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BackgroundThere is no established treatment for the acute exacerbation of trigeminal neuralgia. We aimed to investigate the efficacy and safety of intravenous fosphenytoin for this disease.MethodsWe conducted a retrospective observational study of data from 41 patients with trigeminal neuralgia who received intravenous fosphenytoin therapy. Fosphenytoin diluted with physiological saline was administered intravenously at a loading dose of 9.8–20.7 mg/kg or at a dose of 7.5–9.5 mg/kg when maintenance therapy was needed. Pain was evaluated using a numerical rating scale (NRS), assessed immediately before administration (baseline) and at 2, 12, and 24 h after administration.ResultsThe mean (± standard deviation) NRS score was 9.85 ± 0.69, 0.49 ± 1.47, 1.60 ± 2.19, and 3.46 ± 3.19 at baseline, 2, 12, and 24 h after administration, respectively (p < 0.001). Intravenous fosphenytoin therapy was effective for the acute exacerbation of trigeminal neuralgia regardless of whether it was administered during the perioperative period of microvascular decompression (MVD) or the type of drugs used concomitantly. Fosphenytoin was effective when re-administered (n = 14) or at a maintenance dose (n = 2). The adverse drug reactions observed were mild dizziness in six patients, abnormal auditory perception and thirst in three patients each, and somnolence, decreased SpO2, and drug eruption in one patient each, all of which were transient.ConclusionsIntravenous fosphenytoin therapy can immediately eliminate pain during acute exacerbation of trigeminal neuralgia and can be a useful therapeutic drug in emergency response or until elective treatment, such as MVD, is performed.

Abstract Aim The coronavirus disease 2019 (COVID‐19) pandemic greatly impacted medical resources such as cancer screening, diagnosis, and treatment given to people for various diseases. We surveyed the impacts of the pandemic on the incidence of complications and mortality following pancreaticoduodenectomy for pancreatic cancer in Japan. Methods Data on patients who underwent pancreaticoduodenectomy for pancreatic cancer were extracted from the Japanese National Clinical Database (NCD) between 2018 and 2021. The number of the pancreaticoduodenectomy for pancreatic cancer were obtained and then the morbidity and mortality rates were evaluated using a standardized morbidity/mortality ratio (SMR), which is the ratio of the observed number of incidences to the expected number of incidences calculated by the risk calculator previously developed by the NCD. Results This study included 22 255 cases. The number of pancreaticoduodenectomies exhibited an increasing trend even during the COVID‐19 pandemic. The mean observed incidence rates of Grade C pancreatic fistula and Clavien–Dindo grade ≥4 complications, and the 30‐day mortality and surgical mortality rates were 0.8%, 1.8%, 0.8% and 0.9%, respectively. The standardized morbidity ratios did not increase during the COVID‐19 pandemic. The standardized mortality ratios remained within the range of variations observed before the COVID‐19 pandemic. Conclusion The increasing trend in the number of pancreaticoduodenectomies and favorable short‐term outcomes even in the COVID‐19 pandemic suggest the medical care for pancreatic cancer in Japan functioned well during the pandemic.

Abstract Aim To examine the potential negative effects of the COVID‐19 pandemic on short‐term postoperative outcomes of emergency surgery for gastroduodenal perforation in Japan. Methods A total of 7973 cases of gastroduodenal perforation from 2019 to 2021 were retrieved from the National Clinical Database (NCD), which includes >95% of surgical cases in Japan. Data were analyzed nationally and in subgroups for subjects in areas with high infection levels (HILs). Postoperative 30‐d mortality, surgical mortality, and complications (Clavien–Dindo (CD) grade ≥3) were examined. Months were considered to have significantly high or low mortality or complication rates, if the 95% confidence interval (CI) of the standardized mortality (morbidity) ratio (SMR) does not contain 1. Results Nationally, data from 2019 vs 2020 and 2021 showed 30‐d mortality of 175 (6.7%) vs 398 (7.4%), surgical mortality of 250 (9.5%) vs 537 (10.1%), and complications (CD ≥3) of 558 (21.2%) vs 1163 (21.8%). Among these data, the only significantly high SMR was found for complications in July 2020 (1.36 [95% CI: 1.001–1.80]). In areas with HILs, data from 2019 vs 2020 and 2021 indicated 30‐d mortality of 91 (6.3%) vs 215 (7.3%), surgical mortality of 135 (9.4%) vs 294 (10.0%), and complications (CD ≥3) of 304 (21.1%) vs (23.1%). In these data, no month had a significantly high SMR. Conclusion The COVID‐19 pandemic had few negative effects on outcomes after surgery for gastroduodenal perforation. These findings suggest that the emergency system for gastroduodenal perforation in Japan was generally maintained during the pandemic.

Fenestration is a rare anatomical variation in the posterior cerebral artery. To the best of our knowledge, there are few reports of fenestrations at the posterior cerebral artery P1-P2 junction. Herein, we report a case of fenestration of the posterior cerebral artery P1-P2 junction diagnosed by 3-T magnetic resonance imaging and magnetic resonance angiography. A 75-year-old woman visited our hospital because of headaches. Magnetic resonance imaging incidentally showed fenestration around the P1-P2 segment of the right posterior cerebral artery. Magnetic resonance angiography revealed a small fenestration at the right posterior cerebral artery P1-P2 junction. The vessel diameter of both limbs forming the fenestration was nearly equal. Careful imaging assessment is important to identify fenestration of the posterior cerebral artery P1-P2 junction. Both magnetic resonance angiography and magnetic resonance imaging were useful for diagnosis in this case.

Cerebral hyperperfusion syndrome is a rare but serious complication after revascularization procedures for cerebrovascular diseases. Cerebral hyperperfusion syndrome can develop after treatment of acute ischemic stroke, including intravenous thrombolysis and endovascular treatment of large vessel occlusion. However, to the best of our knowledge, there are no previous reports describing cerebral hyperperfusion syndrome after endovascular treatment of medium vessel occlusion (eg, anterior cerebral artery A2/3 segment). We report a case of cerebral hyperperfusion syndrome after endovascular reperfusion therapy for medium vessel occlusion. A 70-year-old woman with a history of hypertension and dyslipidemia was transferred by ambulance to our hospital because of immobility and slurred speech. She had mild right lower extremity paralysis, and her symptoms appeared improved compared with onset. She was diagnosed with cerebral infarction in the left frontal lobe. After hospitalization, her neurological symptoms worsened and she was referred to our department. We performed endovascular reperfusion therapy for left anterior cerebral artery A2 occlusion. Recanalization was achieved with residual stenosis. Despite the lack of complications associated with the procedure, the patient had prolonged disorientation, severe hemiplegia, and aphasia. Arterial spin labeling demonstrated hyperperfusion in the left anterior cerebral artery area. The symptoms gradually improved under strict blood pressure control. This report provides evidence that cerebral hyperperfusion syndrome can occur even after endovascular treatment for medium vessel occlusion. Arterial spin labeling was useful in detecting hyperperfusion.

