Daytime spatial relationships in a family group of black rhinoceros Diceros bicornis at the Hiroshima City Asa Zoological Park, Japan.

Although black rhinoceros Diceros bicornis are mostly solitary in the wild, the Hiroshima City Asa Zoological Park (Asa Zoo) has kept a family group together during the daytime, with good reproductive performance over five decades. Management procedures at the zoo include temporary single housing of the mother before and after giving birth, which facilitates maintenance of a compatible family group. We recorded intra-group spatial relationships for 4 years and 4 months, during which time an adult female reared two consecutive calves. During daytime she remained in an enclosure with her new calf, one or two older offspring, and an adult male, the sire of all her offspring. Proximity (within two adult body-lengths) scores between the mother and her two calves were especially high during the first year after birth, and only slightly lower for her older offspring. The adult male had the lowest proximity scores. The spatial relationships were visualized by applying multidimensional scaling (MDS) to the proximity scores. Mother and calves were plotted close to each other, with older offspring slightly farther apart on the two-dimensional MDS representation; the adult male was more distant from the other group members. These findings indicate clear follower-type characteristics in the mother-calf pair and also older immature offspring, albeit to a lesser degree. Although black rhinoceros are generally solitary in the wild, our results duplicate observations of some wild black rhinoceros groups containing an adult female, her calf, and an older immature, with adult males being largely solitary.

Factors affecting captive female giraffe stress response: Male presence, small enclosure, and low temperature.

To improve animal welfare based on suitable social housing conditions, it is important to understand the factors that trigger high-stress responses. Wild giraffes live in a fission-fusion society and males and females are rarely in the same herd for a long period. The captive condition of belonging to a herd with the same individuals for months or years is uncommon in nature. To understand the effect of male presence on female stress levels, fecal glucocorticoid metabolite (fGCM) levels and social interactions in two captive female giraffes were investigated. Additionally, the effect of enclosure size and temperature on fGCM level and social interactions were examined. The results showed no significant difference in the fGCM levels of females based on male presence. The frequency of agonistic behavior by the dominant female toward the subordinate female was significantly increased when a male was present. The subordinate female was significantly less likely to approach the dominant female and showed decreased affiliative and agonistic interactions toward the dominant female when a male was present. The frequencies of agonistic interactions between females were higher in the small enclosure regardless of male presence. Low temperature triggered higher fGCM levels and increased agonistic interaction in an aged female. The findings of this study suggest that these multiple factors should be considered individually to promote the welfare of captive giraffes.

A Novel Approach for Determining the Critical Quality Attributes of Mesenchymal Stem Cells by Specifying Cell Population With Replication Potential.

We introduce a novel approach to determine the critical quality attributes (CQAs) of mesenchymal stem cells (MSCs) expected to exert immunosuppressive effects. MSCs retained homeostatic replication potentials, such as sustainable growth and consistent cell morphology as a population, in early passages, but lost them in late passages. Characteristic surface markers of MSCs (ie, CD73, CD90, and CD105) were no longer expressed at 2 weeks after subcutaneous transplantation into NOG mice when MSCs from late passages were transplanted, but not when MSCs from early passages were transplanted, suggesting that the biological effects of the MSCs differed according to the timing of cell harvesting and highlighting the importance of specifying MSCs that retained homeostatic features to define the CQAs. The homeostatic features of MSCs related to the balance of the redox system, nutrient requirements, and mitochondrial function were also observed until a certain passage. Therefore, we could define the CQAs of MSCs related to manufacturing by selecting process parameters (PPs) underlying the homeostatic features of MSCs and measuring these PPs quantitatively to specify the cell population with homeostatic features by limiting the passage number. The validity of the PPs stipulated in our pilot study was verified using an SKG murine arthritis model, and critical PPs (CPPs) were then selected among the PPs. Thus, CQAs related to manufacturing in the developmental phase could be defined by the CPPs in this manner, and the concept of CQAs could be refined continuously toward commercial manufacturing.

Gelation of konjac glucomannan by acetylmannan esterases from Aspergillus oryzae.

