Higher power achieves greater local impedance drop, shorter ablation time, and more transmural lesion formation in comparison to lower power in local impedance guided radiofrequency ablation of atrial fibrillation.

BACKGROUND: Since the local impedance (LI) of the ablation catheter reflects tissue characteristics, the efficacy of higher power (HP) compared to lower power (LP) in LI-guided ablation may differ from other index-guided ablations. OBJECTIVE: This study aimed to assess the efficacy of HP ablation in LI-guided ablation of atrial fibrillation (AF). METHODS: A prospective observational study was conducted, enrolling patients undergoing de novo ablation for AF. Pulmonary vein isolation was performed using point-by-point ablation with a RHYTHMIA HDxTM Mapping System and an open-irrigated ablation catheter with mini-electrodes (IntellaNav MIFI OI). Ablation was stopped when the LI drop reached 30 ohms, three seconds after the LI plateaued, or when ablation time reached 30 s. To balance the baseline differences, a unique method was used in which the power was changed between HP (45 W to anterior wall/40 W to posterior wall) and LP (35 W/30 W) alternately for each adjacent point. RESULTS: A total of 551 ablations in 10 patients were analyzed (HP, n = 276; LP, n = 275). The maximum LI drop was significantly larger (HP: 28.3 ± 5.4 vs. LP: 24.8 ± 6.3 ohm), and the time to minimum LI was significantly shorter (HP: 15.0 ± 6.3 vs. LP: 19.3 ± 6.6 s) in the HP setting. The unipolar electrogram analysis of three patients revealed that the electrogram indicating transmural lesion formation was observed more frequently in the HP setting. CONCLUSION: In LI-guided ablation, the HP could achieve a larger LI drop and shorter time to minimum LI, which may result in more transmural lesion formation compared to a LP setting.

A novel catheter ablation strategy for non-paroxysmal atrial fibrillation combining cryoballoon, radiofrequency, and Marshall-vein ethanol ablations.

BACKGROUNDS: Catheter ablation for non-paroxysmal atrial fibrillation (non-PAF) remains challenging and more effective strategy has been required to reduce postoperative arrhythmia recurrences. This study aims to investigate the efficacy and safety of a novel extensive ablation strategy for non-PAF, that is based on a combination of cryoballoon (CBA), radiofrequency (RFA), and Marshall-vein ethanol ablations (EA-VOM). METHODS: The study was a single-center, retrospective observational study. We enrolled 171 consecutive patients who underwent de-novo catheter ablation for non-PAF under conscious sedation with a novel extensive ablation strategy that included CBA for pulmonary vein isolation (PVI) and left atrial roof ablation (LARA), RFA for mitral isthmus (MI) ablation, superior vena cava isolation, and other linear ablations and EA-VOM. Recurrence of atrial arrhythmias over 1 year, procedure outcomes, and procedure-related complications were investigated. RESULTS: A total of 139 (81.3%) patients remained in sinus rhythm during 1-year follow-up. Of the 139 patients, 51 patients (29.8%) received antiarrhythmic drugs. The mean procedure time was 204 ± 45 min. PVI and LARA ablation by CBA and MI block by RFA and EA-VOM were completed in 171 (100%) and 166 (97.1%) patients, respectively. No serious procedure-related complications were observed except for one case of delayed pericardial effusion. CONCLUSION: Approximately 80% of the study patients were AF-free during 1-year follow-up period after a single procedure based on the novel extensive ablation strategy combining CBA, RFA, and EA-VOM. This strategy for non-PAF may be preferred in terms of maintenance of sinus rhythm, safety even in high-risk patients, and relatively short procedure time.

A Simple and Accurate Model for Predicting Fall Injuries in Hospitalized Patients: Insights from a Retrospective Observational Study in Japan.

