejection fraction (LVEF) less than 0.40 (p=0.042), use of CPB (p=0.046), and postoperative need for continuous hemofiltration (p=0.037). After follow-up of 49±42 months, the overall survival rates were 76.9%, 60.0%, 43.9%, and 36.2% and the cardiac events-free rates were 77.0%, 70.1%, 55.9%, and 44.8% at 3, 5, 8, and 10 years, respectively, in the Kaplan-Meier model. A multivariate Cox proportional hazard model identified age older than 63 years (p=0.014), DM (p=0.036), and peripheral artery disease (PAD) (p=0.044) as predictors for late death, and DM (p=0.038) and LVEF less than 0.40 (p=0.027) as predictors for late cardiac events. CONCLUSIONS: Although early outcomes have been improved by off-pump techniques, late outcomes are not satisfactory in patients who rely on HD and undergo CABG. To improve late outcomes we may need aggressive management of DM, PAD, and low LVEF in those patients.

Can we predict the site of entry tear by computed tomography in patients with acute type a aortic dissection?

BACKGROUND: In patients with acute type A aortic dissection (AAD), localization of the primary entry tear to be excluded is of major importance for intervention. HYPOTHESIS: There are reliable indirect computed tomography (CT) findings to predict the entry site. METHODS: In 83 patients with type A AAD whose primary entry tears were identified surgically between 2003 and 2009, we retrospectively examined the diagnostic CT scans regarding pericardial effusion, the largest short-axial diameter of the aorta, widths of true and false lumens, and false lumen thrombosis at 6 levels of thoracic aorta from the aortic root to the descending aorta. RESULTS: The primary entry sites identified intraoperatively were proximal ascending in 21 patients, middle ascending in 21, distal ascending in 21, arch in 17, and descending or unknown in 16. The multivariate logistic analysis revealed that pericardial effusion (odds ratio [OR]: 2.2, 95% confidence interval [CI]: 1.2-3.4, P < 0.001) and dilated ascending aorta (OR: 1.6, 95% CI: 1.1-2.4, P = 0.012) were the significant CT findings to predict the entry tear in the ascending aorta. It also revealed that the significant CT finding to predict the entry tear distal to the aortic arch was nonthrombosed false lumen in the descending aorta (OR: 1.2, 95% CI: 1.1-2.1, P = 0.048). CONCLUSIONS: We can predict the primary entry site by the preoperative CT findings in patients with type A AAD, considering pericardial effusion, aortic diameter, widths of true and false lumens, and false lumen thrombosis at different anatomic levels.

Long-term size follow-up of knitted Dacron grafts (Gelseal™) used in the ascending aorta.

There is limited information about the size change of a knitted Dacron graft (Gelseal™) used in the thoracic aorta. We evaluated the diameters of the Gelseal™ grafts at a long-term follow-up for 3.7 ± 1.3 years (1-5.9 years; median, 4.0 years), which were used for replacement of the ascending aorta in 59 patients with acute aortic dissection. The early and late dilatation rates (LDRs) of the prosthetic grafts were calculated retrospectively based on the graft diameter at the level equivalent to the ascending aorta on the pre-discharge computed tomography (CT) scans and follow-up CT scans performed every year after surgery. Immediately after surgery (15 ± 7 days), the early dilatation of the Gelseal™ grafts was 26.0 ± 6.0% with significant correlations with the number of post-operative days (R = 0.500, P = 0.003). At the follow-up for 3.7 ± 1.3 years, the LDR was 10.5 ± 6.6%, which was also significantly correlated with the number of the post-operative years (R = 0.608, P = 0.001). Linear regression analysis indicated that the annual dilatation rate was ≈ 3.23%. During the follow-up, we have experienced no redo surgery due to graft fracture or false aneurysm formation at the anastomosis sites associated with the graft dilatation. In conclusion, the Gelseal™ graft used in the ascending aorta demonstrates a small but continuous increase in the diameter, up to 5 years after implantation, without any adverse events.

Neuroanatomical distribution of disease-associated prion protein in experimental bovine spongiform encephalopathy in cattle after intracerebral inoculation.

The pathologic disease-associated prion protein (PrP(Sc)) has been shown to be expressed in the central nervous system of Holstein cattle inoculated intracerebrally with 3 sources of classical bovine spongiform encephalopathy (BSE) isolates. Several regions of the brain and spinal cord were analyzed for PrP(Sc) expression by immunohistochemical and Western blotting analyses. Animals euthanized at 10 months post-inoculation (mpi) showed PrP(Sc) deposits in the brainstem and thalamus, but no vacuolation; this suggested that the BSE agent might exhibit area-dependent tropism in the brain. At 16 and 18 mpi, a small amount of vacuolation was detected in the brainstem and thalamus, but not in the cerebral cortices. At 20 to 24 mpi, when clinical symptoms were apparent, heavy PrP(Sc) deposits were evident throughout the brain and spinal cord. The mean time to the appearance of clinical symptoms was 19.7 mpi, and the mean survival time was 22.7 mpi. These findings show that PrP(Sc) accumulation was detected approximately 10 months before the clinical symptoms of BSE became apparent. In addition, the 3 sources of BSE prion induced no detectable differences in the clinical signs, incubation periods, neuroanatomical location of vacuoles, or distribution and pattern of PrP(Sc) depositions in the brain.