Abstract Aim Possible negative effects of the COVID‐19 pandemic on short‐term postoperative outcomes for colorectal perforation in Japan were examined in this study. Methods The National Clinical Database (NCD) is a large‐scale database including more than 95% of surgical cases in Japan. We analyzed 13 107 cases of colorectal perforation from 2019 to 2021. National data were analyzed, and subgroup analyses were conducted for subjects in prefectures with high infection levels (HILs) and metropolitan areas (Tokyo Met. and Osaka Pref.). Postoperative 30‐day mortality, surgical mortality, and postoperative complications (Clavien–Dindo grade ≥3) were examined. Months were considered to have significantly high or low mortality or complication rates, if the 95% confidence interval (CI) of the standardized mortality (morbidity) ratio (SMR) does not contain 1. Results In the NCD, postoperative 30‐day mortality occurred in 1371 subjects (10.5%), surgical mortality in 1805 (13.8%), and postoperative complications in 3950 (30.1%). Significantly higher SMRs were found for 30‐day mortality in November 2020 (14.6%, 1.39 [95% CI: 1.04–1.83]) and February 2021 (14.6%, 1.48 [95% CI: 1.10–1.96]), and for postoperative complications in June 2020 (37.3%, 1.28 [95% CI: 1.08–1.52]) and November 2020 (36.4%, 1.21 [95% CI: 1.01–1.44]). The SMRs for surgical mortality were not significantly high in any month. In prefectures with HILs and large metropolitan areas, there were few months with significantly higher SMRs. Conclusions The COVID‐19 pandemic had limited negative effects on postoperative outcomes in patients with colorectal perforation. These findings suggest that the emergency system for colorectal perforation in Japan was generally maintained during the pandemic.

Abstract Background Anemia has negative effects on long‐term outcomes of rectal cancer patients; however, its status as a risk factor for severe complications is disputed. Perioperative risks may differ based on the severity of pre‐surgical anemia; nonetheless, no previous study has investigated these differences. This study identified risks of severe postoperative complications in rectal cancer patients based on severity of their pre‐surgical anemia. Materials and Methods This study enrolled patients who underwent low anterior resection for rectal cancer and were registered in the Japanese National Clinical Database (NCD) between 2017 and 2019. Anemia severity was categorized into three levels: mild, moderate, and severe. A logistic regression model was applied to calculate the risk‐adjusted odds ratio (OR) of severe complications after surgery. Results This study analyzed a cohort of 51 765 rectal cancer patients who underwent low anterior resection. Results showed that severe complications occurred in 10.9% of patients and were significantly more frequent in patients with anemia (13.6%) than those with normal hemoglobin levels (9.2%). Risk‐adjusted ORs of severe complications in the severe, moderate, and mild anemia groups versus the normal group for males were 1.19 (95% confidence interval [CI]: 0.89–1.58), 1.47 (1.34–1.62), and 1.21 (1.12–1.31), respectively. Those for females were 1.39 (0.90–2.15), 1.64 (1.37–1.97), and 1.36 (1.16–1.58), respectively. Conclusions According to this large cohort study, pre‐surgical anemia significantly increases the risk of severe postoperative complications in rectal cancer patients. Even mild anemia presents a significant risk.

Abstract Background The COVID‐19 outbreak made conventional medical care impossible, forcing changes in both healthcare providers and patients. In Japan, COVID‐19 infection began spreading in earnest in 2020 and exploded in 2021. There was concern that the medical impact of COVID‐19 in 2021 would differ from that in 2020. We aimed to clarify the impact of COVID‐19 on mortality and anastomotic leakage in laparoscopic surgery for gastric cancer and rectal cancer in Japan using the National Clinical Database (NCD). Methods We collected data from patients who underwent laparoscopic distal gastrectomy (LDG) and laparoscopic low anterior resection (LLAR) from January 2018 to December 2021 from the NCD, a web‐based surgical registration system in Japan. The number of surgical cases, monthly incidence of mortality and morbidity (anastomotic leakage), standardized mortality ratio (SMR), and standardized morbidity‐leakage ratio (SMLR [ratio of observed patients to expected patients calculated using the risk calculator established in the NCD]) were evaluated. Results The numbers of LDG and LLAR cases continued to decline in the first year of the pandemic in 2020 and were as low in 2021 as in 2020. Although the numbers of robot‐assisted LDG and LLAR cases increased, the growth rate was lower than the rate of increase prior to the pandemic. Mortality and anastomotic leakage, two of the most important complications, as assessed by SMR and SMLR, did not worsen during the pandemic in comparison to the pre‐pandemic period. Conclusions Laparoscopic surgeries were performed safely in Japan and were not affected by the COVID‐19 pandemic.

Common carotid artery occlusion is rare. Bilateral common carotid artery occlusion is extremely rare and, to our knowledge, has hardly ever been reported. This report describes a case of fatal stroke with acute simultaneous bilateral common carotid artery occlusion presenting as sudden coma. A 90-year-old woman was transferred to our hospital by ambulance with a sudden coma. She had a history of atrial fibrillation but had not taken any oral antithrombotic medication in recent years. She had been receiving house calls for dehydration in the previous week. Magnetic resonance imaging showed extensive cerebral infarcts in both cerebral hemispheres, and magnetic resonance angiography revealed bilateral common carotid artery occlusion. Acute recanalization therapy was not performed because of the extensive cerebral infarction, the patient's advanced age, and her poor ability to perform activities of daily living. On the day after onset, she died of massive cerebral infarction and marked brain swelling.

Abstract Aim The Coronavirus Disease 2019 (COVID‐19) pandemic affected the allocation of various medical resources to several areas, including intensive care units (ICUs). However, currently, its impact on the short‐term postoperative outcomes of gastrointestinal cancer surgeries remains unclear. We aimed to evaluate the impact of the pandemic on the incidence of complications occurring after low anterior resection in patients with rectal cancer in Japan. Methods Data from the Japanese National Clinical Database between 2018 and 2021 were retrospectively examined. The primary outcome of the study was the postoperative morbidity and mortality rates before and after COVID‐19 pandemic. Moreover, the postoperative ICU admission rate was assessed. Morbidity and mortality rates were also assessed using a standardized morbidity/mortality ratio (SMR, the ratio of the actual number of incidences to the expected number of incidences calculated by the risk calculator). Results This study included 74 181 patients, including 43 663 (58.9%) from COVID‐19 epidemic areas. The mean actual incidences of anastomotic leakage (AL) and pneumonia during the study period were 9.2% and 0.9%, respectively. The SMRs of these complications did not increase during the pandemic but those of AL declined gradually. The mean 30‐day mortality and operative mortality rates were 0.3% and 0.5%, respectively. Moreover, SMRs did not change significantly in the pandemic or regional epidemic status. The ICU admission rate temporarily decreased, especially in the epidemic areas. Conclusion Although the pandemic temporarily decreased the ICU admission rate, its impact on short‐term outcomes following low anterior resection in patients with rectal cancer was insignificant in Japan.