BACKGROUND While several predictive models for falls have been reported such as we reported in 2020, those for fall "injury" have been unreported. This study was designed to develop a model to predict fall injuries in adult inpatients using simple predictors available immediately after hospitalization. MATERIAL AND METHODS This was a single-center, retrospective cohort study. We enrolled inpatients aged ≥20 years admitted to an acute care hospital from April 2012 to March 2018. The variables routinely obtained in clinical practice were compared between the patients with fall injury and the patients without fall itself or fall injury. Multivariable analysis was performed using covariables available on admission. A predictive model was constructed using only variables showing significant association in prior multivariable analysis. RESULTS During hospitalization of 17 062 patients, 646 (3.8%) had falls and 113 (0.7%) had fall injuries. Multivariable analysis showed 6 variables that were significantly associated with fall injuries during hospitalization: age (P=0.001), sex (P=0.001), emergency transport (P<0.001), medical referral letter (P=0.041), history of falls (P=0.012), and abnormal bedriddenness ranks (all P≤0.001). The area under the curve of this predictive model was 0.794 and the shrinkage coefficient was 0.955 using the same data set given above. CONCLUSIONS We developed a predictive model for fall injuries during hospitalization using 6 predictors, including bedriddenness ranks from official Activities of Daily Living indicators in Japan, which were all easily available on admission. The model showed good discrimination by internal validation and promises to be a useful tool to assess the risk of fall injuries.

Effects of Caregiver's Gender or Distance Between Caregiver and Patient's Home on Home Discharge from Hospital in 285 Patients Aged ≥75 Years in Japan.

BACKGROUND Many hospitalized aged patients in Japan, the most super-aged society, are unable to be discharged home. This study was performed to clarify the factors associated with home discharge, not to a long-term care (LTC) facility or another hospital, among inpatients aged ≥75 years. MATERIAL AND METHODS A single-center prospective cohort study was performed for inpatients aged ≥75 years in a rural acute-care hospital in Japan, from November 2017 to October 2019. We divided the patients into 2 groups: those who resided at home or had died at home by 30 days after discharge, and others. We obtained data from medical charts and questionnaires given to patients and their caregivers. For each factor shown to be statistically significant by the univariable analysis, a multivariable analysis with adjustment was conducted. RESULTS In all, 285 patients agreed to participate. With adjustment by where the patient was admitted from, residing with other family members, cognitive function scores, and Barthel index, multivariable analysis using each factor identified as relevant by univariable analysis identified the following as associated with home discharge: being less informed about LTC insurance; cost of home-visit medical, nursing, or LTC services; shorter hospital stays; close proximity between patient and caregiver; main caregiver being female; and life expectancy of over 6 months (P<0.05). CONCLUSIONS Male gender and a long distance between the caregiver and patient's home significantly hindered home discharge in patients aged ≥75 years, suggesting the need to provide information regarding home-visit services under Japan's LTC insurance system for such caregivers.

Evaluation of a Previously Developed Predictive Model for Infective Endocarditis in 320 Patients Presenting with Fever at 4 Centers in Japan Between January 2018 and December 2020.

BACKGROUND In our previous single-center study, we developed an infective endocarditis (IE) prediction model among patients with undiagnosed fever (UF) based on 5 factors that can be obtained on admission: ambulance transfer, presence of cardiac murmur or pleural effusion, blood neutrophil percentage, and platelet count. The present study aimed to retrospectively evaluate the prediction model for IE in 320 patients presenting with fever at 4 university hospitals in Japan from January 2018 to December 2020. MATERIAL AND METHODS Patients aged ≥20 years admitted to 4 hospitals with I-330 (IE) or R-50-9 (UF) according to the International Statistical Classification of Diseases and Related Health Problems-10 were enrolled. More than 2 physicians at each hospital reviewed the patient diagnoses using the modified Duke criteria, allocating "definite IE" to IE group (n=119) and "non-definite IE" to UF group (n=201). Five factors on admission were analyzed by multivariate logistic regression. The discriminative ability and calibration of the model were evaluated using the area under the curve (AUC) and the shrinkage coefficient, respectively. RESULTS A total of 320 patients were enrolled. The odds ratios (95% confidence intervals) were as follows: ambulance transfer 1.81 (0.91-3.55); cardiac murmur 13.13 (6.69-27.36); pleural effusion 2.34 (0.62-2.42); blood neutrophil percentage 1.09 (1.06-1.14); and platelet count 0.96 (0.93-0.99). The AUC was 0.783 (0.732-0.834) with a shrinkage coefficient of 0.961. CONCLUSIONS The IE prediction model is useful to estimate the probability of IE immediately after admission for fever in patients aged ≥20 years.

