Risk Factor Analysis for Type 2 Diabetes Patients About Hypoglycemia Using Continuous Glucose Monitoring: Results from a Prospective Observational Study.

Introduction: To determine the relationship between hypoglycemia and glucose variability in outpatients with type 2 diabetes mellitus (T2DM). Materials and Methods: The study participants were 999 outpatients with T2DM who used the FreeStyle Libre Pro for continuous glucose monitoring (FLP-CGM). Hypoglycemia was defined as glucose level of <3.0 mM, and the frequency of episodes and duration of hypoglycemia were evaluated by comparing patients who did or did not achieve time-below-range <3.0 mM (TBR<3.0) of <1% of the time. The association of TBR<3.0 and long% coefficient of variation (%CV) with medications used was examined using multivariate analysis with a proportional odds model. Results: The average TBR<3.0 was 0.33% (4.75 min). The TBR<3.0 >1% group comprised 71/999 patients. Patients of the TBR<3.0 >1% group had lower body mass index, longer disease duration, and poorer renal function. For the TBR<3.0 >1% group, the predicted cutoff values were 7.19 mM average glucose (AG), and 30.30% for %CV. When AG <7.19 mM and %CV >30.30% were considered as hypoglycemic risk factors, the frequency and duration of hypoglycemia increased as the risk factor values increased. In multivariate analysis, sulfonylurea (SU) use, insulin use, and low blood glucose index correlated significantly with increased length of TBR<3.0 and %CV, even after adjustment for concomitant diabetes medications. Conclusion: In T2DM, maintaining TBR<3.0 <1% requires to keep AG >7.2 mM and %CV <30%, in addition to comprehensive management of CGM metrics. Since SU and insulin use is associated with prolonged TBR<3.0 and increased %CV, their doses should be adjusted to avoid excessive fall in AG and raising %CV.

Three millimeter needlescopic splenectomy using three-port technique: report of three cases.

We report our experience with needlescopic splenectomy (NS) for the surgical treatment of idiopathic thrombocytopenic purpura using a 3-mm needlescope with three ports. One patient was male and two were females, and their mean age was 58 years. The patient was placed in the right lateral decubitus position. The first 12-mm port was introduced through the lateral margin of the left rectus abdominis muscle, and the other two 3-mm ports were inserted in the left upper quadrant. NS was performed by a standard technique under the observation of 3.3-mm needlescope. The surgical procedure was successfully completed in all the patients. The mean duration of surgery, intra-operative bleeding volume and post-operative hospital stay were 176 min, 70 ml and 4.7 days, respectively. There were no particular peri-operative complications in spite of dense adhesions or simultaneous laparoscopic procedures. Our method is safe and feasible with low morbidity and without impairing cosmetic benefits.

New frontiers in Japanese Forest Policy: Addressing ecosystem disservices in the 21st century.

Forests are a potential solution to numerous global environmental issues, and their restoration is widely pursued. Forty percent of Japan's forests are planted forests. This has caused the common occurrence of forest ecosystem disservices in the country, like-wildlife damage, pollinosis, and driftwood damage. Forest policy processes in Japan are characterized by incrementalism, central mobilization, and hegemony of career civil servants. Responses to forest ecosystem disservices have changed the central mobilization policy pattern. Punctuated equilibrium theory can be applied to several policy processes in Japan, but it provides only limited explanation for policy responses to forest ecosystem disservices. The responses are influenced by national governance and public administration traditions and cultures. It is relevant to expand research on policy responses to forest ecosystem disservices, recognizing that ideal responses may require unusual approaches not within traditional policy making or outside of established policy cultures.

Sensitive monitoring of volatile chemical warfare agents in air by atmospheric pressure chemical ionization mass spectrometry with counter-flow introduction.

A new method for sensitively and selectively detecting chemical warfare agents (CWAs) in air was developed using counter-flow introduction atmospheric pressure chemical ionization mass spectrometry (MS). Four volatile and highly toxic CWAs were examined, including the nerve gases sarin and tabun, and the blister agents mustard gas (HD) and Lewisite 1 (L1). Soft ionization was performed using corona discharge to form reactant ions, and the ions were sent in the direction opposite to the airflow by an electric field to eliminate the interfering neutral molecules such as ozone and nitrogen oxide. This resulted in efficient ionization of the target CWAs, especially in the negative ionization mode. Quadrupole MS (QMS) and ion trap tandem MS (ITMS) instruments were developed and investigated, which were movable on the building floor. For sarin, tabun, and HD, the protonated molecular ions and their fragment ions were observed in the positive ion mode. For L1, the chloride adduct ions of L1 hydrolysis products were observed in negative ion mode. The limit of detection (LOD) values in real-time or for a 1 s measurement monitoring the characteristic ions were between 1 and 8 µg/m(3) in QMS instrument. Collision-induced fragmentation patterns for the CWAs were observed in an ITMS instrument, and optimized combinations of the parent and daughter ion pairs were selected to achieve real-time detection with LOD values of around 1 µg/m(3). This is a first demonstration of sensitive and specific real-time detection of both positively and negatively ionizable CWAs by MS instruments used for field monitoring.

Right colectomy with simultaneous vascular reconstruction for celiac and superior mesenteric arterial occlusion.

INTRODUCTION: Identification of the primary feeding vessel and its removal with corresponding lymphatics is crucial for oncologic bowel resection for colon cancer. However, this notion would be challenged if we encountered abnormal mesenteric vascular anatomy. We report a case of colon cancer with abnormal mesenteric circulation, for whom we performed oncologic colectomy with vascular reconstruction. PRESENTATION OF CASE: A 61-year-old man presented with obstructing transverse colon cancer. A contrast-enhanced computed tomography (CT) scan showed complete occlusion at the root of the superior mesenteric artery (SMA) and the celiac artery (CA), with evidently dilated marginal artery (MA). An X-ray angiography revealed retrograde arterial blood flow originating from the inferior mesenteric artery (IMA) via the MA, the SMA, and to the CA. At laparotomy, we found remarkably dilated MA with the mid-transverse colon cancer. There were no other communicating vessels between the IMA and the SMA. Right colectomy with proper lymph node dissection was completed, following vascular anastomosis between the MA to the SMA. His postoperative course was uneventful. A postoperative CT angiography showed revascularization of the areas where the SMA and the CA supplied. DISCUSSION: In this patient, if the abberant mesenteric circulation remained unrecognized at the time of surgery, and the MA were divided without vascular reconstruction, severe ischemia and subsequent gangrene of large part of the visceral organs would have occurred. CONCLUSION: This case illustrates the fundamental importance of assessment for vascular anatomy in patients undergoing oncologic abdominal surgery which associates with division of major mesenteric arteries.