Konjac glucomannan (KGM) is a principal component of the gelatinous food Konjac. Konjac production through alkali treatment releases an undesirable amine-odor. Two acetylesterases (AME1 and AME2) active against konjac glucomannan (polymer or oligomer) were purified from the supernatant of Aspergillus oryzae RIB40 culture. We cloned the genes encoding AME1 and AME2 based on the genomic information of A. oryzae, constructed their expression systems in A. oryzae, and obtained the recombinant enzymes (rAME1 and rAME2). rAME1 did not act on the KGM polymer but only on the KGM oligomer, releasing approximately 60% of the acetic acid in the substrate. However, rAME2 was active against both KGM substrates, releasing approximately 80% and 100% of acetic acid from the polymer and oligomer, respectively. Both enzymes were active against xylan and exhibited a trace activity on ethyl ferulate. The acetyl group position specificities of both enzymes were analyzed via heteronuclear single quantum correlation NMR using oligosaccharides of glucomannan prepared from Aloe vera (AGM), which has a higher acetyl group content than KGM. rAME1 acted specifically on single-substituted acetyl groups and not on double-substituted ones. In contrast, rAME2 appeared to act on all the acetyl groups in AGM. Treatment of 3% KGM with rAME2 followed by heating to 90 °C resulted in gel formation under weakly acidic conditions. This is the first study to induce gelation of KGM under these conditions. A comparison of the breaking and brittleness properties of gels formed by alkaline and enzymatic treatments revealed similar texture of the two gels. Furthermore, scanning electron microscopy of the surface structure of both gels revealed that both formed a fine mesh structure. Our findings on enzymatic gelation of KGM should lead to the development of new applications in food manufacturing industry.

Higher Serum Soluble TREM2 as a Potential Indicative Biomarker for Cognitive Impairment in Inadequately Controlled Type 2 Diabetes Without Obesity: The DOR-KyotoJ-1.

Objective: Type 2 diabetes is a risk factor for dementia. We investigated whether serum levels of soluble triggering receptor expressed on myeloid cell 2 (sTREM2), a soluble form of the cell surface receptor TREM2, were predictive of cognitive impairment in type 2 diabetes without obesity. Methods: A total of 166 Japanese patients with type 2 diabetes without obesity were followed-up for 2 years. We measured clinical parameters, assessed cognitive function using the mini-mental state examination (MMSE), quantified and divided serum sTREM2 levels into quartiles, and examined the longitudinal associations. Results: During the follow-up, HbA1c levels were elevated in 98 patients and decreased in 68 patients. In the HbA1c-elevated group, higher sTREM2 levels at baseline showed a significant association with a greater tendency for reduction in MMSE scores (P for trend = 0.015), whereas they were not significantly associated with other examined parameters. In the HbA1c-decreased group, there was no significant association between sTREM2 levels at baseline and changes in MMSE scores, but higher sTREM2 levels at baseline were significantly associated with a greater tendency for reduction in waist circumference (P for trend = 0.027), homeostasis model assessment of insulin resistance (P for trend = 0.039), and sTREM2 levels (P for trend = 0.023). Conclusions: Glycemic control is suggested to be important in preventing cognitive impairment in patients with type 2 diabetes without obesity. Higher serum sTREM2 levels would be a predictive marker for cognitive impairment in inadequately controlled type 2 diabetes without obesity.

Data on long-term survival of the NOD/Shi-scid IL-2Rγnull (NOG) mouse in two facilities.

The objective of this study was to investigate an appropriate observation period for an evaluation of tumorigenicity in NOD/Shi-scid IL-2 Rγnull (NOG) mice. At SNBL, 19 male and 19 female NOG mice were observed the general condition from 7 weeks old up to 68 weeks old and at FBRI, 7 male and 16 female NOG mice were observed the general condition throughout the lifespan from 7 weeks old. The survival rate started to decline rapidly around 54 to 56 weeks of age in both facilities without a facility difference. Based on these survival data, it seems reasonable to terminate a tumorigenicity study at 52 weeks of age.

A Retrospective Multicenter Study on the Usefulness of 50 g Glucose Challenge Test in Gestational Diabetes Mellitus Screening.

