Safety and feasibility of retrograde INOUE-BALLOON for balloon aortic valvuloplasty without rapid ventricular pacing during transcatheter aortic valve replacement.

Rapid ventricular pacing (RVP) is commonly employed during transcatheter aortic valve replacement (TAVR); however, frequent TAVR is associated with worse prognoses. The retrograde INOUE-BALLOON® (IB) allows balloon aortic valvuloplasty (BAV) without RVP. The aim of this study was to evaluate the feasibility of retrograde IB for TAVR preparation. The study population included 178 consecutive patients (mean age, 84 ± 5 years; male, 47%) who underwent retrograde BAV before prosthetic valve replacement via the transfemoral approach. Patients were divided into a retrograde IB group without RVP (n = 74) and a conventional balloon (CB) group with RVP (n = 104). The primary endpoint was prolonged hypotension after BAV (reduced systolic pressure < 80 mmHg for over 1 min or vasopressor drug requirement). The incidence of prolonged hypotension after BAV was significantly lower in the IB group compared with the CB group (4% vs. 16%, p = 0.011). Balloons were able to penetrate and expand the aortic valve in both groups. RVP was used less for total TAVR in the IB group compared with the CB group. The aortic valve area-index after BAV was not significantly different between the two groups (0.72 ± 0.14 cm2/m2 vs. 0.71 ± 0.12 cm2/m2; p = 0.856). Multivariate analysis demonstrated that IB use was associated with avoidance of prolonged hypotension (OR, 0.27 [0.059-0.952]; p = 0.041). In conclusion, BAV using retrograde IB without RVP is both safe and feasible. More stable hemodynamics were achieved using retrograde IB by avoiding RVP during TAVR.

Additive Value of CT to Age, Aortic Diameter, and Echocardiography in Diagnosis and Classification of Bicuspid Aortic Valve in Patients with Severe Aortic Stenosis.

PURPOSE: To develop and validate a CT diagnostic algorithm for bicuspid aortic valve (BAV) classification. MATERIALS AND METHODS: This retrospective study included 212 consecutive patients with severe aortic stenosis who underwent CT followed by aortic valve replacement (mean age, 71 years [range, 27-93 years]; 125 women; 37% with a BAV) from 2012 to 2017. BAV diagnosis and BAV category were determined by using the CT diagnostic algorithm developed and were compared with those attained through surgical diagnosis. Reproducibility and agreement were assessed using the Cohen kappa (κ) coefficient. The value of adding CT to age, aortic diameter index, and transthoracic echocardiography (TTE) was evaluated by using the area under the receiver operating characteristic curve (AUC), net reclassification improvement (NRI), and decision-curve analysis. RESULTS: Intra- and interobserver reproducibility were good or excellent for all CT diagnoses (κ ≥ 0.6 for all). Agreement between CT and surgical diagnoses was excellent (κ = 0.90) for BAV detection and good (κ = 0.69) for BAV categorization. Sixteen percent (five of 31) of patients with functional BAV diagnosed by using CT received a diagnosis of congenital BAV at surgery. The addition of CT to age, aortic diameter, and TTE showed a higher AUC (with CT, 0.97 [95% CI: 0.91, 0.99] vs without CT, 0.91 [95% CI: 0.85, 0.95]; P = .003) and NRI (1.79 [95% CI: 1.65, 1.92], P < .001) and a higher net benefit among all BAV probabilities. CONCLUSION: CT diagnosis was consistent with surgical diagnosis and had an additive value over traditional diagnostic methods; however, there was a risk of overlooking congenital BAV in patients with functional BAV diagnosed by using CT.Supplemental material is available for this article.© RSNA, 2021.

Clear Evidence of LAMA5 Gene Biallelic Truncating Variants Causing Infantile Nephrotic Syndrome.