Leadless pacemaker implantation sites confirmed by computed tomography and their parameters and complication rates.

BACKGROUND: Implantations of leadless pacemakers in the septum lower the risk of cardiac perforation. However, the relationship between the implantation site and the success rate, complication rate, and pacemaker parameters are not well-investigated. METHODS: Patients who underwent leadless pacemaker implantation with postprocedural computed tomography (CT) between September 2017 and November 2020 were analyzed. Septum was targeted with fluoroscopic guidance with contrast injection. We divided patients into two groups based on the implantation site confirmed by CT: septal and non-septal, which included the anterior/posterior edge of the septum and free wall. We compared the complication rates and pacemaker parameters between the two groups. RESULTS: A total of 67 patients underwent CT after the procedure; among them, 28 were included in the septal group and 39 were included in the non-septal group. The non-septal group had significantly higher R wave amplitudes (6.5 ± 3.3 vs. 9.7 ± 3.9 mV, p = .001), lower pacing threshold (1.0 ± 0.94 vs. 0.63 ± 0.45 V/0.24 ms, p = .02), and higher pacing impedance (615 ± 114.1 vs. 712.8 ± 181.3 ohms, p = .014) after the procedure compared to the septal group. Cardiac injuries were observed in four patients (one cardiac tamponade, one possible apical hematoma, two asymptomatic pericardial effusion), which were only observed in the non-septal group. CONCLUSIONS: Leadless pacemaker implantation may be technically challenging with substantial number of patients with non-septal implantation when assessed by CT. Septal implantation may have a lower risk of cardiac injury but may lead to inferior pacemaker parameters than non-septal implantation.

A Prospective Observational Study Conducted at a Single Center in Japan to Validate a Previously Developed Predictive Formula of In-Hospital Mortality for Patients Aged ≥65 Years with Endogenous Diseases Transported by Ambulance.

BACKGROUND In 2019, we developed a predictive formula of in-hospital mortality for inpatients aged ≥65 years transported by ambulance for endogenous diseases. In this study, we aimed to validate this previously developed predictive formula. MATERIAL AND METHODS In this single-center prospective observational study, we enrolled all patients aged ≥65 years who were transported by ambulance and admitted to an acute care hospital in Japan for endogenous diseases. We calculated the score according to our developed formula using age, disturbance of consciousness, the shock index, and amount of oxygen administered, with each item scoring 1 point and then totaling them. We subsequently evaluated the in-hospital mortality rate, stratum-specific likelihood ratio, and area under the receiver operating characteristic curve (AUC) of the formula, using in-hospital mortality as the primary outcome. RESULTS In total, 325 patients were included in this study. Forty-two patients died during hospitalization. Multivariable logistic regression analysis (forced-entry method) revealed that disturbance of consciousness and oxygen administration 5 L/min or more were significantly associated with mortality during hospitalization. In contrast, aged ≥90 years and shock index of 1 or higher were not significant. The mortality and stratum-specific likelihood ratios for scores in the predictive formula of 3 and 4 were 40.9% and 4.66, and 66.7% and 13.48, respectively. The AUC of the predictive formula for in-hospital mortality was 0.670 (95% confidence interval: 0.574-0.767). CONCLUSIONS This study showed that our predictive formula, consisting of factors available immediately after ambulance transport in older patients, is feasible with sufficient discrimination ability and reliability.

External validation of a new predictive model for falls among inpatients using the official Japanese ADL scale, Bedriddenness ranks: a double-centered prospective cohort study.