Abstract Background The coronavirus disease 2019 (COVID‐19) pandemic had resulted in either failure to provide required medical resources or delayed treatment for gastric cancer patients. This study aimed to investigate the impact of COVID‐19 on the incidence of postoperative complications using a nationwide Japanese database of patients undergoing distal gastrectomy for gastric cancer. Methods We collected the data of patients who underwent distal gastrectomy from January 2018 to December 2021 from the National Clinical Database (NCD), a web‐based surgical registration system in Japan. The number of surgical cases, the use of intensive care units, and the incidence of morbidity per month were analyzed. We also calculated the standardized mortality ratio (SMR), defined as the ratio of the number of observed patients to the expected number of patients calculated using the risk calculator established in the NCD, for several morbidities, including pneumonia, sepsis, 30‐day mortality, and surgical mortality. Results A decrease of 568 gastrectomies was observed from April 2020 to May 2020. Although the absolute number of patients admitted to intensive care units had declined since 2020, the proportion of patients admitted to the ICU did not change before and after the pandemic. Mortality and critical morbidity (such as pneumonia and sepsis) rates were not worse during the pandemic compared to pre‐pandemic periods per the SMR. Conclusions Surgical management was conducted adequately through the organized efforts of the entire surgery department in our country even in a pandemic during which medical resources and staff may have been limited.

Vertebral artery dissection can occur in intracranial or extracranial vertebral arteries. However, the simultaneous dissection of both intracranial and extracranial vertebral arteries is extremely rare. We describe a 45-year-old man with simultaneous intracranial and extracranial vertebral artery dissections in separate sites. The patient visited a neurosurgical clinic because of headache; he was diagnosed with right vertebral artery dissection and referred to our hospital. Magnetic resonance imaging showed an intramural hematoma and mild dilation of the external lumen in the right vertebral artery distal to the posterior inferior cerebellar artery. Magnetic resonance angiography revealed poor delineation of the entire right vertebral artery, including the proximal portion from the posterior inferior cerebellar artery. Computed tomography angiography revealed right extracranial vertebral artery dissection. Careful imaging assessment is thus important for identifying simultaneous intracranial and extracranial vertebral artery dissections.

Abstract Aim This study aimed to evaluate the impact of the coronavirus disease (COVID‐19) pandemic on elective endoscopic surgeries in Japan using the National Clinical Database. Methods We retrospectively analyzed the clinicopathological factors and surgical outcomes of laparoscopic cholecystectomy (LC), laparoscopic distal gastrectomy (LDG), and laparoscopic low anterior resection (LLAR) and compared the monthly numbers of each procedure performed in 2020 with those in 2018 and 2019. The degree of infection in prefectures was classified into low and high groups. Results In 2020, the number of LCs (except for acute cholecystitis) was 76 079 (93.0% of that in 2019), the number of LDGs was 14 271 (85.9% of that in 2019), and the number of LLARs was 19 570 (88.1% of that in 2019). Although the number of robot‐assisted LDG and LLAR cases increased in 2020, the growth rate was mild compared with that in 2019. There was little difference in the number of cases in the degree of infection in the prefectures. The numbers of LC, LDG, and LLAR cases decreased from May to June and recovered gradually. In late 2020, the proportion of T4 and N2 cases of gastric cancer and the number of T4 cases of rectal cancer increased compared with those in 2019. There was little difference between the proportions of postoperative complications and mortality in the three procedures between 2019 and 2020. Conclusion The number of endoscopic surgeries decreased in 2020 as a result of the COVID‐19 pandemic. However, the procedures were performed safely in Japan.

Objective:. To investigate the oncological outcomes after transanal total mesorectal excision (TaTME) for rectal cancer and risk factors for local recurrence (LR). Background:. A high LR rate with a multifocal pattern early after TaTME has been reported in Norway and the Netherlands, causing controversy over the oncological safety of this technique. Methods:. Twenty-six member institutions of the Japan Society of Laparoscopic Colorectal Surgery participated in this retrospective cohort study. A total of 706 patients with primary rectal cancer who underwent TaTME between January 2012 and December 2019 were included for analysis. The primary endpoint was the cumulative 3-year LR rate. Results:. A total of 253 patients had clinical stage III disease (35.8%) and 91 (12.9%) had stage IV. Intersphincteric resection was performed in 318 patients (45.0%) and abdominoperineal resection in 193 (27.3%). There was 1 urethral injury (0.1%). A positive resection margin (R1) was seen in 42 patients (5.9%). Median follow-up was 3.42 years, and the 2- and 3-year cumulative LR rates were 4.95% (95% confidence interval: 3.50–6.75) and 6.82% (95% confidence interval: 5.08–8.89), respectively. A multifocal pattern was observed in 14 (25%) of 56 patients with LR. Tumor height from the anal verge, pathological T4 disease, pathological stage III/IV, positive perineural invasion, and R1 resection were significant risk factors for LR in multivariable analysis. Conclusions:. In this selected cohort in which intersphincteric resection or abdominoperineal resection was performed in more than half of cases, oncological outcomes were acceptable during a median follow-up of more than 3 years.

Carotid artery stenting is a treatment option for patients with significant symptomatic or asymptomatic carotid artery stenosis. Although use of an embolic protection device during carotid artery stenting can prevent distal embolization, device retrieval after stenting can be difficult. In this report, during an embolic protection device retrieval, it was not possible to advance recapture catheters through the distal flare segment of the stent because the device wire would catch on the flare or become jammed between the flare and vessel wall. Then, an extension wire was connected to the end of the device and a 5.2-Fr JB2-type balloon catheter was advanced over the wire, which was able to pass through the stent. The use of a 5.2-Fr JB2-type balloon catheter to retrieve a trapped embolic protection device is feasible and effective if standard maneuvers fail.

Intracranial artery dissection accounts for a small percentage (1%-2%) of all ischemic strokes. Vertebral artery dissection sometimes extends to the basilar artery but very rarely to the posterior cerebral artery. We report a case of bilateral vertebral artery dissection extending to the left posterior cerebral artery with the characteristic distribution of intramural hematoma. A 51-year-old woman presented with right hemiparesis and dysarthria 3 days after sudden neck pain. Magnetic resonance imaging on admission revealed infarcts in the left thalamus and temporo-occipital lobe and findings suggestive of bilateral vertebral artery dissection. No infarct was detected in the brainstem. The patient was treated conservatively. Initially, we suspected that infarction in the left posterior cerebral artery territory had been caused by artery-to-artery embolism from the dissected vertebral arteries. However, T1-weighted imaging on day 15 of admission revealed intramural hematoma extending from the left vertebral artery to the left posterior cerebral artery. Therefore, we diagnosed bilateral vertebral artery dissection extending to the basilar artery and the left posterior cerebral artery. The patient's symptoms subsequently improved with conservative treatment, and she was discharged with a modified Rankin Scale score of 1 on day 62 of admission. In this case, intramural hematoma of the basilar artery was found in the anterior vessel wall. Brainstem infarction is less likely when intramural hematoma is located in the anterior vessel wall of the basilar artery in vertebrobasilar artery dissection. T1-weighted imaging is useful for the diagnosis of this rare condition and can predict potentially impaired branches and possible symptoms.