Neuroanatomical distribution of disease-associated prion protein in cases of bovine spongiform encephalopathy detected by fallen stock surveillance in Japan.

Bovine spongiform encephalopathy (BSE) is a fatal neurodegenerative disorder of cattle characterized by accumulation of the disease-associated prion protein (PrP(Sc)) in the central nervous system (CNS). The immunohistochemical patterns and distribution of PrP(Sc) were investigated in the CNS, brains, and spinal cords of 7 naturally occurring BSE cases confirmed by the fallen stock surveillance program in Japan. No animals showed characteristic clinical signs of the disease. Coronal slices of 14 different brain areas in each case were immunohistochemically analyzed using an anti-prion protein antibody. Immunolabeled PrP(Sc) deposition was widely observed throughout each brain and spinal cord. Intense PrP(Sc) deposition was greater in the thalamus, brainstem, and spinal cord of the gray matter than in the neocortices. The topographical distribution pattern and severity of PrP(Sc) accumulation were mapped and plotted as immunohistochemical profiles of the different brain areas along the caudal-rostral axis of the brain. The distribution pattern and severity of the immunolabeled PrP(Sc) in the CNS were almost the same among the 7 cases analyzed, suggesting that the naturally occurring cases in this study were at the preclinical stage of the disease. Immunohistochemical mapping of the PrP(Sc) deposits will be used to clarify the different stages of BSE in cattle.

Simplified management of hemodialysis-dependent patients undergoing cardiac surgery.

BACKGROUND: The mortality and morbidity rates are high after cardiac surgery in hemodialysis (HD)-dependent patients. To improve their outcomes, optimal perioperative managements should be discussed. METHODS: A retrospective analysis of 245 HD patients who underwent cardiac surgery between 1994 and 2007 was conducted. The basic management strategies were (1) low-potassium HD for 2 days before surgery, (2) only hemofiltration during cardiopulmonary bypass, and (3) start of regular intermittent HD on the first postoperative day. Continuous venovenous hemodiafiltration was applied only for patients with hemodynamic instability. RESULTS: The causes of renal failure included diabetic (n = 89, 36%), glomerulonephritis (n = 49, 20%), and unknown (n = 75, 31%). The history of HD was 9.7 +/- 7.6 years. The operative procedures included coronary (n = 135), valve (n = 103), and others. The amount of intraoperative ultrafiltration was 6,123 +/- 324 mL during cardiopulmonary bypass for 197 +/- 67 minutes. Two hundred eight patients (85%) were managed with only intermittent HD, whereas 36 patients (15%) needed continuous venovenous hemodiafiltration. The use of continuous venovenous hemodiafiltration significantly declined during the year (26% before 2003 and 3% after 2003; p < 0.001). The amount of fluid removal on the first postoperative day was 1,297 +/- 81 mL. The hospital mortality was 9.7% with the causes including infection (n = 11), cardiac events (n = 6), gastrointestinal events (n = 5), and stroke (n = 2). A multivariate logistic regression analysis revealed that selection of intermittent HD or continuous venovenous hemodiafiltration was not related to the hospital mortality. CONCLUSIONS: Simplified management only with intermittent HD can be safely performed in most HD-dependent patients undergoing cardiac surgery.

Transit-time flow characteristics of in situ right gastroepiploic arterial grafts in coronary artery bypass grafting.

OBJECTIVE: We investigated flow characteristics of right gastroepiploic arterial grafts, widely used to extend in situ arterial conduits in coronary artery bypass grafting. METHODS: Intraoperative transit-time measurements and postoperative angiographic findings were obtained for 111 patients undergoing coronary artery bypass grafting with gastroepiploic artery and bilateral internal thoracic arteries: mean, maximum, and minimum flows; pulsatility index; insufficiency rate; and differentiated index of early diastolic flow. RESULTS: Favored target for gastroepiploic artery was posterior descending artery (106 patients, 95%). Patency rates were 91.0% for gastroepiploic artery, 98.2% for left internal thoracic artery, and 97.5% for right internal thoracic artery. There were four flow profiles of gastroepiploic arteries: A (systolic protruded), B (trapezoidal), C (sine waved), and D (diastolic-dominant biphasic). Functional gastroepiploic arteries showed A in 16 cases, B in 6, C in 31, and D in 48, with prevalence according to severity of stenosis in target coronary artery. Two occluded gastroepiploic arteries showed type A, and reverse or competitive flows were types A in 1, B in 1, C in 4, and D in 2. Relative to functional internal thoracic arteries, functional gastroepiploic arteries showed significantly lower minimum flow, higher insufficiency rate, and lower differentiated index of early diastolic flow. CONCLUSION: Intraoperative transit-time flow profiles of patent in situ gastroepiploic arterial grafts were classified into four types, closely associated with disease severity of target coronary artery. Patent in situ gastroepiploic arterial grafts show more regurgitant flow and lower differentiated index of early diastolic flow than in situ internal thoracic arterial grafts.