BACKGROUND: Several reliable predictive models for falls have been reported, but are too complicated and time-consuming to evaluate. We recently developed a new predictive model using just eight easily-available parameters including the official Japanese activities of daily living scale, Bedriddenness ranks, from the Ministry of Health, Labour and Welfare. This model has not yet been prospectively validated. This study aims to prospectively validate our new predictive model for falls among inpatients admitted to two different hospitals. METHODS: A double-centered prospective cohort study was performed from October 1, 2018, to September 30, 2019 in an acute care hospital and a chronic care hospital. We analyzed data from all adult inpatients, for whom all data required by the predictive model were evaluated and recorded. The eight items required by the predictive model were age, gender, emergency admission, department of admission, use of hypnotic medications, previous falls, independence of eating, and Bedriddenness ranks. The main outcome is in-hospital falls among adult inpatients, and the model was assessed by area under the curve. RESULTS: A total of 3,551 adult participants were available, who experienced 125 falls (3.5%). The median age (interquartile range) was 78 (66-87) years, 1,701 (47.9%) were men, and the incidence of falls was 2.25 per 1,000 patient-days and 2.06 per 1,000 occupied bed days. The area under the curve of the model was 0.793 (95% confidence interval: 0.761-0.825). The cutoff value was set as - 2.18, making the specificity 90% with the positive predictive value and negative predictive value at 11.4% and 97%. CONCLUSIONS: This double-centered prospective cohort external validation study showed that the new predictive model had excellent validity for falls among inpatients. This reliable and easy-to-use model is therefore recommended for prediction of falls among inpatients, to improve preventive interventions. TRIAL REGISTRATION: UMIN000040103 (2020/04/08).

Left ventricular lead placement using inner guiding catheter alone in cardiac resynchronization therapy device implantation.

BACKGROUND: Subselection inner catheters (Inner-Cath) are used adjunctively with outer guiding catheters (Outer-Cath) during cardiac resynchronization therapy (CRT) device implantation. This study aims to investigate the feasibility and efficacy of left ventricular lead placement (LV-LP) guided by Inner-Cath alone. METHODS: A total of 74 patients undergoing de novo CRT implantation were investigated. LV-LP was initially guided by Inner-Cath in 42 patients (Inner-Cath group) and Outer-Cath in 32 patients (Outer-Cath group). In the Inner-Cath group, a 7Fr Inner-Cath was advanced to the coronary sinus through a 7 Fr sheath inserted in a subclavian vein. In the Outer-Cath group, 9Fr or 10Fr Outer-Caths were used. Success rate of LV-LP, additional use of inner or outer catheters and procedure-related complications were compared between groups. RESULTS: LV-LP was successful in all patients in the Inner-Cath group, while LV-LP had to be abandoned in two patients (6.3%) of the Outer-Cath group due to CS perforation caused by Outer-Cath manipulation. Procedure time was significantly shorter in the Inner-Cath group (148 vs. 168 min; p = .024). Deployment of both an inner and outer cath became necessary less frequently for the Inner-Cath group (4.8% vs. 56.3%; p < .001). Mechanical CS injuries due to guiding catheter manipulation were only observed in the Outer-Cath group (0% vs. 15.6%, p = .013). CONCLUSION: LV-LP guided by Inner-Cath alone was feasible in over 95% of the patients without severe complications. This methodology for LV-LP may be preferable in CRT candidates with severe LV dysfunction in terms of shorter procedure time, smaller guiding sheath, and less procedure-related complications.

High inter-rater reliability of Japanese bedriddenness ranks and cognitive function scores: a hospital-based prospective observational study.

