The frequency of postoperative BNP measurement and intervention threshold of BNP concentration in pediatric cardiac intensive care unit: a prospective multicenter observational study.

PURPOSE: The purpose of this study is to investigate the current status of postoperative BNP measurement in the pediatric cardiac intensive care unit (PCICU). METHODS: This was a prospective multicenter observational study. Children under 15 years old who underwent pediatric cardiac surgery were included. Postoperatively, all BNP measurement was collected in PCICU. We checked whether each BNP measurement was used for the decision-making of intervention or not. We divided the BNP measurements into 4 groups: group A 0-299 pg/ml (reference), group B 300-999 pg/ml, group C 1000-1999 pg/ml, group D ≧ 2000 pg/ml. We performed logistic regression analysis to compare the intervention ratio between group A and B, C, D. We also did multiple comparison analyses to compare the intervention ratio in each group. RESULTS: Thirty-nine (15.8%) measurements were used as a criterion to intervene in all BNP measurements. There was no protocol for the measurement of BNP in all institutions. The number of BNP measurements in each group is as follows: group A 113 (45.9%), group B 81 (32.9%), group C 45 (18.3%), group D 7 (2.8%). The intervention ratio in each group was 6.2% (group A), 8.6% (group B), 44.4% (group C), and 71.4% (group D). The intervention ratio of group C and D were significantly higher than group A: (Odds ratio (95%CI): 12.1(4.8-33.9), p < 0.0001, 25.2(5.2-146.2), p < 0.0001). The result of multiple comparisons is similar to logistic regression analysis. CONCLUSION: High BNP concentration, especially more than 1000 pg/ml, was more often intervened upon compared to that of less than 1000 pg/ml.

[Video-assisted Transaortic Left Ventricular Thrombectomy].

A 50-year-old woman visited a previous hospital because of aphasia. She was diagnosed as having cardiogenic embolism and left ventricular thrombus. Anticoagulant therapy was performed but was unsuccessful because of hypermenorrhea due to the myoma of the uterus. She was transferred to our hospital to receive surgical treatment. After uterine myomectomy, we performed video-assisted transaortic left ventricular thrombectomy. Her postoperative course was uneventful. Left ventriculotomy has been the standard approach for left ventricular thrombectomy. However, this approach carries a risk of ventricular dysfunction. We report our experience of a successful outcome with video-assisted transaortic left ventricular thrombectomy, thereby avoiding a left ventriculotomy.

Effects of an invasive ant on land snails in the Ogasawara Islands.

We investigated how Pheidole megacephala has affected endemic achatinellid snails because these snails are excellent indicators of the impact of ants and they have high conservation value in Ogasawara. In 2015 we surveyed the Minamizaki area of Hahajima Island of Ogasawara, designated a core zone of the World Heritage Site, for P. megacephala. In Minamizaki, we determined the distribution and density of achatinellid snails in 2015 and compared these data with their distribution and density in 2005. Land cover in the survey area was entirely forest. We also tested whether P. megacephala preyed on achatinellid snails in the laboratory. P. megacephala was present in the forested areas of Minamizaki. Achatinellid snails were absent in 19 of 39 sites where P. megacephala was present, whereas in other areas densities of the snails ranged from 2 to 228 individuals/site. In the laboratory, P. megacephala carried 6 of 7 achatinellid snails and a broken shell was found. Snail distribution and density comparisons and results of the feeding experiments suggest that the presence of P. megacephala has contributed to the decline of achatinellid snails in forests in the survey area. Yet, P. megacephala is not on the official list of invasive non-native species. Stakeholders using the list of invasive species to develop conservation programs should recognize that invasiveness of non-native species differs depending on the ecosystem and that official lists may not be complete.

Comparative epidemiology of influenza A and B viral infection in a subtropical region: a 7-year surveillance in Okinawa, Japan.