Abstract Aim This study aimed to investigate the effect of the coronavirus disease pandemic on the number of surgeries for gastroenterological cancer cases in Japan. Methods The data recorded in the National Clinical Database of Japan between 2018 and 2020 were utilized for this study. Five specific surgeries for primary cancers and surgery for acute diffuse peritonitis were considered the primary endpoints. We divided the study period into the prepandemic and postpandemic (after April 2020) periods and examined the number of surgeries in relation to clinical factors. Results Overall, 228 860 surgeries were analyzed. Among the five primary cancer surgeries, the number of distal gastrectomies for gastric cancer decreased the most (to 81.0% of the monthly number in the prepandemic period), followed by that of low anterior resections for rectal cancer (91.4%). In contrast, the number of pancreaticoduodenectomies for pancreatic cancer increased by 7.1%, while that of surgeries for peritonitis remained stable. This trend was observed nationwide. We also noted a marked reduction in the number of distal gastrectomy (to 72.5%), low anterior resection (84.0%), and esophagectomy (88.8%) procedures for T1 tumors. The noncurative resection rate and mortalities were low despite the increased proportion of T4 tumors and older patients. Conclusion A marked reduction in surgeries for gastric and rectal cancers with early T factors may reflect prioritization of surgeries and reduction in cancer screenings. Although the quality of the surgery was maintained in terms of reduced mortalities and morbidities, the long‐term effects of this pandemic should be monitored.

Carotid webs are known to cause acute ischemic stroke in younger adults and have a high recurrence rate. Herein, we report a case of a symptomatic carotid web in a 51-year-old man who was transferred to our hospital after developing consciousness disturbance and left hemiparesis. He was diagnosed with right middle cerebral artery occlusion and underwent mechanical thrombectomy. Because his carotid web was the likely embolic source, we performed carotid artery stenting using a dual-layer stent to crimp the vessel wall and secure closure of the web pocket. Follow-up angiography was performed at 3 weeks after stenting, and endothelialization on the web pocket was confirmed. The high scaffolding effect of the dual layer stent may promote the endothelialization on the carotid web.

Japanese native chickens (JNCs) comprise approximately 50 breeds, making Japan a diversity hotspot for native chicken breeds. JNCs were established through the repeated introduction of chickens from foreign countries. Jidori, which is the generic name of JNC breeds whose ancestral morphology resembles that of their wild progenitor (red junglefowls), is generally thought to have propagated from north East Asia (Korea and north China) to ancient Japan. However, mitochondrial haplogroup D, which is abundant in Island Southeast Asia (ISEA) as well as the Pacific but relatively rare in other regions, can be observed in some Jidori breeds (e.g., Tosa-Jidori, Tokuji-Jidori) with high frequency, leading to speculation that chickens from ISEA or the Pacific also contributed genetically to JNCs. To test this hypothesis, we sequenced the mitochondrial genomes of Jidori breeds and conducted phylogeographic analysis. Our results indicate that the JNC Haplogroup D belongs to Sub-haplogroup D2, which is currently only observed in Xinjiang, northwest China, and not to Sub-haplogroup D1, which is widely distributed in the ISEA-Pacific region. The other mitochondrial haplogroups of Jidori examined in this study also showed affinity to those of chickens native to north East Asia. Therefore, our findings support the north East Asian origin hypothesis for Jidori.

Posterior reversible encephalopathy syndrome, an acute onset neurological syndrome, is among the conditions that must be differentiated from stroke. Herein, we report a rare case of posterior reversible encephalopathy syndrome mimicking subacute ischemic stroke. A 68-year-old man was transferred by ambulance to our hospital because of visual disturbance. He showed left homonymous hemianopsia. Magnetic resonance imaging (diffusion-weighted imaging and fluid-attenuated inversion recovery imaging) revealed high signal intensity in the right occipital lobe. We suspected subacute cerebral infarction. After admission, he developed cortical blindness and increased blood pressure. Fluid-attenuated inversion recovery imaging revealed high signal intensity and elevated apparent diffusion coefficient values in the bilateral occipital lobes. We diagnosed the patient with posterior reversible encephalopathy syndrome. Antihypertensive treatment improved his clinical symptoms. Careful imaging assessment, including of changes over time, is important for diagnosing posterior reversible encephalopathy syndrome.

Vertebral artery stump syndrome is rare, but one of the most important causes of posterior circulation stroke. To our knowledge, no optimal treatment for vertebral artery stump syndrome has been established, and there are no reports of long-term follow-up. We describe a 69-year-old man with vertebral artery stump syndrome who attended our hospital because of vertigo. Magnetic resonance imaging detected right cerebellar infarcts. Digital subtraction angiography revealed severe stenosis (functional obstruction) at the origin of the right vertebral artery, with distal antegrade collateral flow from the deep cervical artery. We started him on argatroban and cilostazol, but symptoms recurred after 1 month. We changed from cilostazol to aspirin and clopidgrel, then terminated aspirin 1 month after recurrence. He continued on clopidgrel, and follow-up after 7 years showed no recurrence, including asymptomatic lesions.

Abstract Background The risk of choking increases with aging, and the number of cases of choking-induced cardiac arrest is increasing. However, few studies have examined the prognosis of choking-induced cardiac arrest. The aim of this study was to reveal the rates of survival and dependence on devices in the long term after choking-induced cardiac arrest. Methods We analyzed data from the Shizuoka Kokuho Database, which consists of claims data of approximately 2.2 million people, from April 2012 to September 2018. We selected patients with choking-induced cardiac arrest who received cardiopulmonary resuscitation in the hospital. Patients were excluded if they were less than 20 years old, had an upper airway tumor, received ventilation assistance, or received enteral nutrition in the month prior to cardiac arrest. The primary outcome was death, and the secondary outcomes were the rates of survival at 3-months and independence on devices. Descriptive statistics are presented and compared among age groups (20–64 years, 65–74 years, 75–84 years, 85 years and older), and survival time analysis (Kaplan-Meier method) was performed. Results In total, 268 patients were analyzed, including 26 patients in the 20–64 age group, 33 patients in the 65–74 age group, 70 patients in the 75–84 age group, and 139 patients in the ≥85 age group. The overall 3-month survival rate was 5.6% (15/268). The 3-month survival rates were 3.8% (1/26) in the 20–64 age group, 15.2% (5/33) in the 65–74 age group, 8.6% (6/70) in the 75–84 age group, and 2.2% (3/139) in the ≥85 age group. The overall 12-month survival rate was 2.6% (7/268). Of the 7 patients who survived for 12 months, 3 received ventilation management and 5 received tube or intravenous feedings at 3 months. These survivors were still receiving ventilation assistance and tube feedings in the hospital and had not been discharged at 12 months. Conclusions The prognosis of choking-induced cardiac arrest was extremely poor when patients were not resuscitated before hospital arrival. Those who survived were mostly dependent on assistive devices. Additionally, none of the survivors dependent on assistive devices had discontinued the use of the devices at the long-term follow-up.