BACKGROUND: The statistical validities of the official Japanese classifications of activities of daily living (ADLs), including bedriddenness ranks (BR) and cognitive function scores (CFS), have yet to be assessed. To this aim, we evaluated the ability of BR and CFS to assess ADLs using inter-rater reliability and criterion-related validity. METHODS: New inpatients aged ≥75 years were enrolled in this hospital-based prospective observational study. BR and CFS were assessed once by an attending nurse, and then by a social worker/medical clerk. We evaluated inter-rater reliability between different professions by calculating the concordance rate, kappa coefficient, Cronbach's α, and intraclass correlation coefficient. We also estimated the relationship of the Barthel Index and Katz Index with the BR and CFS using Spearman's correlation coefficients. RESULTS: For the 271 patients enrolled, BR at the first assessment revealed 66 normal, 10 of J1, 15 of J2, 18 of A1, 31 of A2, 37 of B1, 35 of B2, 22 of C1, and 32 of C2. The concordance rate between the two BR assessments was 68.6%, with a kappa coefficient of 0.61, Cronbach's α of 0.91, and an intraclass correlation coefficient of 0.83, thus showing good inter-rater reliability. BR was negatively correlated with the Barthel Index (r = - 0.848, p < 0.001) and Katz Index (r = - 0.820, p < 0.001), showing justifiable criterion-related validity. Meanwhile, CFS at the first assessment revealed 92 normal, 47 of 1, 19 of 2a, 30 of 2b, 60 of 3a, 8 of 3b, 8 of 4, and 0 of M. The concordance rate between the two CFS assessments was 70.1%, with a kappa coefficient of 0.62, Cronbach's α of 0.87, and an intraclass correlation coefficient 0.78, thus also showing good inter-rater reliability. CFS was negatively correlated with the Barthel Index (r = - 0.667, p < 0.001) and Katz Index (r = - 0.661, p < 0.001), showing justifiable criterion-related validity. CONCLUSIONS: BR and CFS could be reliable and easy-to-use grading scales of ADLs in acute clinical practice or large-scale screening, with high inter-rater reliabilities among different professions and significant correlations with well-established, though complicated to use, instruments to assess ADLs. TRIAL REGISTRATION: UMIN000041051 (2020/7/10).

Improvement in the Quality of Life and Exercise Performance in Relation to the Plasma B-Type Natriuretic Peptide Level After Catheter Ablation in Patients With Asymptomatic Persistent Atrial Fibrillation.

BACKGROUND: Efficacy of catheter ablation (CA) of asymptomatic persistent atrial fibrillation (AF) remains unclear. We assessed the quality of life (QOL), exercise performance (EP), and plasma B-type natriuretic peptide (BNP) levels following CA in patients with asymptomatic AF.Methods and Results:We enrolled 34 patients with asymptomatic persistent AF. QOL, was assessed by 2 questionnaires: the Short Form-36 (SF-36) and a QOL questionnaire specific for AF (AFQLQ). The QOL, EP, and plasma BNP level were examined before and 6 months after CA. In the SF-36 survey 5 of 8 components and all 3 subsets of the AFQLQ significantly improved in the patients without recurrences (30 patients, 88%), but there were no differences in those with recurrences. In patients without recurrences, there was an increase in the metabolic equivalents of task (10.2±2.3 vs. 11.6±2.3 METs, P<0.0001), duration of maximal exercise (476±144 vs. 605±143 s, P<0.0001), and plasma BNP decrease (146.6±124.3 vs. 33.8±35.6 pg/dL, P<0.0001), with a linear correlation in the increased duration of exercise and plasma BNP decrease (R=0.620, P<0.0001). CONCLUSIONS: Maintenance of sinus rhythm after successful CA improved the QOL, EP, and plasma BNP level in patients with asymptomatic persistent AF. CA may be primarily applicable in such patients with previously unrecognized impairment in their QOL and EP.

Mechanisms of Diuresis for Acute Decompensated Heart Failure by Tolvaptan.