BACKGROUND: The epidemic patterns of influenza B infection and their association with climate conditions are not well understood. Influenza surveillance in Okinawa is important for clarifying transmission patterns in both temperate and tropical regions. Using surveillance data, collected over 7 years in the subtropical region of Japan, this study aims to characterize the epidemic patterns of influenza B infection and its association with ambient temperature and relative humidity, in a parallel comparison with influenza A. METHODS: From January 2007 until March 2014, two individual influenza surveillance datasets were collected from external sources. The first dataset, included weekly rapid antigen test (RAT) results from four representative general hospitals, located in the capital city of Okinawa. A nation-wide surveillance of influenza, diagnosed by RAT results and/or influenza-like illness symptoms, included the age distribution of affected patients and was used as the second dataset. To analyze the association between infection and local climate conditions, ambient temperature and relative humidity during the study period were retrieved from the Japanese Meteorological Agency website. RESULTS: Although influenza A maintained high number of infections from December through March, epidemics of influenza B infection were observed annually from March through July. The only observed exception was 2010, when the pandemic strain of 2009 dominated. During influenza B outbreaks, influenza patients aged 5 to 9 years old and 10 to 14 years old more frequently visited sentinel sites. Although both ambient temperature and relative humidity are inversely associated with influenza A infection, influenza B infection was found to be directly associated with high relative humidity. CONCLUSION: Further studies are needed to elucidate the complex epidemiology of influenza B and its relationship with influenza A. In the subtropical setting of Okinawa, epidemics of influenza B infection occur from March to July following the influenza A epidemic, and primarily affect school-age children. These findings help to define unknown aspects of influenza B and can inform healthcare decisions for patients located outside temperate regions.

Relationship between epicardial adipose tissue thickness and early impairment of left ventricular systolic function in patients with preserved ejection fraction.

Epicardial adipose tissue (EAT) is metabolically bioactive fat. The present study aimed to clarify the relationship between EAT amount and early impairment of left ventricular (LV) systolic function in patients with preserved ejection fraction (EF), all evaluated echocardiographically. Participants comprised 62 elderly women (mean age ± standard deviation, 68 ± 11 years) with lifestyle-related diseases and EF ≥ 60 %. EAT amount was evaluated as thickness. Parameters suggesting early impairment of systolic function such as decreases in systolic mitral annular velocity (S') and tissue mitral annular displacement percentage (TMAD %) were evaluated along with EF. Correlations between EAT thickness and these LV systolic functions were assessed. Influences of various factors on the resultant significant relationships were also assessed. EAT thickness correlated inversely with S' and TMAD % (r = -0.402, p = 0.001 and r = -0.585, p < 0.001, respectively), but did not correlate with EF (r = 0.054, not significant). These significant relationships were maintained after considering factors such as body mass index, age, presence of lifestyle-related diseases and blood test results. A significant relationship existed between EAT amount and early impairment of LV systolic function in patients with preserved EF. Accumulation of EAT might contribute to the initial development of LV systolic dysfunction.

Safety study of somatostatin analogue octreotide for autosomal dominant polycystic kidney disease in Japan.

BACKGROUND: The total kidney volume (TKV) and total liver volume (TLV) increase and renal function decreases progressively in patients with autosomal dominant polycystic kidney disease (ADPKD). Somatostatin analogues, such as octreotide, reduce these increases in TKV and TLV. The aim of this study was to examine the safety of the short-term administration of octreotide long-acting release (octreotide-LAR) in a small number of cases. METHODS: Four ADPKD patients with an estimated glomerular filtration rate (eGFR) > 45 mL/min/1.73 m(2), TKV > 1,000 mL, and TLV > 3,000 mL were enrolled. Two 20-mg octreotide-LAR intramuscular injections were repeated every 4 weeks for 24 weeks. Laboratory and clinical assessments were repeated every 4 weeks, and TKV and TLV were measured by magnetic resonance imaging before and after the study. RESULTS: In the laboratory tests, there was no abnormal variable except for a significant decrease of alanine aminotransferase. The means of TKV and TLV decreased from 2,007 to 1,903 mL and from 9,197 to 8,866 mL, respectively, but the changes were not significant. eGFR did not change significantly. Adverse events involved loose stools in two patients, as well as injection site granuloma and abdominal pain in one patient each, which resolved spontaneously. CONCLUSION: Octreotide-LAR may be safe and effective for preventing TKV and TLV increases (UMIN000009214).

First aid with color atlas for the use of intestinal ultrasound for inflammatory bowel disease in daily clinical practice.