Background: Pathogenic variants in single genes encoding podocyte-associated proteins have been implicated in about 30% of steroid-resistant nephrotic syndrome (SRNS) patients in children. However, LAMA5 gene biallelic variants have been identified in only seven patients so far, and most are missense variants of unknown significance. Furthermore, no functional analysis had been conducted for all but one of these variants. Here, we report three patients with LAMA5 gene biallelic truncating variants manifesting infantile nephrotic syndrome, and one patient with SRNS with biallelic LAMA5 missense variants. Methods: We conducted comprehensive gene screening of Japanese patients with severe proteinuria. With the use of targeted next-generation sequencing, 62 podocyte-related genes were screened in 407 unrelated patients with proteinuria. For the newly discovered LAMA5 variants, we conducted in vitro heterotrimer formation assays. Results: Biallelic truncating variants in the LAMA5 gene (NM_005560) were detected in three patients from two families. All patients presented with proteinuria within 6 months of age. Patients 1 and 2 were siblings possessing a nonsense variant (c.9232C>T, p.[Arg3078*]) and a splice site variant (c.1282 + 1G>A) that led to exon 9 skipping and a frameshift. Patient 3 had a remarkable irregular contour of the glomerular basement membrane. She was subsequently found to have a nonsense variant (c.8185C>T, p.[Arg2720*]) and the same splice site variant in patients 1 and 2. By in vitro heterotrimer formation assays, both truncating variants produced smaller laminin α5 proteins that nevertheless formed trimers with laminin ß1 and γ1 chains. Patient 4 showed SRNS at the age of 8 years, and carried compound heterozygous missense variants (c.1493C>T, p.[Ala498Val] and c.8399G>A, p.[Arg2800His]). Conclusions: Our patients showed clear evidence of biallelic LAMA5 truncating variants causing infantile nephrotic syndrome. We also discerned the clinical and pathologic characteristics observed in LAMA5-related nephropathy. LAMA5 variant screening should be performed in patients with congenital/infantile nephrotic syndrome.

Sex-Related Differences in Cardiac Remodeling and Reverse Remodeling After Transcatheter Aortic Valve Implantation in Patients with Severe Aortic Stenosis in a Japanese Population.

Left ventricular (LV) remodeling with aortic stenosis (AS) appears to differ according to sex, but reverse remodeling after transcatheter aortic valve implantation (TAVI) has not been elucidated in a Japanese population. This study aims to determine whether any sex-related differences in LV or reverse remodeling after TAVI exist in the context of severe AS.Of 208 patients who received TAVI for severe AS in our institution, 100 (men, 42; mean age, 83.0 ± 4.9 years) underwent transthoracic echocardiography before and 3 months after TAVI. Despite similar valvular gradients, women with severe AS had lower indexed LV mass (LVMi) than did men (152.3 ± 35.4 versus 173.2 ± 44.6 g/m2, P = 0.005), with smaller indexed LV end-diastolic (LVEDVi) (50.2 ± 13.3 versus 61.4 ± 20.7 mL/m2, P = 0.001) and end-systolic (LVESVi; 17.9 ± 8.7 versus 24.3 ± 13.8 mL/m2, P = 0.006) volumes. After TAVI, women (-6.0% ± 14.4%) had higher reduction in the rate of change of relative wall thickness (RWT) than did men (4.4% ± 19.0%, P = 0.003). Men (-8.9% ± 3.9%) had higher reduction in the rate of change of LVEDVi than did women (1.5% ± 3.3%, P = 0.045). Incidence of LV reverse remodeling defined as a reduction in LVESV of >15% was significantly higher in men (50%) than in women (26%, P = 0.013).In addition to sex differences in the pattern of LV remodeling with AS, reverse LV remodeling after TAVI also differed between sexes.

Association between Neighborhood Environment and Quality of Sleep in Older Adult Residents Living in Japan: The JAGES 2010 Cross-Sectional Study.

Poor sleep is associated with lifestyle, however, few studies have addressed the association between sleep quality and the neighborhood environment. This study aimed to investigate the associations between living environment factors and sleep quality in older people. Participants were community-dwelling people aged ≥65 years who participated in the 2010 Japanese Gerontological Evaluation Study. The data of 16,650 people (8102 men, 8548 women) were analyzed. Sleep quality (good or poor) was evaluated using a self-administered questionnaire. Multilevel Poisson regression analysis stratified by depressive status (measured by the Geriatric Depression Scale-15 [GDS]) was conducted with sleep quality as the dependent variable and social and physical environmental factors as explanatory variables. The 12,469 non-depressive respondents and 4181 depressive respondents were evaluated. The regression analysis indicated that non-depressive participants slept better if they lived in environments with few hills or steps (prevalence ratio [PR] = 0.75, 95% CI: 0.56-0.9) and with places where they felt free to drop in (PR = 0.51, 95% CI: 0.26-0.98). For depressive participants, these associations were not evident. Living alone, poor self-rated health, low income, and unemployment were associated with poor sleep quality. In addition to support with these individual factors, improving environmental factors at the neighborhood level may improve the sleep quality of community-dwelling older adults.