INTRODUCTION: To clarify the usefulness of glucose challenge test (GCT), the rate of gestational diabetes mellitus (GDM) detection and perinatal outcomes were compared between the groups of random blood glucose level (RBG) and 50 g GCT in this study. METHODS: The first survey was conducted at 255 institutions registered by the Kanto Society of Obstetrics and Gynecology and clinical training institutions in the Kanto Area, followed by a second survey. The included women were broadly classified into the RBG and GCT groups, according to the mid-trimester blood glucose screening method, and the perinatal outcomes of the two groups were retrospectively compared. The primary outcomes were the proportion of infants weighing 3,500 g or more and birth weight ≥90th-percentile infants. RESULTS: The rate of GDM diagnosis was significantly higher in the GCT group (7.6%) than that in the RBG group (4.8%). However, no significant differences were observed in perinatal outcomes, i.e., the proportion of infants weighing 3,500 g or more or birth weight ≥90th percentile. CONCLUSIONS: GCT is not superior for predicting infants weighing 3,500 g or more and birth weight ≥90th percentile, as compared with RBG.

The impact of Masai giraffe nursery groups on the development of social associations among females and young individuals.

Fission-fusion social systems involve the splitting and merging of subgroups with frequent changes in membership occurring as a result of a number of ecological and social factors, such as demographic processes including birth, movement, or death. Giraffe reside in fission-fusion social systems, and we studied how reproductive status influence associations among females, as well as how associations differ between calves and juveniles. Data were collected in Katavi National Park, Tanzania, during five study periods. We used social network analysis to identify whether reproductive status and developmental stages predict differences in giraffe social association. We found that females with offspring maintain stronger associations than females without offspring. We also revealed that calves and juveniles had similar network association patterns. Our results suggest that the presence of dependent offspring influences the social associations of females and individuals less than 1.5 years of age are still maintaining strong social associations with nursery group members. We conclude that nursery groups among giraffe are co-operative rearing units that probably reduce the costs of rearing to mothers, and may provide a group structure for animals to begin to develop skills useful for their future life in a fission-fusion social system.

Nighttime Suckling Behavior in Captive Giraffe (Giraffa camelopardalis reticulata).

Suckling behaviors are useful to better understand mother-offspring relationships. However, in many species, knowledge about nighttime suckling behavior is sparse. In the present study, we investigated suckling behavior in four calves of the reticulated giraffe (Giraffa camelopardalis reticulata) and their mother in the Kyoto City Zoo, Japan, by analyzing video clips of 9614 h. The relation between a calf's age and the mean duration and frequency of suckling were consistent with the results of previous daytime studies: the longest duration (80 ± 4 s) and highest frequency (0.41/h) of suckling occurred when the calves were young, and decreased thereafter. Suckling frequency was lower at night than during the day, probably because the mother spent much of the time resting at night. The mother initiated suckling behavior in offspring until six months of age. Most often, the mother terminated suckling except during the first few weeks after birth. Additionally, we reported that the average weaning period was 448 days (n = 5) and that the last born (sixth) continued to suckle for more than 750 days, which is a rare phenomenon. We believe the present report helps to fill the lack of knowledge about nighttime suckling behavior in giraffe.

Texture analysis of sonographic muscle images can distinguish myopathic conditions.

Given the recent technological advent of muscle ultrasound (US), classification of various myopathic conditions could be possible, especially by mathematical analysis of muscular fine structure called texture analysis. We prospectively enrolled patients with three neuromuscular conditions and their lower leg US images were quantitatively analyzed by texture analysis and machine learning methodology in the following subjects :  Inclusion body myositis (IBM) [N=11] ; myotonic dystrophy type 1 (DM1) [N=19] ; polymyositis/dermatomyositis (PM-DM) [N=21]. Although three-group analysis achieved up to 58.8% accuracy, two-group analysis of IBM plus PM-DM versus DM1 showed 78.4% accuracy. Despite the small number of subjects, texture analysis of muscle US followed by machine learning might be expected to be useful in identifying myopathic conditions. J. Med. Invest. 66 : 237-240, August, 2019.

Sleep-related behaviors in zoo-housed giraffes (Giraffa camelopardalis reticulata): Basic characteristics and effects of season and parturition.