Intestinal ultrasound (IUS) is a promising modality for the management of inflammatory bowel disease (IBD) and has the potential to particularly contribute in monitoring disease activity, an advantage crucial for optimizing the therapeutic strategy. While many IBD physicians appreciate and are interested in the use of IUS for IBD, currently only a limited number of facilities can employ this examination in daily clinical practice. A lack of guidance is one of the major barriers to introducing this procedure. Standardized protocols and assessment criteria are needed such that IUS for IBD can be considered a feasible, reliable examination in clinical practice, and multicenter clinical studies can be conducted for further clinical evidence of the application of IUS in IBD for best patient care. In this article, we provide an overview of how to start IUS for IBD and introduce basic procedures. Furthermore, IUS images from our practice are provided as a color atlas for understanding sonographic findings and scoring systems. We anticipate this "first aid" article will be helpful to promote IUS for IBD in daily practice.

Characterization of polymorphic microsatellite markers for the Japanese endangered land snail Mandarina.

OBJECTIVE: Mandarina is an endangered land snail genus of the oceanic Ogasawara archipelago. On Chichijima Island, the largest inhabited island in Ogasawara, this genus is almost extinct in the wild due to predation by invasive species. Although ex situ conservation programs started in 2010, genetic diversity and population structure remain unclear due to a lack of genetic markers with sufficient genetic variation. In this study, we designed polymorphic microsatellite markers of Mandarina to enable genetic analysis and to develop appropriate conservation plans. RESULTS: Twenty-three polymorphic microsatellite markers were identified from the genomic DNA of wild samples of Mandarina mandarina. We assessed the genetic diversity of each marker. In 16 markers, neither linkage disequilibrium nor deviation from Hardy-Weinberg equilibrium was detected. These 16 markers were tested for multiplex PCR using low-density DNA extracted non-lethally from captive samples of M. mandarina, M. chichijimana and M. suenoae. Of the 16 markers, 15, 12 and 9 were usable for multiplex PCR, respectively. Genetic analysis using these microsatellite loci will be an important resource for the conservation of Mandarina.

Ratio of submucosal thickness to total bowel wall thickness as a new sonographic parameter to estimate endoscopic remission of ulcerative colitis.

BACKGROUND: The development of feasible, reliable parameters and criteria for intestinal ultrasound (IUS) to estimate endoscopic remission of ulcerative colitis (UC) is a crucial clinical challenge. Such parameters must be simple, objective, and reproducible so that IUS can be widely used in daily practice. We developed a new parameter called the submucosa index (SMI), defined as a percentage of the submucosal thickness (SMT) in the total bowel wall thickness (BWT), and investigated its clinical potential. METHODS: The inclusion criteria were performance of both IUS and endoscopy (sigmoidoscopy or colonoscopy) for UC and a ≤ 15-day time interval between IUS and endoscopy. Loss of stratification was defined as inability to identify the submucosa even with a BWT of > 3 mm. The vascularity of the colon was assessed by the modified Limberg score (mLS) and evaluated as bowel wall flow (BWF) ( -) or ( +) using color Doppler mode. A Mayo endoscopic subscore (MES) of 0 or 1 was defined as endoscopic remission. RESULTS: Seventy-four colonic segments were analyzed. The SMI, mLS, and BWF could distinguish an MES of 1 versus 2 (p < 0.05, p < 0.01, and adjusted p < 0.001, respectively). The criteria using the BWT and SMI and using the BWT and BWF had the same estimating ability for endoscopic remission (sensitivity, 70.0%; specificity, 97.7%; positive predictive value, 95.5%; and negative predictive value, 82.7%). CONCLUSION: The SMI is a practical, quantitative parameter based on the bowel wall structure and may be used to estimate endoscopic remission of UC.

Long-Term Exposure to Morphine Induces Cross-Tolerance to Acute Antinociceptive Effect of Remifentanil on Somatic and Visceral Stimuli in Rats.