Correction: Treatment with silver nitrate versus topical steroid treatment for umbilical granuloma: A non-inferiority randomized control trial.

[This corrects the article DOI: 10.1371/journal.pone.0192688.].

Large bowel obstruction caused by urinary retention from benign prostate hyperplasia.

Although large bowel obstruction is a common surgical emergency, its occurrence due to bladder distension is rarely reported in the literature. We report a case of large bowel obstruction caused by bladder distention secondary to benign prostate hyperplasia in a 67-year-old man. This case demonstrates a grossly distended urinary bladder compressing the rectosigmoid colon against the sacrum, presenting as a complete large bowel obstruction. Management consisted of transurethral urinary catheter insertion, which resulted in complete resolution of the bowel obstruction with drainage of a large amount of urine. Early recognition of the underlying etiology resulted in the expeditious treatment of large bowel obstruction.

Treatment with silver nitrate versus topical steroid treatment for umbilical granuloma: A non-inferiority randomized control trial.

OBJECTIVE: The aim of this prospective multicenter randomized controlled trial was to compare the efficacy of silver nitrate cauterization against that of topical steroid ointment in the treatment of neonatal umbilical granuloma. METHODS: An open-label, non-inferiority randomized controlled trial was conducted from January 2013 to January 2016. The primary endpoint for the silver nitrate cauterization and topical steroid ointment groups was the healing rate after 2 weeks of treatment, applying a non-inferiority margin of 10%. The healing rate was evaluated until completion of 3 weeks of treatment. RESULTS: Participants comprised 207 neonates with newly diagnosed umbilical granuloma, randomized to receive silver nitrate cauterization (n = 104) or topical steroid ointment (n = 103). Healing rates after 2 weeks of treatment were 87.5% (91/104) in the silver nitrate cauterization and 82% (82/100) in the topical steroid ointment group group. The difference between groups was -5.5% (95% confidence interval, -19.1%, 8.4%), indicating that the non-inferiority criterion was not met. After 3 weeks of treatment, the healing rate with topical steroid ointment treatment was almost identical to that of silver nitrate cauterization (94/104 [90.4%] vs. 91/100 [91.0%]; 0.6% [-13.2 to 14.3]). No major complications occurred in either group. CONCLUSIONS: This study did not establish non-inferiority of topical steroid ointment treatment relative to silver nitrate cauterization, presumably due to lower healing rates than expected leading to an underpowered trial. However, considering that silver nitrate cauterization carries a distinct risk of chemical burns and that the overall efficacy of topical steroid ointment treatment is similar to that of silver nitrate cauterization, topical steroid ointment might be considered as a good alternative in the treatment of neonatal umbilical granuloma due to its safety and simplicity. To clarify non-inferiority, a larger study is needed.

3D-computed tomography to compare the dimensions of the left atrial appendage in patients with normal sinus rhythm and those with paroxysmal atrial fibrillation.

Although paroxysmal atrial fibrillation (PAF) is an important cause of cardioembolic stroke, in contrast to chronic AF patients, the anatomical features of the left atrial appendage (LAA) in PAF patients remain unknown. Here, we investigated differences in LAA structures in patients with PAF and those with normal sinus rhythms (NSR) using 3D-computed tomography (3D-CT), which allows us to visualize complicated LAA structures at high spatial resolution. Study subjects were 30 consecutive PAF and 30 NSR patients with complete enhanced cardiac 3D-CT images available. After reconstruction of 3D LAA images, anatomical parameters of the LAA were measured and compared according to three proposed definitions of the LAA orifice plane determined by the following anatomical landmarks: DEF#1, center of warfarin ridge and centerline of proximal left circumflex artery; DEF#2, slope of warfarin ridge and mitral valve annulus; DEF#3, observers' discretion by progressive rotation using the observers' best estimate without the use of landmarks. The LAA volumes of the PAF groups were significantly greater than the NSR group according to all 3 definitions (DEF#1: 1.43 times, DEF#2: 1.44 times, and DEF#3: 1.36 times greater). The LAA orifice area was significantly larger in PAF than in NSR according to DEF#2, but was similar by DEF#1 and DEF#3. Intra-observer and inter-observer variations for any LAA measurements were very low. In conclusion, 3D-CT-based quantitative assessment of the LAA provides highly reproducible and detailed measurements, which can successfully discriminate differences of LAA volume between patients with NSR and those with PAF, suggesting significantly greater volumes in the latter.