Despite increasing interest in the behavior of zoo animals, studies of nocturnal behavior of zoo animals are limited. In this study, we investigated the relationship between parturition, season, and the sleep-related behaviors in captive reticulated giraffes to better understand the nocturnal life in giraffes. The subjects were two adult reticulated giraffes living in Kyoto City Zoo, Japan. Observations were made via an infrared camera that was mounted in the indoor enclosure between June 2007 and August 2009. We analyzed video clips that were recorded between 16:30 and 09:00 the next morning, over a total of 199 days. Sleep-related behaviors were classified into two categories based on the posture of the giraffes; recumbent posture and paradoxical sleep. We also recorded the laterality of recumbent posture, which was coded based on the direction of the legs against the torso (right or left). Seasonal differences in sleep behaviors between summer and winter were observed in both individuals. They tended to start to lie down earlier in the winter than in the summer. Parturition also affected the behaviors as both individuals decreased the behaviors before and after the parturition of the female. Additionally, the female lay on her left side less frequently than her right when resuming a recumbent posture in the pre-parturition period, while such laterality was not observed in the baseline and post-parturition period. These results suggested that season and parturition are important factors for determining the sleep-related behaviors in giraffes. Further studies are needed to understand how these changes in sleep affect other welfare parameters.

Detection and management of cardiomyopathy in female dystrophinopathy carriers.

Regular health checkups for mothers of patients with Duchenne muscular dystrophy have been performed at National Hospital Organization Tokushima Hospital since 1994. Among 43 mothers participated in this study, 28 dystrophinopathy carriers were identified. Skeletal and cardiac muscle functions of these subjects were examined. High serum creatine kinase was found in 23 subjects (82.1%). Obvious muscle weakness was present in 5 (17.8%) and had progressed from 1994 to 2015. Cardiomyopathy was observed in 15 subjects (60.0%), including dilated cardiomyopathy-like damage that was more common in the left ventricular (LV) posterior wall. Late gadolinium enhancement on cardiac MRI was found in 5 of 6 subjects, suggesting fibrotic cardiac muscle. In speckle tracking echocardiography performed seven years later, global longitudinal strain was decreased in these subjects, indicating LV myocardial contractile abnormality. These results suggest that female dystrophinopathy carriers should receive regular checkups for detection and treatment of cardiomyopathy, even if they have no cardiac symptoms.

[A Case of Merkel Cell Carcinoma Complicated with Severe Thrombocytopenia Treated with Carboplatin/Etoposide Regimen after Surgery].

Thrombocytopenia is often caused by myelosuppression during chemotherapy. However, when platelet transfusions are required, pathological conditions such as idiopathic thrombocytopenic purpura(ITP)and thrombotic thrombocytopenic purpura( TTP)also occur. We report a case of Merkel cell carcinoma complicated with severe thrombocytopenia treated with carboplatin/etoposide regimen after surgery. The patient's platelet count did not increase in spite of platelet transfusions. However, the platelet count increased after steroid treatment was chosen under the diagnosis of ITP. Subsequent examinations revealed that the patient had HLA antibody, which caused the platelet transfusion refractoriness. When the platelet count does not increase in spite of platelet transfusions during chemotherapy, the possibility that the platelet transfusion refractoriness is due to the presence of HLA antibody should be considered.

Effect of Home Blood Pressure on Inducing Remission/Regression of Microalbuminuria in Patients With Type 2 Diabetes Mellitus.

BACKGROUND: The Home Blood Pressure for Diabetic Nephropathy study is a prospective observational study conducted to determine the effect of home blood pressure (HBP) on remission/regression of microalbuminuria in patients with type 2 diabetes mellitus (DM). METHODS: Patients with type 2 DM having microalbuminuria were followed-up for 3 years. Remission of microalbuminuria was defined as shift from microalbuminuria to normoalbuminuria. Regression of microalbuminuria was defined as a 50% reduction in urinary albumin-creatinine ratio from baseline. All measurements of morning and evening HBP were averaged every year and defined as all HBP. RESULTS: In total, 235 patients were followed up. The 3-year cumulative incidences of remission and regression were 32.3% and 44.7%, respectively. Following analysis of all cases, the degree of decline in all home systolic blood pressure (AHSBP), rather than mean AHSBP, influenced the incidence of remission/regression. There was a strong relationship between the decline in AHSBP during the follow-up period and AHSBP at baseline. Therefore, separate analyses of the patients with AHSBP below 140 mm Hg at baseline were performed, which revealed that mean AHSBP during the follow-up period independently affected the incidence of remission/regression. The hazard ratio for inducing remission/regression was significantly lower in patients with AHSBP during the follow-up period above 130 mm Hg than in those with AHSBP below 120 mm Hg. CONCLUSIONS: Optimal AHSBP for the induction of remission/regression of microalbuminuria might be below 130 mm Hg. It is required to confirm whether keeping AHSBP below 130 mm Hg leads to subsequent renoprotection or not. CLINICAL TRIALS REGISTRATION: Trial Number UMIN000000804.