Abstract Background Elective laparoscopic surgery is now widely accepted in the treatment of abdominal diseases because of its minimal invasiveness and rapid postoperative recovery. It is also used in the emergency setting for the diagnosis and treatment of acute diffuse peritonitis regardless of the causative disease. However, the value of laparoscopy in acute diffuse peritonitis remains unclear. In this study we aimed to show trends in the use of laparoscopy over time and compare the real‐world performance of laparoscopic surgery with that of open surgery for acute diffuse peritonitis due to gastrointestinal perforation. Methods We extracted data from the National Clinical Database, a nationwide surgery registration system in Japan, for patients with a diagnosis of acute diffuse peritonitis due to gastroduodenal or colorectal perforation between 2016 and 2019. Trends in the use of laparoscopy over time were identified. Patient characteristics, laboratory findings, surgical findings, and postoperative complications were compared between laparoscopic surgery and open surgery. Results Patients in poor condition and those with abnormal laboratory findings tended to undergo open surgery. Anesthesia time and operating time were longer for laparoscopic surgery in patients with gastroduodenal perforation but shorter in those with colorectal perforation. Fewer complications occurred in patients who underwent laparoscopic surgery. The number of institutions where laparoscopic surgery was performed and the proportion of the use of laparoscopy at each institution increased over time. Conclusion The use of laparoscopy is becoming common in surgery for acute diffuse peritonitis due to gastrointestinal perforation. This approach may be a useful option for acute diffuse peritonitis.

Abstract Background Esophagectomy followed by gastric conduit reconstruction is a standard surgical procedure for esophageal cancer. However, there is no evidence of the superiority or inferiority of the posterior mediastinal (PM) versus the retrosternal (RS) reconstruction route with regard to short‐term outcomes after esophagectomy. We aimed to elucidate whether the reconstruction route can affect the short‐term outcomes after esophagectomy followed by gastric conduit reconstruction. Methods We reviewed the clinical data of patients who underwent esophagectomy between 2016 and 2018 from the Japanese National Clinical Database. This study included 9786 patients who underwent gastric conduit reconstruction through the PM or RS route with cervical anastomosis. Results Of the 9786 patients analyzed, 3478 and 6308 underwent gastric conduit reconstruction thorough the PM and RS routes, respectively. The incidence of anastomotic leak and surgical site infection (SSI) was significantly lower in the PM group than in the RS group (11.7% vs 13.8%, P = .005 and 8.4% vs 14.9%, P

Agenesis of the left common carotid artery with separate origins of the left internal and external carotid arteries from the aorta is an extremely rare anomaly. This anomaly is typically asymptomatic unless associated with other conditions. We report a case of separate origins of the left internal and external carotid arteries from the aorta in a patient with intracerebral hemorrhage. A 42-year-old man was transferred to our hospital by ambulance because of left hemiparesis. Computed tomography scan revealed right putaminal hemorrhage. Computed tomography angiography and digital subtraction angiography demonstrated independent origins of the left internal carotid artery and external carotid artery from the aortic arch. Right internal carotid angiography revealed blood supply to the left anterior cerebral artery and middle cerebral artery via the anterior communicating artery. The separate origins of the left internal and external carotid arteries from the aorta may cause hemodynamic stress to the contralateral side, leading to right intracerebral hemorrhage.

Abstract Background Scintillating scotoma caused by optic nerve compression by aneurysm is rare. We report a case of scintillating scotoma following optic nerve compression caused by an unruptured anterior communicating artery aneurysm. Case presentation A 64-year-old woman visited our department with a scintillating scotoma. Magnetic resonance imaging demonstrated no new lesions, although her previously diagnosed anterior communicating artery aneurysm had increased in size. Thus, we performed neck clipping. The operative view showed that the aneurysm compressed the right optic nerve. Her symptoms disappeared after the operation. These findings suggest that scintillating scotoma may be caused by compression of the optic nerve by the anterior communicating artery aneurysm. Conclusion Although scintillating scotoma is a common condition, aneurysms should be considered as a potential cause.

Abstract Since the start of the coronavirus disease 2019 (COVID-19) pandemic, it has remained unknown whether conventional risk prediction tools used in intensive care units are applicable to patients with COVID-19. Therefore, we assessed the performance of established risk prediction models using the Japanese Intensive Care database. Discrimination and calibration of the models were poor. Revised risk prediction models are needed to assess the clinical severity of COVID-19 patients and monitor healthcare quality in ICUs overwhelmed by patients with COVID-19.

Abstract Aim We aimed to investigate whether later weekdays are related to worse short‐term outcomes after elective right hemicolectomy for colon cancer. Methods We retrospectively analyzed adult patients who underwent elective right hemicolectomy for colon cancer between 2012 and 2017. Records lacking details about surgical mortality were excluded, and multiple imputation was performed for other missing data (variables). The primary endpoint was surgical mortality, defined as the sum of 30‐day mortality and in‐hospital deaths within 90 days postoperatively. Using 22 clinical variables, hierarchal logistic regression modeling with clustering of patients from the same institutes was performed. Results Of the 112 658 patients undergoing elective right hemicolectomy for colon cancer, the 30‐day mortality and surgical mortality were 0.6% and 1.1%, respectively. Surgery on Friday was less frequent, accounting for 17.1% of all cases. The occurrence of severe postoperative complications, anastomotic leakage, or unadjusted odds ratio for surgical mortality did not show significant differences between weekdays. A hierarchal logistic regression model identified 19 independent factors for surgical mortality. Adjusted odds ratios for surgical mortality were 1.01 (95% confidence interval: 0.83‐1.22, P = .915), 0.86 (95% confidence interval: 0.71‐1.05, P = .144), 0.86 (95% confidence interval: 0.71‐1.05, P = .408), and 0.83 (95% confidence interval: 0.68‐1.03, P = .176) for Tuesday, Wednesday, Thursday, and Friday, respectively, showing no significant differences. Conclusion This study did not identify an evident difference in surgical mortality between weekdays; a safe elective right hemicolectomy for colon cancer is being offered throughout the week in Japan.

Abstract Aim Appendicitis is divided into two categories: complicated appendicitis (CA) and uncomplicated appendicitis (UA). In pediatric patients with CA, the use of interval appendectomy (IA), which is non‐operative management followed by elective surgery, has decreased the number of postoperative complications. Before discussing the merit of IA for adult patients, we need to clarify whether the frequency and seriousness of the complication rate after emergency surgery is higher for CA than for UA. Methods This retrospective cohort study included adult patients who underwent appendectomy and who were registered in the National Clinical Database (NCD) from 2014 to 2016. Patients with CA who underwent emergency appendectomy comprised the CA group. Patients with UA comprised the UA group. Patients with chronic or recurrent appendicitis who underwent elective appendectomy comprised the elective appendectomy (EA) group. Primary outcomes were all morbidity, serious morbidity, and mortality within 30 days after appendectomy. Results We included 109 256 patients in the study: 14 798 CA, 86 876 UA, and 7582 EA patients. Compared with the UA group, the rates of all morbidity, serious morbidity, and mortality were significantly higher in the CA group. All morbidity, serious morbidity, and mortality rates were significantly lower in the EA group than in the other two groups. Conclusions We confirmed that emergency surgery for CA places the patient at relatively higher risk. We also showed that the risk associated with EA is significantly lower than that for the other methods.