Social participation and risk of influenza infection in older adults: a cross-sectional study.

OBJECTIVES: Influenza infection can cause severe pneumonia, which is sometimes fatal, particularly in older adults. Influenza results in 3-5 million cases of severe illness and about 250 000 to 500 000 deaths annually worldwide. Social participation in the context of influenza infection is controversial because, although social participation is beneficial in maintaining physical function and mental health, it also increases the risk of contact with infected people. This study examined the association between social participation and influenza infection in Japanese adults aged 65 years or older. DESIGN: Cross-sectional study. SETTING: Japanese functionally independent adults aged 65 years or older. PARTICIPANTS: Among the respondents to the Japan Gerontological Evaluation Study (JAGES) 2013 survey, which took place during the period from October to December 2013, 12 231 men and 14 091 women responded to questions on influenza vaccination and influenza infection. OUTCOME MEASURES: Using JAGES data for 12 231 men and 14 091 women aged ≥65 years, we examined the association between social participation and influenza infection. The association between influenza infection and number of groups in which respondents participated was investigated among adults aged≥65 years, stratified by vaccination status and sex. RESULTS: Unvaccinated women who participated in two or more social activities were 2.20 times (95% CI 1.47 to 3.29) as likely to report an influenza infection as those who reported no social participation. In contrast, vaccinated women who participated in two or more social groups had no additional risk of influenza infection as compared with female elders with no social participation. Among men, participation in social activities was not significantly associated with influenza infection, regardless of vaccination status. CONCLUSIONS: Social participation was associated with a higher risk of influenza infection among unvaccinated older women, which suggests a need for further efforts to promote influenza vaccination, particularly among socially active elderly women.

Association between income inequality and dental status in Japanese older adults: Analysis of data from JAGES2013.

Objectives　Personal income affects dental status in older people. However, the impact of income inequality on dental status at the community level (junior high school district) is unclear. The purpose of this study was to examine the association between dental status and community level income inequity after adjust for individual socio-economic status in Japanese older adults, and to verify the relative income hypothesis, also known as the Wilkinson hypothesis.Methods　We used data from the Japan Gerontological Evaluation Study (JAGES) conducted in Niigata city. JAGES is a postal survey of functionally independent adults aged 65 years or older. We enrolled 4,983 respondents (response rate 62.3%) and used data on 3,980 of them after excluding incomplete data. We evaluated health condition and socio-economic status using questionnaires. The Gini coefficient, as an indicator of income inequality, was calculated by junior high school district (57 districts) based on the data from the questionnaire. Additionally, the Pearson's coefficient of correlation was calculated to evaluate the association between the mean number of remaining teeth and the community level Gini coefficient. Then we evaluated the mean number of remaining teeth among the groups stratified by the Gini coefficient conditions. Next, we conducted a multilevel analysis using an ordinal logistic regression model. The number of remaining teeth was set as the dependent variable, while sex, age, household size, education, smoking status, diabetes treatment, current living conditions, and equivalent income were used as independent variables at the individual level. The Gini coefficient and average equivalent income in the junior high school district were used as independent variables at the community level.Results　The Pearson's correlation coefficient for the relationship between the Gini coefficient and the mean number of remaining teeth in the junior high school district was -0.44 (P<0.01). Wider income disparity area (Gini coefficient≧0.35) revealed a significantly small number of remaining teeth (P<0.001). The multilevel analysis showed that a higher Gini coefficient and a lower average equivalent income at the community level were significantly associated with a lower number of remaining teeth, and with educational attainment, smoking status, current living conditions, and equivalent income at the individual level, after adjusting for sex and age. On the other hand, educational attainment at the individual level, and average equivalent income at the community level were not significant factors after adjusting for all individual level variables.Conclusion　This study showed that, in addition to individual socio-economic status, income inequality at the community level was significantly associated with number of remaining teeth in Japanese older adults. Although the precise mechanism of this association is still unclear, our result supports the relative income hypothesis.