Purpose: Remifentanil is one of the most commonly used opioids intraoperatively. Previous reports indicate that long-term use of opioids may lead to cross-tolerance to remifentanil, which poses a challenge in the control of acute pain intraoperatively. However, there is limited information regarding cross-tolerance to remifentanil, especially in visceral pain. Therefore, this study aimed to examine cross-tolerance to remifentanil in somatic and visceral tolerance using morphine-tolerant rats. Methods: Six male Sprague-Dawley rats were allocated to the morphine and saline groups each. Tolerance to the antinociceptive effect of morphine was induced in rats in the morphine group. Remifentanil was continuously infused intravenously at 10 mcg/kg/min for 120 min to assess cross-tolerance from morphine to remifentanil. The antinociceptive effects on somatic and visceral nociceptive stimuli were measured using the tail-flick (TF) and colorectal distension (CD) tests, respectively. The antinociceptive efficacy was evaluated by converting the response threshold to the percentage maximal possible effect (%MPE). Results: Remifentanil increased the %MPE in the morphine and saline groups in both the tests; however, the increase in %MPE was attenuated significantly in the morphine group compared with that in the saline group at 60, 90, and 120 min (all P < 0.01) in the TF test and at 90 and 120 min in the CD test (all P <0.05). Conclusion: Our results indicate that morphine-tolerant rats exhibit cross-tolerance to remifentanil's acute antinociceptive effects on somatic and visceral stimuli. Cross-tolerance to remifentanil should be considered in the perioperative management of patients using morphine.

Artificial intelligence (AI) models for the ultrasonographic diagnosis of liver tumors and comparison of diagnostic accuracies between AI and human experts.

BACKGROUND: Ultrasonography (US) is widely used for the diagnosis of liver tumors. However, the accuracy of the diagnosis largely depends on the visual perception of humans. Hence, we aimed to construct artificial intelligence (AI) models for the diagnosis of liver tumors in US. METHODS: We constructed three AI models based on still B-mode images: model-1 using 24,675 images, model-2 using 57,145 images, and model-3 using 70,950 images. A convolutional neural network was used to train the US images. The four-class liver tumor discrimination by AI, namely, cysts, hemangiomas, hepatocellular carcinoma, and metastatic tumors, was examined. The accuracy of the AI diagnosis was evaluated using tenfold cross-validation. The diagnostic performances of the AI models and human experts were also compared using an independent test cohort of video images. RESULTS: The diagnostic accuracies of model-1, model-2, and model-3 in the four tumor types are 86.8%, 91.0%, and 91.1%, whereas those for malignant tumor are 91.3%, 94.3%, and 94.3%, respectively. In the independent comparison of the AIs and physicians, the percentages of correct diagnoses (accuracies) by the AIs are 80.0%, 81.8%, and 89.1% in model-1, model-2, and model-3, respectively. Meanwhile, the median percentages of correct diagnoses are 67.3% (range 63.6%-69.1%) and 47.3% (45.5%-47.3%) by human experts and non-experts, respectively. CONCLUSION: The performance of the AI models surpassed that of human experts in the four-class discrimination and benign and malignant discrimination of liver tumors. Thus, the AI models can help prevent human errors in US diagnosis.

Sonographically Measured Adipose Tissue Thickness Correlates with Laboratory Test Abnormalities Reflecting Metabolic State in Elderly Women.

Background: Accumulation of adipose tissue progresses to metabolic diseases. Sonography is a convenient modality for measuring the thickness of adipose tissue. The present study aimed to clarify the site of adipose tissue thickness that correlated best with laboratory test values reflecting metabolic abnormalities. Methods: Subjects comprised 37 elderly women with metabolic diseases or an almost healthy state (median age, 71 years; interquartile range, 62-78 years). Abdominal visceral adipose tissue (VAT), subcutaneous adipose tissue, peritoneal adipose tissue, perirenal adipose tissue, and epicardial adipose tissue (EAT) thicknesses were measured. Correlations were evaluated between laboratory test values and these adipose tissue thicknesses. Results: VAT thickness measured at the level of the umbilicus correlated positively with values of triglycerides (TGs) (r = 0.593, P = 0.0009) and hemoglobin A1c (r = 0.490, P = 0.0081) and negatively with the value of high-density lipoprotein cholesterol (r = -0.521, P = 0.0045), even after adjusting for body mass index. Significant positive correlations were also found between EAT thickness and TGs (r = 0.542, P = 0.0029). Conclusions: Among the adipose tissue thicknesses measured at several sites by sonography, VAT thickness correlated most closely with laboratory test values representing metabolic abnormalities in elderly women.

[Mitral regurgitation with concomitant atrial septal aneurysm; report of a case].