Abstract Background The Acute Physiology and Chronic Health Evaluation (APACHE) III-j model is widely used to predict mortality in Japanese intensive care units (ICUs). Although the model’s discrimination is excellent, its calibration is poor. APACHE III-j overestimates the risk of death, making its evaluation of healthcare quality inaccurate. This study aimed to improve the calibration of the model and develop a Japan Risk of Death (JROD) model for benchmarking purposes. Methods A retrospective analysis was conducted using a national clinical registry of ICU patients in Japan. Adult patients admitted to an ICU between April 1, 2018, and March 31, 2019, were included. The APACHE III-j model was recalibrated with the following models: Model 1, predicting mortality with an offset variable for the linear predictor of the APACHE III-j model using a generalized linear model; model 2, predicting mortality with the linear predictor of the APACHE III-j model using a generalized linear model; and model 3, predicting mortality with the linear predictor of the APACHE III-j model using a hierarchical generalized additive model. Model performance was assessed with the area under the receiver operating characteristic curve (AUROC), the Brier score, and the modified Hosmer–Lemeshow test. To confirm model applicability to evaluating quality of care, funnel plots of the standardized mortality ratio and exponentially weighted moving average (EWMA) charts for mortality were drawn. Results In total, 33,557 patients from 44 ICUs were included in the study population. ICU mortality was 3.8%, and hospital mortality was 8.1%. The AUROC, Brier score, and modified Hosmer–Lemeshow p value of the original model and models 1, 2, and 3 were 0.915, 0.062, and < .001; 0.915, 0.047, and < .001; 0.915, 0.047, and .002; and 0.917, 0.047, and .84, respectively. Except for model 3, the funnel plots showed overdispersion. The validity of the EWMA charts for the recalibrated models was determined by visual inspection. Conclusions Model 3 showed good performance and can be adopted as the JROD model for monitoring quality of care in an ICU, although further investigation of the clinical validity of outlier detection is required. This update method may also be useful in other settings.

Objective: In parent artery occlusion (PAO) for ruptured vertebral artery dissecting aneurysms (RVADA), target embolization using coils in a short segment to occlude only the vasodilated area containing the rupture point is selected as a first-choice procedure at our institute. We focused on RVADA involving the posterior inferior cerebellar artery (PICA) and evaluated the treatment results.Methods: This study consisted of eight cases with RVADA involving the PICA which were treated between October 2007 and January 2020. Based on radiological findings such as the bleb, the rupture points were located at the affected vertebral artery (VA) distal to PICA in all cases. Target embolization, by which only coiling at the dilated segment distal to the VA was performed. We aimed to preserve blood flow to the PICA. The incidence and extent of medullary infarctions, and neurological outcome were retrospectively assessed.Results: Regarding the diameter of bilateral VA, there were no differences in six cases while the affected VA with RVADA were larger in the remaining two cases. PICA was preserved in all cases but one in which occlusion of complementary PICA was observed. Postoperative medullary infarction was not noted. There was no rebleeding during the follow-up period. However, recanalization of the VA was observed in four cases and additional coil embolization was performed. All patients were discharged with a good outcome (modified Rankin Scale [mRS] 0; seven patients, mRS 2; one patient).Conclusion: Target embolization preserving the PICA in PICA-involved type RVADA was considered to be an effective treatment method for cases whose rupture point was located in the VA distal to PICA orifice.

Abstract Aim The advantages of laparoscopic right hemicolectomy over open surgery for colon cancer in general clinical practice are debated, as evidenced by the continued use of open surgery in a significant proportion of patients worldwide. This study aimed to assess and compare the clinical outcome of laparoscopic and open right hemicolectomy for colon cancer using data from the Japanese National Clinical Database. Methods A total of 72 299 patients who underwent laparoscopic (n = 46 084) and open (n = 26 215) right hemicolectomy for colon cancer between 2014 and 2018 were enrolled in this retrospective study. Short‐term outcome was compared between groups using propensity score matching analysis. Results The incidence of overall postoperative morbidity ≥ Clavien‐Dindo classification grade 3 was significantly higher in the open surgery group than the laparoscopic group (4.7% vs 3.2%, P

Abstract Aim This study aimed to evaluate the association between surgeons certified via the Endoscopic Surgical Skill Qualification System (ESSQS) of the Japan Society for Endoscopic Surgery (JSES) and surgical outcomes of laparoscopic distal gastrectomy (LDG) and laparoscopic low anterior resection (LLAR). Methods Japanese National Clinical Database data on the patients undergoing LDG and LLAR between 2014‐2016 were analyzed retrospectively. The proportion of cases performed by ESSQS‐certified surgeons was calculated for each procedure, and clinicopathological factors with or without participation of ESSQS‐certified surgeons as an operator were assessed. Then, effects of operations performed by ESSQS‐certified surgeons on short‐term patient outcomes were analyzed using generalized estimating equations logistic regression analysis. Results There were 110 610 and 65 717 patients who underwent LDG and LLAR, respectively. The operations performed by ESSQS‐certified surgeons in each procedure totaled 28 467 (35.3%) and 12 866 (31.2%), respectively. A multivariable logistic regression model showed that odds ratios of mortality for LDG and LLAR performed by ESSQS‐certified surgeons were 0.774 (95% CI, 0.566‐1.060, P = 0.108) and 0.977 (0.591‐1.301, P = 0.514), respectively. Odds ratios for secondary endpoints of anastomotic leakage in LDG and LLAR performed by ESSQS‐certified surgeons were 0.835 (95% CI, 0.723‐0.964, P = 0.014) and 0.929 (0.860‐1.003, P = 0.059), respectively, whereas that of ileus/bowel obstruction for LLAR performed by ESSQS‐certified surgeons was 1.265 (1.132‐1.415, P

Abstract Background Emergency gastrointestinal surgery, although rare, is known for its high mortality and morbidity. However, the risks of emergency surgery for gastrointestinal cancer have not been investigated in depth. This study aimed to investigate the impact of emergency surgery on mortality and morbidity in patients with gastrointestinal cancers and to identify associated risk factors. Methods We extracted data from the National Clinical Database, a nationwide surgery registration system in Japan, for patients with gastrointestinal cancer who underwent esophageal resection, total gastrectomy, distal gastrectomy, right hemicolectomy, or low anterior resection between 2012 and 2017. The impacts of emergency surgery on 30‐day mortality and incidence of overall postoperative complications were compared with those of non‐emergency surgery. Risk factors for mortality and overall postoperative complications were then sought in patients who underwent emergency surgery. Results Thirty‐day mortality and incidence of overall postoperative complications were significantly higher in emergency surgeries for gastric, colon, and rectal cancers than in non‐emergency surgeries (odds ratios 4.86‐6.98 and 1.68‐2.18, respectively; all P