Characteristics of Anatomy and Function of the Left Atrial Appendage and Their Relationships in Patients with Cardioembolic Stroke: A 3-Dimensional Transesophageal Echocardiography Study.

BACKGROUND: Increasing attention is being paid to the left atrial appendage (LAA) in the context of risk stratification in cardioembolic stroke (CES) and the requirement for meticulous planning of percutaneous closure device implantation. However, detailed systematic assessment of the LAA remains limited. METHODS: This study evaluated the anatomy and function of LAA using 3-dimensional transesophageal echocardiography (3D-TEE) on 194 consecutive patients older than 50 years old hospitalized exclusively for CES. Patients were stratified into 3 groups on the basis of cardiac rhythm: (1) chronic atrial fibrillation (AF), n = 53; (2) paroxysmal AF, n = 26; and (3) no detected AF, n = 115. RESULTS: Significant differences between the groups were observed for anatomical (orifice area [OA], depth, diastolic volume) and functional parameters (ejection fraction [EF], flow velocity [FV]), as measured by 3D-TEE. The anatomical parameters were consistently the greatest, and functional parameters were the poorest, in the group with chronic AF. There were significant inverse correlations between them (r = -.33, P = .0003 for depth and EF; r = -.27, P = .0020 for depth and FV; r = -.22, P = .016 for OA and EF; and r = -.38, P < .0001 for OA and FV). CONCLUSIONS: LAA morphology and function were strongly affected by cardiac rhythm disturbances. Patients with chronic AF had the greatest LAA dimensions, areas, and volumes as well as the lowest LAA functions. An inverse correlation was observed between LAA size and function.

Comparison of the effects of bepridil and aprindine for the prevention of atrial fibrillation after cardiac and aortic surgery: A prospective randomized study.

BACKGROUND: Approximately one-third of the patients undergoing cardiovascular surgery reportedly experience paroxysmal atrial fibrillation (AF) during the postoperative period. However, the usefulness of antiarrhythmic drugs for preventing postoperative AF recurrence in the Japanese population has not been extensively studied. METHODS: From a total of 118 patients who developed postoperative paroxysmal AF between April 2009 and March 2011, 72 patients (45 men, mean age 68±8 years) requiring treatment for postoperative AF due to symptoms lasting ≥30 min were enrolled to prospectively investigate the efficacy of oral bepridil (100 mg/day, n=37) or aprindine (40 mg/day, n=35). RESULT: The AF recurrence-free survival rates at 1, 3, 7, and 14 days were 100%, 94%, 57%, and 49%, respectively, in the aprindine group, and 100%, 97%, 86%, and 76%, respectively, in the bepridil group (P=0.028, aprindine vs. bepridil). CONCLUSION: Bepridil, at a fixed dose of 100 mg/day, was considered to be more effective than a routine dose of aprindine for the prevention of postoperative AF recurrence.

Possible usefulness of gadolinium-enhanced brain MRI for evaluating risk of perioperative hemorrhage: a case of infective endocarditis.

A 59-year-old woman visited a local hospital for fever and was diagnosed as having infective endocarditis (IE) on the basis of blood cultures and transthoracic echocardiography. Based on clinical episodes of subarachnoid hemorrhage after admission, it was judged that she was not a good candidate for urgent open heart surgery, and it was decided to treat her with conservative medical therapy for the acute phase. We explored the optimum timing for surgery by employing gadolinium (Gd) contrast medium-enhanced magnetic resonance imaging (MRI) T2* weighted image (black dots) due to her high risk of perioperative cerebral hemorrhage. After the disappearance of the contrast media enhancement effect around the black dots, open heart surgery was performed successfully on the 103rd hospitalization day. The patient was discharged 22 days after the surgery with no clinical complications. This case suggests that disappearance of the contrast media enhancement effect around the black dots may be a useful marker for optimal timing of surgery to minimize the risk of perioperative cerebral hemorrhage in patients with IE. Learning Objective. The MRI T2* weighted images including those with Gd contrast medium enhancement effect may be useful for evaluating the risk of perioperative intracranial hemorrhage in IE.

Long-term outcome of pediatric renal transplantation: a single center study in Japan.