A 64-year-old female was admitted to our hospital because of severe dyspnea. Echocardiography revealed mitral valve regurgitation and atrial septal aneurysm (ASA). After instituting medical treatment for congestive heart failure, euvolemic status was achieved, and the patient underwent; (1) prosthetic patch repair for ASA; (2) mitral valvuloplasty with partial quadrangular resection of the posterior mitral leaflet; and (3) mitral annuloplasty using Physio ring. Pathological examination revealed myxomatous degeneration of the mitral valve, but the resected atrial septum was without any abnormality. ASA can lead to cerebral or pulmonary embolism even in the absence of an atrial septal defect. However, ASA without atrial septal defect is typically asymptomatic and rarely requires surgical correction. By contrast, ASA with concomitant mitral valve prolapse is associated with a high risk of cerebral or pulmonary embolism. Aspirin therapy is indicated for the prevention of thromboembolism in patients with ASA who do not undergo surgical management, and these patients also require careful observation.

Value of Low-Mechanical-Index Contrast-Enhanced Transabdominal Ultrasound for Diagnosis of Pancreatic Cancer: A Meta-analysis.

The incidence and mortality rates of pancreatic cancer (PC) are increasing. It is important to discriminate PC from the other pancreatic lesions; however, differential diagnosis based on conventional transabdominal ultrasound (US) remains challenging even though US is often the first examination performed. Transabdominal contrast-enhanced ultrasound (CEUS) has high diagnostic accuracy for PC. This meta-analysis aimed to examine the utility of low-mechanical-index CEUS with enhancement for PC diagnosis. A systematic meta-analysis of all potentially relevant articles was performed. Fixed-effects or random-effects models were used to investigate pooled sensitivity, specificity, positive likelihood ratio (LR) and negative LR. The study enrolled 983 patients from nine eligible studies. The pooled estimates of sensitivity and specificity were 92% (95% confidence interval [CI]: 0.89-0.94) and 76% (95% CI: 0.71-0.81), respectively. The diagnostic odds ratio (DOR) for CEUS was high (53.62). The area under the summary receiver operating characteristic curve was 0.95. Funnel plots revealed no publication bias, and there was no significant relationship between the DORs and study characteristics, including continent, type of contrast agent, contrast agent dosage and scan phase. Only number of patients affected diagnostic ability. This meta-analysis indicates that CEUS with enhancement pattern is useful for diagnosis of PC.

Ancient drainage networks mediated a large-scale genetic introgression in the East Asian freshwater snails.

Biogeography and genetic variation of freshwater organisms are influenced not only by current freshwater connections but also by past drainage networks. The Seto Inland Sea is a shallow enclosed sea in Japan, but geological evidence showed that a large freshwater drainage had intermittently appeared in this area between the late Pliocene and Pleistocene. Here, we demonstrated that this paleodrainage greatly affected the genetic variation of the East Asian freshwater snails, Semisulcospira spp. We found that the mtDNA haplotypes originated in the Lake Biwa endemic Semisulcospira species at the upstream side of the paleodrainage were frequently observed in the riverine Semisulcospira species at its downstream side. The genome-wide DNA and morphological analyses consistently showed that there was no clear evidence of nuclear introgression between the Lake Biwa endemics and riverine species. These results suggest that the large paleodrainage had facilitated mitochondrial introgression and had broadly spread the introgressed mtDNA haplotypes to its downstream region around the Seto Inland Sea. Our study highlights the role of paleodrainages in shaping the genetic variation of freshwater organisms.

Cheater genotypes in the parthenogenetic ant Pristomyrmex punctatus.

Cooperation is subject to cheating strategies that exploit the benefits of cooperation without paying the fair costs, and it has been a major goal of evolutionary biology to explain the origin and maintenance of cooperation against such cheaters. Here, we report that cheater genotypes indeed coexist in field colonies of a social insect, the parthenogenetic ant Pristomyrmex punctatus. The life history of this species is exceptional, in that there is no reproductive division of labour: all females fulfil both reproduction and cooperative tasks. Previous studies reported sporadic occurrence of larger individuals when compared with their nest-mates. These larger ants lay more eggs and hardly take part in cooperative tasks, resulting in lower fitness of the whole colony. Population genetic analysis showed that at least some of these large-bodied individuals form a genetically distinct lineage, isolated from cooperators by parthenogenesis. A phylogenetic study confirmed that this cheater lineage originated intraspecifically. Coexistence of cheaters and cooperators in this species provides a good model system to investigate the evolution of cooperation in nature.