Tolvaptan, a vasopressin type 2 receptor antagonist, does not affect kidney circulation or cause worsening of renal function (WRF) in patients with acute decompensated heart failure (ADHF). Bioelectrical impedance analysis (BIA) can be used to evaluate intravascular volume by calculating the ratio of extracellular water (ECW) to intracellular water (ICW). There have been no reports examining the mechanisms of tolvaptan-induced diuresis using BIA. We investigated whether tolvaptan decreases excess volume while maintaining intravascular volume in ADHF patients.Study patients included 29 ADHF patients (age 48-95, men 69%) diagnosed between April 2013 and May 2016 and who underwent BIA before and after treatment. Fifteen patients were treated with tolvaptan in addition to conventional diuresis therapy (tolvaptan group), and 14 patients were treated with conventional diuresis therapy only (control group). In the control group, the numerical value of serum creatinine (Cre) significantly increased from 0.89 ± 0.22 mg/ dL to 1.07 ± 0.29 mg/dL (P = 0.004), and the ECW/ICW significantly decreased from 0.696 ± 0.036 to 0.673 ± 0.032 (P = 0.004). These values were not significantly different from those obtained for the tolvaptan group. Furthermore, regression analysis showed a negative correlation between ΔCre and ΔECW/ICW, which are the differences between values before and after treatment (ΔCre = -0.002-5.668 × ΔECW/ICW, r2 = 0.306, P = 0.002).Our findings suggest that WRF is caused by a reduction in intravascular volume and that tolvaptan treatment can decrease the excess volume while maintaining intravascular volume.

A case of an atrial tachycardia originating from an occluded coronary sinus ostium with a persistent left superior vena cava.

We present a case of a 37-year-old female who complained of frequent palpitations caused by an atrial tachycardia and atrial premature contractions. Angiography revealed that the coronary sinus was occluded at the ostium and connected to a persistent left superior vena cava. An electrophysiological study and three-dimensional mapping revealed that the origin of the atrial tachycardia and atrial premature contractions was at the coronary sinus ostium in the right atrium. After repeat applications of radiofrequency energy at that site, no further atrial tachycardia or atrial premature contractions were induced by atrial burst pacing. To the best of our knowledge, this is the first report of an atrial tachycardia originating from an occluded coronary sinus ostium.

Clinical course of hepatitis B surface antigen positive subjects following screening: A retrospective observational study from April 2008 to January 2013.

AIM: Determination of the percentage of hepatitis B surface antigen (HBsAg) positive participants who undergo screening and treatment may reduce the development of hepatocellular carcinoma. This study assessed the percentages of HBsAg positive participants detected by free screening at medical institutions in Saga Prefecture who underwent detailed examinations and antiviral treatment. METHODS: Participants were screened for HBsAg positivity at medical institutions in Saga Prefecture from April 2008 to January 2013, with some visiting physicians for detailed examinations and applying for reimbursement. Participants in the database of the Health Promotion Division of Saga Prefecture and results of detailed examinations were analyzed retrospectively. RESULTS: Screening revealed 193 eligible participants, 105 men (54%) and 88 women (46%), of a mean age of 55.5 ± 14.9 years. Of these 193 participants, 147 (76%) visited physicians for detailed examinations, 24 (16%) were regarded as needing treatment and seven (3.6%) were reimbursed for antiviral treatments. The 46 participants who did not undergo detailed examinations were significantly younger than the 147 examined participants (50.9 ± 13.2 vs 56.9 ± 15.2 years, P = 0.018). Of the 110 participants thought to require observation, 68 (62%) were assigned to this group without determination of alanine aminotransferase or hepatitis B virus DNA concentration, and 15 (14%) had indications for antiviral treatment according to the 2014 guidelines of the Japanese Society of Hepatology. CONCLUSION: The proportion of HBsAg positive participants receiving antiviral treatment was lower than that of participants undergoing detailed examinations.

Epithelial Pten controls acute lung injury and fibrosis by regulating alveolar epithelial cell integrity.