Little is known about the risk factors for long-term poor outcome in pediatric renal transplantation. Between 1973 and 2010, 111 renal transplants (92 living donations) were performed in 104 children (56 males, mean age, 12.5 yr) at the Social Insurance Chukyo Hospital, and followed-up for a mean period of 13.6 yr. The patient survival at 1, 5, 10, 15, 20 (living- and deceased-donor transplants), and 30 yr (living-donor transplants only) was 98.1%, 92.8%, 87.8%, 84.9%, 82.6%, and 79.3%. The graft survival at 1, 5, 10, 15, 20, and 30 yr was 92.0%, 77.3%, 58.4%, 50.8%, 38.5%, and 33.3%. The most common cause of graft loss was CAI, AR, death with functioning, recurrent primary disease, ATN, and malignancy. Donor gender, ATN, malignancy/cardiovascular events, and eras affected patient survival. AR and CAI were the risk factors for graft loss. The evolved immunosuppression protocols improved the outcome by reducing AR episodes and ATN but not CAI, suggesting CAI as the major risk factor for graft loss. CAI was correlated with AR episodes, CMV infection, and post-transplant hypertension. Strategies for preventing the risk factors for malignancy/cardiovascular events and CAI, including hypertension/infection, are crucial for better outcomes.

Photochemical behavior of single-walled carbon nanotubes in the presence of propylamine.

This report describes the photochemical behavior of single-walled carbon nanotubes (SWNTs) in the presence of propylamine. The SWNTs are characterized by absorption and Raman spectroscopy. The spectral changes due to photoirradiation indicate that reactions occur predominantly with the metallic SWNTs and small-diameter SWNTs. The detection of amine radicalcation species by ESR spectroscopy reveals photoinduced electron transfer from the amine to the excited SWNTs. After exposure of the photoirradiated SWNTs to air, the characteristic spectra were recovered, except for that of the small-diameter SWNTs. The results suggest that, after photoreduction of the SWNTs, subsequent selective sidewall functionalization of the small-diameter SWNTs occurs.

Usefulness of transesophageal echocardiography in diagnosis of hemolytic anemia post total aortic arch replacement using the elephant trunk technique.

We report a rare case of a patient with hemolytic anemia who underwent emergency total arch replacement using the elephant trunk technique for type A acute aortic dissection 3 years earlier. The 78-year-old woman was referred to our hospital for diagnosis of the cause of the hemolytic anemia, which required twice weekly blood transfusion. Although contrast-enhanced computed tomography could not provide sufficient information, transesophageal echocardiography (TEE) revealed graft flection with high velocity. After percutaneous balloon dilatation, the hemolytic anemia improved and follow-up TEE showed no re-stenosis of the dilatation site.

Mild renal dysfunction on admission is an important prognostic predictor in patients with infective endocarditis: a retrospective single-center study.

OBJECTIVE: Infective endocarditis (IE) continues to be associated with high mortality. The aim of the present study was to identify prognostic predictors for short-term mortality in patients with IE. METHODS: We conducted a retrospective study of 119 consecutive patients with IE (mean age 58±17). Prognostic predictors for mortality at the early phase of admission were determined using a multivariate regression analysis, and a receiver operating characteristic (ROC) analysis was carried out to evaluate the predictive ability. RESULTS: Eleven of 119 patients died during hospital admission. In this non-survivor group, the clinical parameters at the time of admission, including serum creatinine (Cr), the estimated glomerular filtration rate (eGFR), the red blood cell count, the white blood cell count, the serum CRP level and heart rate, differed significantly from those observed in the survivors (all; p<0.05). According to a logistic regression analysis, an increase in log-serum Cr per one standard deviation (odds ratio=2.18, 95%CI=1.08-4.41) and a decrease in log-eGFR per one standard deviation (odds ratio=0.51, 95%CI=0.26-0.98) were significantly associated with in-hospital death. The area under the ROC curve for serum Cr to predict the outcome was 0.80, the sensitivity was 64% and the specificity was 85% at a cut-off value of 1.16 mg/dL. For eGFR, the area under the ROC curve was 0.77, the sensitivity was 64% and the specificity was 86% at a cut-off value of 47.5 mL/min./1.73 m(2). CONCLUSION: Mild renal dysfunction at the time of admission is an important predictor of early phase mortality in patients with IE.