Community-acquired fulminant colitis caused by binary toxin-producing Clostridium difficile in Japan.

We report a case of community-acquired fulminant colitis caused by Clostridium difficile in Japan. A 46-year-old woman was diagnosed with severe infectious enterocolitis and was admitted at another hospital. The stool culture was positive for toxigenic C. difficile. Since the patient presented with fulminant C. difficile infection (CDI) with toxic megacolon, respiratory insufficiency, and circulatory failure, she was transferred to Kyorin University Hospital for intensive care. Intubation and antibiotic therapy were performed. The general condition improved with conservative treatment, and she was discharged without sequelae. While the recovered isolate was toxin A and B-positive and binary toxin-positive, it was identified as polymerase chain reaction (PCR) ribotype ts0592 and slpA sequence type ts0592. The isolate was different from PCR ribotype 027 epidemic in Europe and North America. In Japan, binary toxin-producing strains are rare and have not caused an epidemic to date. Furthermore, there are few data on community-acquired CDI in Japan. In this case, a non-elderly woman with no major risk factors such as antibiotic use, administration of proton pump inhibitor and history of gastrointestinal surgery developed community-acquired fulminant CDI caused by the binary toxin-positive strain, and ICU treatment was required. Further studies focusing on the role of binary toxin-positive C. difficile in the severity of community-acquired CDI are necessary.

Visceral fat thickness in overweight men correlates with alterations in serum fatty acid composition.

BACKGROUND: We examined relationships between visceral fat amount and alterations in serum fatty acid composition, both of which represent critical factors in the development of metabolic syndrome. METHODS: Correlations were analyzed between visceral fat thickness as measured by ultrasonography and proportions of individual fatty acids in 21 normal-weight and 24 overweight Japanese men. RESULTS: Significant associations were identified in overweight subjects. Visceral fat thickness displayed positive correlations to levels of palmitic acid and saturated fatty acids (r=0.475, P<0.05 and r=0.545, P<0.01, respectively); and negative correlations to levels of linoleic acid and polyunsaturated fatty acids (r=-0.513, P<0.05 and r=-0.428, P<0.05, respectively). Visceral fat thickness was also correlated with estimated desaturase activities, with positive correlations to Delta9- and Delta6-desaturase activities and negative correlations to Delta5-desaturase activity (r=0.580, P<0.01, r=0.669, P<0.01 and r=-0.559, P<0.01, respectively). No significant associations were identified in normal-weight subjects. CONCLUSIONS: Significant associations between visceral fat amount and alterations in serum fatty acid composition were identified, but only in overweight individuals.

Induction chemoradiotherapy prior to surgery for non-small cell lung cancer invading the left atrium.

We present a case of a 58-year-old man with diagnosis of lung adenocarcinoma invading the left atrium. He was treated with induction chemoradiotherapy for T4N1M0 disease, showing objective response. Then, a left upper lobectomy with a partial resection of the left atrium was performed without cardiopulmonary bypass. No residual tumor cells existed in the resected specimens, showing pathological complete response. Our case suggests that induction chemoradiotherapy prior to surgery can be an appropriate strategy among carefully selected patients with non-small cell lung cancer invading the left atrium.

Optimal temperature of graft preservation after ex vivo gene transfer in lung isografts.

The aim of this study was to determine the optimal temperature of graft preservation after ex vivo gene transfer to rat lung isografts. Left lungs were harvested and infused with cationic lipid/LacZ-DNA complex via the pulmonary artery, and the grafts were stored for 4h. The grafts (n7) were allocated into groups I-IV according to the storage temperature:4, 10, 16, and 23, respectively. Forty-eight h after orthotopic transplantation, the arterial blood gas was analyzed and the peak airway pressure (PAP) and the level of LacZ protein production in the grafts were measured by reverse transcription polymerase chain reaction. After reperfusion, the grafts were stained with hematoxylin and eosin. The grafts in groups III and IV showed more deterioration as evidenced by decreased arterial oxygen tension, increased PAP, and predominant infiltration of inflammatory cells compared with groups I and II. The level of LacZ production was significantly lower in group I than in groups II-IV. The optimal temperature of lung graft preservation after ex vivo gene transfer was determined to be 10, balancing considerations of lung injury and efficiency of transgene expression.