[A comparison of evaluation among different media stimulation of housing space].

The purpose of this study is to show the differences in impression evaluation among different media stimuli for housing space. We conducted an impression evaluation experiment for a pamphlet, material samples, and real rooms for media stimulation using an SD method with 85 participants to extract similar and the dissimilar impression evaluations among the media stimuli. The results indicated that the evaluations for real rooms were more positive than those for a pamphlet or material samples as a whole; especially, for brightness and youthfulness among different forms of stimulation. The evaluation structure by factor analysis of a pamphlet and real rooms were almost same; however, those by material samples were different, suggesting that a pamphlet is useful to express a real room, but material samples assist in stimulation of the residential space.

Correlation between the ABC classification and radiological findings for assessing gastric cancer risk.

PURPOSE: To investigate the correlation between ABC risk assessment and radiological findings of gastric mucosa and to propose an improved method for gastric cancer screening. MATERIALS AND METHODS: We evaluated 318 participants with Helicobacter pylori (Hp) antibody titers, serum pepsinogen (PG) and upper GI radiography and then classified them into three groups: A, double-negative; B, Hp-positive, PG-negative; C, PG-positive. Group A was subclassified as: A-1, Hp antibody titer <3.0 U/ml; A-2, Hp antibody titer ≥3.0 U/ml. Results for group A and non-A (B or C) participants and radiological findings of gastric mucosa (fold and area gastricae) were analyzed retrospectively. RESULTS: Radiological findings differed significantly between the 207 A-1 and 98 non-A group. Odds ratios were 17.72 for fold distribution, 10.63 for fold thickness, 6.10 for fold characteristics, and 10.62 for area gastricae. Presence of ≥2 risk factors offered 90.3 % sensitivity, 94.7 % specificity, and 93.3 % accuracy. Nine (69.2 %) of the 13 A-2 group participants and 11 (5.3 %) A-1 group participants had a risk for gastric cancer according to radiological findings. CONCLUSION: A good correlation exists between ABC classifications and radiological findings for gastric cancer risk, but some discrepant cases exist. We recommend both methods as screening for gastric cancer.

HCl Treatment for Preventing Diapause Causes Ca2+ Efflux in Bombyx mori Eggs.

To elucidate the mechanism for preventing entry into embryonic diapause or breakdown of diapause in Bombyx mori by HCl and dimethyl sulfoxide (DMSO) treatment or a combination of cold and HCl treatment, we performed quantitative analysis of Ca2+ and Mg2+ in the chorion and egg content using inductively coupled plasma atomic emission spectrometry (ICP-AES). When diapause eggs that had been incubated at 25°C for 2 days from oviposition and at 4°C for an additional six days were treated with HCl solution, the amount of Ca2+ in the chorion and egg content after HCl treatment was reduced to one-seventh, as compared with the amount before treatment. In contrast, there was no change in the amount of Mg2+ with HCl treatment. The amount of Ca2+ in the HCl solution after the diapause eggs were treated increased 7.5-fold, as compared with that of eggs treated with water. Even when 17-day-old diapausing eggs were treated with HCl, which did not break diapause, the amount of Ca2+ in the chorion and egg content was reduced to one-fifth, as compared with the control. Meanwhile, changes in Ca2+ and Mg2+ contents were not observed in 12-hr-old diapause-destined eggs before or after treatment with DMSO, which effectively prevents diapause. These data may suggest that Ca2+ efflux from diapause eggs by HCl is not directly associated with preventing entry into diapause or breaking of diapause. In addition, we discovered that the amount of Ca2+ in diapause-destined eggs was more than 2.4-fold larger than in non-diapause-destined eggs.

THEMIS two-point measurements of the cross-tail current density: A thick bifurcated current sheet in the near-Earth plasma sheet.