Abstract Background The cardiopulmonary resuscitation guidelines revised in 2015 recommend target chest compression rate (CCR) and chest compression depth (CCD) of 100–120 compressions per minute (cpm) and 5–6 cm, respectively. We hypothesized that the new guidelines are harder to comply with, even with proper feedback. Methods This prospective observational study using data collected from the participants of an Immediate Cardiac Life Support course included the evaluation of chest compressions using performance data from a feedback device after the completion of the course. Participants completed chest compressions for 1 min and were provided with feedback, after which they performed another cycle of CC. Primary outcome measures were CCR and CCD as well as the correct CCR percentage and CCD percentage for pre and post feedback. Results The study included a total of 88 participants. The median pre-CCR was 112.5 cpm (interquartile range [IQR] 108–116 cpm), and the median correct pre-CCR percentage was 96% (IQR 82.5–99.5%). After the feedback, there was a slight increase in the correct CCR percentage (99% [IQR 92.5–100%]). Conversely, the median pre-CCD was 5.4 cm (IQR 4.9–5.8 cm), and the median pre-correct CCD percentage was 66% (IQR 18.5–90%). The increase in the median post-correct CCD percentage to 72% (IQR 27–94%) observed after the feedback was not statistically significant (P = 0.361). Conclusions Compliance with the new guidelines for chest compressions, especially those regarding the CCD, might be difficult. However, whether the changes in guidelines affect outcomes in actual clinical settings is uncertain and requires further investigation.

Prolonged ICU stays are associated with high costs and increased mortality. Thus, early prediction of such stays would help clinicians to plan initial interventions, which could lead to efficient utilization of ICU resources. The aim of this study was to develop models for predicting prolonged stays in Japanese ICUs using APACHE II, APACHE III and SAPS II scores. In this multicenter retrospective cohort study, we analyzed the cases of 85,558 patients registered in the Japanese Intensive care Patient Database between 2015 and 2019. Prolonged ICU stay was defined as an ICU stay of >14 days. Multivariable logistic regression analyses were performed to develop three predictive models for prolonged ICU stay using APACHE II, APACHE III and SAPS II scores, respectively. After exclusions, 79,620 patients were analyzed, 2,364 of whom (2.97%) experienced prolonged ICU stays. Multivariable logistic regression analyses showed that severity scores, BMI, MET/RRT, postresuscitation, readmission, length of stay before ICU admission, and diagnosis at ICU admission were significantly associated with higher risk of prolonged ICU stay in all models. The present study developed predictive models for prolonged ICU stay using severity scores. These models may be helpful for efficient utilization of ICU resources.

This study aims to understand the relationships among morphological characteristics, their functional roles, and breeder preferences in Japanese native fowls. We analyzed and compared the shapes and sizes of the skeletal forelimb, pectoral girdle, and sternum among six breeds: Chabo, Oh-Shamo, Onagadori, Shokoku, Tosajidori, and Totenko. Because skeletal forelimb, pectoral girdle, and sternum are one of the bases for composing body appearance and for movement of birds such as flapping, we treated those skeletons. All measurements of size were smaller in Chabo than those in other breeds except Tosajidori. The largest measurement values of all parameters were observed in Oh-Shamo. The largest measurement values were observed in all measurements of Oh-Shamo. Short and wide forelimb bones and a short coracoid were observed in Chabo. Oh-Shamo was equipped with a wide sternum and a widely articulated coracoid. Shokoku and Totenko possessed longer bones that constitute the thoracic cavity. We suggest that the small bone size in ornamental fowls contributes toward a cute appearance and that the large bone size of fighting fowls is correlated with their masculinity and aggressiveness. The short forelimb bones, wide articulation, and corpus of forelimb bones in Chabo create a round and soft body silhouette. The observed short coracoid prevents Chabo from dragging its body on the ground while walking. The wide sternum and articulation of the coracoid observed in Oh-Shamo are considered to contribute to the ability to pounce on an opponent by flapping during a fight. The wide sternum of Oh-Shamo is considered to affect its body outline, producing a strong, masculine physical appearance. We also suggest that the characteristics observed in Shokoku and Totenko create a space for the vocal organs, such as clavicle air sacs. We suggest that the observed morphological characteristics underlie the function and breeder preferences of each breed.

A macroscopic examination of the huge leg of the Dong Tao breed from North Vietnam was conducted. Bone and muscular tendon morphometric data demonstrated that the Dong Tao breed was equipped with the extraordinarily thick and large tarsometatarsal bone and distal parts of the related tibiotarsus regions. Morphological differences between dorsal and plantar sides were clearly observed. First, on the dorsal side, fleshy bundles were extended effectively using the enlarged dorsal surface of tarsometatarsal bone shown as Musuculus extensor digitorum brevis, M. extensor digiti I brevis and M. adductor digiti IV. The strong and fleshy extensor bellies of M. tibialis cranialis and M. extensor digitorum longus were enlarged in the crural region, functioning to dorsally pull the heavy tarsometatarsal region through the ankle joint. Second, on the plantar side, the flexor tendon groups around the ankle joint were wider and thicker than those of other ordinary breeds, possibly to stabilize the tarsometatarsal bone and to flex the phalange as observed in M. flexor perforatus digiti II, M. flexor perforans et perforatus digiti II, M. flexor perforatus digiti III, M. flexor perforans et perforatus digiti III, M. flexor perforatus digiti IV, and M. flexor perforans digitorum profundus. The mass of the huge tarsometatarsal region does not contribute to effective locomotion in the Dong Tao fowl in comparison with that associated with normal breeds. However, we suggest that these morphological changes in the musculoskeletal system may functionally compensate for the physical disadvantages of the large weight of the distal part of the hindlimb in the Dong Tao fowl.

Bat communities of mainland Southeast Asia can be highly diverse. Many are under threat. Despite this, regional faunal composition is not well documented for many areas, including regions of Vietnam. We assessed the biodiversity of bats in a watershed protection forest in the southeastern Truong Son (Annamite) Mountains, southwestern Quang Ngai Province, Vietnam in 2011–2013. Twenty species of insectivorous bats were documented including a high diversity of Murina species Tube-nosed Bats. Diversity and abundance indices were compared with that recorded previously in two nature reserves and one national park in Vietnam, and were higher or comparable in several measures despite the lack of a karst substrate for roosts. Reproduction in the insectivorous bat fauna coincided with the early rainy season. In the late dry season, pregnant females of several species were observed but volant juveniles were not present, whereas in the early wet season adult females were lactating or post-lactating and volant juveniles of nine species were detected. We recorded echolocation calls of 14 bat species; for each species, we compared features of calls with those reported previously in other Asian localities. For some species we found discrepancies in call metrics among studies, perhaps suggesting a greater hidden biodiversity of bats in Southeast Asia.