RATIONALE: Injury to alveolar epithelial cells (AECs) and to their repair process is integral to the pathogenesis of acute lung injury (ALI) and idiopathic pulmonary fibrosis (IPF). The mechanisms regulating the integrity of AECs and their intrinsic regulators remain unclear. Pten is a tumor suppressor, and its function in epithelial cells during organ fibrosis is unknown. OBJECTIVES: To determine the role of epithelial Pten in ALI and lung fibrosis. METHODS: Bronchioalveolar epithelium-specific Pten-deleted SP-C-rtTA/(tetO)(7)-Cre/Pten(Δ/Δ) (SOPten(Δ/Δ)) mice were studied by structural, biochemical, and physiologic analyses and compared with wild-type mice. Further mechanistic studies were performed in vivo, in vitro, and on samples from patients with IPF. MEASUREMENTS AND MAIN RESULTS: SOPten(Δ/Δ) mice demonstrated exacerbated alveolar flooding and subsequent augmented lung scarring with enhanced disassembly of tight junctions (TJs) of AECs and degradation of basement membranes. The induction of dominant negative PTEN gene in lung epithelial cells led to augmented transforming growth factor-1-induced disruptions of TJs. Epithelial-derived myofibroblasts were increased in the epithelium-specific Pten-deficient mice. The lungs of bleomycin-treated SOPten(Δ/Δ) mice showed increased pAkt, pS6K, Snail, and matrix metalloproteinase expressions and decreased claudin-4, E-cadherin, and laminin-ß1 expressions. Akt inactivation definitively saved SOPten(Δ/Δ) mice through amelioration of ALI and retention of AEC integrity. We detected a reduction of PTEN expression and AKT hyperactivation in the AECs of human IPF lungs. CONCLUSIONS: Our results highlight epithelial Pten as a crucial gatekeeper controlling ALI and lung fibrosis by modulating AEC integrity, and the Pten/PI3K/Akt pathway as a potential therapeutic target in these intractable diseases.

Marked gallbladder wall thickening caused by Epstein-Barr virus-induced infectious mononucleosis.

Key Clinical Message: In patients with symptoms of viral infection and marked thickening of the gallbladder wall, it is important to suspect acalculous cholecystitis due to Epstein-Barr virus-induced infectious mononucleosis. Abstract: A 35-year-old Japanese man presented with fever, abdominal right upper quadrant pain, and liver dysfunction. Positive immunoglobulin M and -G antibodies and negative nuclear antigen for Epstein-Barr virus were observed. Abdominal ultrasonography revealed a markedly thickened gallbladder wall. Acalculous cholecystitis due to Epstein-Barr virus-induced infectious mononucleosis was diagnosed.

Potential Indicators of Intestinal Necrosis in Portal Venous Gas: A Case Report of an 82-Year-Old Woman on Long-Term Hemodialysis with Ascites and Pneumatosis Coli.

BACKGROUND Several factors have been reported as possible predictors of intestinal necrosis in patients with portal venous gas (PVG). We describe potential indicators of intestinal necrosis in PVG identified by contrasting 3 episodes of PVG in a patient on hemodialysis against previously verified factors. CASE REPORT An 82-year-old woman undergoing hemodialysis was admitted to our hospital thrice for acute abdominal pain. On first admission, she was alert, with a body temperature of 36.3°C, blood pressure (BP) of 125/53 mmHg, pulse rate of 60/min, respiratory rate of 18/min, and 100% oxygen saturation on room air. Computed tomography (CT) revealed PVG, intestinal distension, poor bowel wall enhancement, bubble-like pneumatosis in the intestinal wall, and minimal ascites. PVG caused by intestinal ischemia was diagnosed, and she recovered after bowel rest and hydration. Three months later, she had a second episode of abdominal pain. BP was 115/56 mmHg. CT revealed PVG and a slight accumulation of ascites, without pneumatosis in the intestinal wall. She again recovered after conservative measures. Ten months later, the patient experienced a third episode of abdominal pain, with BP of 107/52 mmHg. CT imaging indicated PVG, considerable ascites, and linear pneumatosis of the intestinal walls. Despite receiving conservative treatment, the patient died. CONCLUSIONS A large accumulation of ascites and linear pneumatosis in the intestinal walls could be potential indicators of intestinal necrosis in patients with PVG caused by intestinal ischemia. As previously reported, hypotension was further confirmed to be a reliable predictor of intestinal necrosis.

Correction: New predictive models for falls among inpatients using public ADL scale in Japan: A retrospective observational study of 7,858 patients in acute care setting.

[This corrects the article DOI: 10.1371/journal.pone.0236130.].