The basic properties of the near-Earth current sheet from 8 RE to 12 RE were determined based on Time History of Events and Macroscale Interactions during Substorms (THEMIS) observations from 2007 to 2013. Ampere's law was used to estimate the current density when the locations of two spacecraft were suitable for the calculation. A total of 3838 current density observations were obtained to study the vertical profile. For typical solar wind conditions, the current density near (off) the central plane of the current sheet ranged from 1 to 2 nA/m2 (1 to 8 nA/m2). All the high current densities appeared off the central plane of the current sheet, indicating the formation of a bifurcated current sheet structure when the current density increased above 2 nA/m2. The median profile also showed a bifurcated structure, in which the half thickness was about 3 RE . The distance between the peak of the current density and the central plane of the current sheet was 0.5 to 1 RE . High current densities above 4 nA/m2 were observed in some cases that occurred preferentially during substorms, but they also occurred in quiet times. In contrast to the commonly accepted picture, these high current densities can form without a high solar wind dynamic pressure. In addition, these high current densities can appear in two magnetic configurations: tail-like and dipolar structures. At least two mechanisms, magnetic flux depletion and new current system formation during the expansion phase, other than plasma sheet compression are responsible for the formation of the bifurcated current sheets.

Comparison of cystatin C- and creatinine-based estimated glomerular filtration rate to predict coronary heart disease risk in Japanese patients with obesity and diabetes.

The aim of this study is to determine which indicator of chronic kidney disease most closely correlates with 10-year Framingham coronary heart disease (CHD) risk among serum creatinine, serum cystatin C (S-CysC), urine albumin-creatinine ratio (UACR), estimated creatinine-based GFRs (eGFRcre), and estimated CysC-based GFRs (eGFRcys) in patients with obesity and diabetes. Serum creatinine, S-CysC, UACR, and cardio-ankle vascular index (CAVI) were examined in 468 outpatients with obesity and type 2 diabetes, free of severe renal dysfunction or previous history of cardiovascular disease, as a cross-sectional survey using baseline data from the multi-centered Japan Diabetes and Obesity Study. S-CysC and eGFRcys had significantly stronger correlations with the 10-year Framingham CHD risk than serum creatinine, eGFRcre, and UACR (creatinine, ρ = 0.318; S-CysC, ρ = 0.497; UACR, ρ = 0.174; eGFRcre, ρ = -0.291; eGFRcys, ρ = -0.521; P < 0.01 by Fisher's z-test). S-CysC and eGFRcys had significantly stronger correlations with CAVI than serum creatinine, eGFRcre, and UACR (creatinine, ρ = 0.198; S-CysC, ρ = 0.383; UACR, ρ = 0.183; eGFRcre, ρ = -0.302; eGFRcys, ρ = -0.444; P < 0.05 by Fisher's z-test). The receiver operating characteristic curves to distinguish the high-risk patients for CHD revealed significantly larger areas under the curve of S-CysC and eGFRcys than those of serum creatinine, UACR, and eGFRcre (serum creatinine, 0.64; S-CysC, 0.75; UACR, 0.56; eGFRcre, 0.63; eGFRcys, 0.76; P < 0.01). The data suggested that eGFRcys can be more predictive of the 10-year CHD risk than eGFRcre in Japanese patients with obesity and diabetes.

[A clinicopathological investigation of two autopsy cases of calpainopathy (LGMD2A)].

In this study, we compared the clinicopathological findings of two autopsy cases of patients with calpainopathy (LGMD2A) from different families. The patient in case 1 was a 72-year-old man with a history of type 2 diabetes mellitus. He exhibited recent memory impairments from the age of 70. ECG revealed an incomplete right bundle branch block. A homozygous frameshift mutation c.1796dupA was found in the CAPN3 gene. Cause of death was respiratory insufficiency and heart failure. The patient in case 2 was a 70-year-old man with a history of hypertension. ECG revealed an incomplete right bundle branch block. A homozygous missense mutation c.1080G>C (p.Trp360Cys) in CAPN3 gene was identified. Cause of death was ischemic cardiomyopathy and systemic circulatory failure. In both cases, muscle pathology revealed severe dystrophic changes. In case 2, cardiac hypertrophy and old myocardial infarcts with stenosis of coronary arteries were observed. Histological examination of the sinoatrial node showed fatty infiltration with ischemic changes in case 2. In both cases, the patients' brains showed cerebral atrophy and well preserved neurons. Calpain 3 abnormality was correlated with skeletal muscle involvement. It should be considered that LGMD2A might be complicated by dysfunction of the cardiac conduction system.