The skull of six Japanese fowl breeds, namely, Chabo, Oh-Shamo, Onagadori, Shokoku, Tosajidori, and Totenko, were morphologically compared in this study. The morphological differences in the skull size and shape among the breeds were as follows. 1) Oh-Shamo possessed a wide bill, thick bill tip, small orbits and wide mandibular joint. The characteristics of the bill and mandible were interpreted as functional characteristics to endure the shock of pecking. We suggest that the small orbits and a wide frontal bone help in protection from pecking in games. 2) Chabo possessed a small skull. In terms of shape, this breed possessed relatively large orbits, a wide and high skull and a short bill. The wide and high skull and the short bill formed a circular-shaped face. We propose that these characteristics have led to its characterisation as ornament-type fowl. 3) Totenko, Shokoku, Onagadori and Oh-Shamo possess a long mandible. The long mandible led to an increase in the volume of the oral cavity. The wide resonance space is responsible for the low-frequency voice. The low-frequency crowing of Totenko, Shokoku, Oh-Shamo and Onagadori is a result of the enlarged resonance space created by the long mandible. The orbits of Totenko and Onagadori were larger than those of Shokoku and Oh-Shamo. We suggest that Shokoku possessed the small orbits as a fighting cock. Since Onagadori and Totenko had been bred as ornament-type fowl, they possessed larger orbits.

Evolution of the middle ear ossicles was a key innovation for mammals, enhancing the transmission of airborne sound. Radiation into various habitats from a terrestrial environment resulted in diversification of the auditory mechanisms among mammals. However, due to the paucity of phylogenetically controlled investigations, how middle ear traits have diversified with functional specialization remains unclear. In order to identify the respective patterns for various lifestyles and to gain insights into fossil forms, we employed a high-resolution tomography technique and compared the middle ear morphology of eulipotyphlan species (moles, shrews and hedgehogs), a group that has radiated into various environments, such as terrestrial, aquatic and subterranean habitats. Three-dimensional geometric morphometric analysis was conducted within a phylogenetically controlled framework. Quantitative shapes were found to strongly reflect the degree of subterranean lifestyle and weakly involve phylogeny. Our analyses demonstrate that subterranean adaptation should include a relatively shorter anterior process of the malleus, an enlarged incus, an enlarged stapes footplate and a reduction of the orbicular apophysis. These traits arguably allow improving low-frequency sound transmission at low frequencies and inhibiting the low-frequency noise which disturbs the subterranean animals in hearing airborne sounds.

Here we examined the kinematic function of the morpho- logically unique first thoracic vertebra in giraffes. The first thoracic vertebra of the giraffe displayed similar shape to the seventh cervical vertebra in general ruminants. The flexion experiment using giraffe carcasses demonstrated that the first thoracic vertebra exhibited a higher dorsoventral mobility than other thoracic vertebrae. Despite the presence of costovertebral joints, restriction in the intervertebral movement imposed by ribs is minimized around the first thoracic vertebra by subtle changes of the articular system between the vertebra and ribs. The attachment area of musculus longus colli, mainly responsible for ventral flexion of the neck, is partly shifted posteriorly in the giraffe so that the force generated by muscles is exerted on the cervical vertebrae and on the first thoracic vertebra. These anatomical modifications allow the first thoracic vertebra to adopt the kinematic function of a cervical vertebra in giraffes. The novel movable articulation in the thorax functions as a fulcrum of neck movement and results in a large displacement of reachable space in the cranial end of the neck. The unique first thoracic vertebra in giraffes provides higher flexibility to the neck and may provide advantages for high browsing and/or male competition behaviours specific to giraffes.

[This corrects the article DOI: 10.1371/journal.pone.0129939.].

Brown adipose tissue (BAT) plays an important role in thermoregulation in species living in cold environments, given heat can be generated from its chemical energy reserves. Here we investigate the existence of BAT in blubber in four species of delphinoid cetacean, the Pacific white-sided and bottlenose dolphins, Lagenorhynchus obliquidens and Tursiops truncates, and Dall's and harbour porpoises, Phocoenoides dalli and Phocoena phocoena. Histology revealed adipocytes with small unilocular fat droplets and a large eosinophilic cytoplasm intermingled with connective tissue in the innermost layers of blubber. Chemistry revealed a brown adipocyte-specific mitochondrial protein, uncoupling protein 1 (UCP1), within these same adipocytes, but not those distributed elsewhere throughout the blubber. Western blot analysis of extracts from the inner blubber layer confirmed that the immunohistochemical positive reaction was specific to UCP1 and that this adipose tissue was BAT. To better understand the distribution of BAT throughout the entire cetacean body, cadavers were subjected to computed tomography (CT) scanning. Resulting imagery, coupled with histological corroboration of fine tissue structure, revealed adipocytes intermingled with connective tissue in the lowest layer of blubber were distributed within a thin, highly dense layer that extended the length of the body, with the exception of the rostrum, fin and fluke regions. As such, we describe BAT effectively enveloping the cetacean body. Our results suggest that delphinoid blubber could serve a role additional to those frequently attributed to it: simple insulation blanket, energy storage, hydrodynamic streamlining or contributor to positive buoyancy. We believe delphinoid BAT might also function like an electric blanket, enabling animals to frequent waters cooler than blubber as an insulator alone might otherwise allow an animal to withstand, or allow animals to maintain body temperature in cool waters during sustained periods of physical inactivity.

Paleontologists have investigated brain morphology of extinct birds with little information on post-hatching changes in avian brain morphology. Without the knowledge of ontogenesis, assessing brain morphology in fossil taxa could lead to misinterpretation of the phylogeny or neurosensory development of extinct species. Hence, it is imperative to determine how avian brain morphology changes during post-hatching growth. In this study, chicken brain shape was compared at various developmental stages using three-dimensional (3D) geometric morphometric analysis and the growth rate of brain regions was evaluated to explore post-hatching morphological changes. Microscopic MRI (μMRI) was used to acquire in vivo data from living and post-mortem chicken brains. The telencephalon rotates caudoventrally during growth. This change in shape leads to a relative caudodorsal rotation of the cerebellum and myelencephalon. In addition, all brain regions elongate rostrocaudally and this leads to a more slender brain shape. The growth rates of each brain region were constant and the slopes from the growth formula were parallel. The dominant pattern of ontogenetic shape change corresponded with interspecific shape changes due to increasing brain size. That is, the interspecific and ontogenetic changes in brain shape due to increased size have similar patterns. Although the shape of the brain and each brain region changed considerably, the volume ratio of each brain region did not change. This suggests that the brain can change its shape after completing functional differentiation of the brain regions. Moreover, these results show that consideration of ontogenetic changes in brain shape is necessary for an accurate assessment of brain morphology in paleontological studies.

Vietnam is recognized as one of the world's biodiversity hotspots. Recent studies have uncovered numerous new mammal species, highlighting the significant biodiversity of Vietnam not only within the region but globally. However, these new species, along with established ones, are currently affected by climate change and human activities, which have led to the decline of certain populations and placed some species at risk of extinction. Since 2001, our surveys and assessments of the current status and distribution of small mammals from the orders Eulipotyphla, Chiroptera, and Rodentia have identified 48 species that are prioritized for conservation with varying conservation levels based on their actual status, especially those with less individual numbers in population, narrow distribution ranges, and those still affected by human activities. The research has identified 17 priority sites for habitat conservation, including two in the Northeast, three in the Northwest, four in the North Central region, three in the Central Highlands, and five in the Mekong Delta. [ABSTRACT FROM AUTHOR]