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Background: Fulminant myocarditis presentation (FMP) is a rare and severe presentation of myocarditis. The natural history of FMP and its clinical features associated with poor outcomes are incompletely understood because there is a lack of generalizable evidence. Methods: This multicenter retrospective cohort study included patients hospitalized with histologically proven myocarditis who underwent catecholamine or mechanical support from 235 cardiovascular training hospitals across Japan between April 2012 and March 2017. Clinical features and the prognostic predictors of death or heart transplantation within 90 days on the basis of clinical and pathologic findings were determined using the Kaplan-Meier method, log-rank test, and Cox regression analysis. Results: This study included 344 patients with histologically proven FMP (median age, 54 years; 40% female). The median follow-up was 600 days (interquartile range, 36 to 1599 days) and the cumulative risk of death or heart transplantation at 90 days was 29% (n=98). Results from multivariable Cox regression analysis showed that older age, nonsinus rhythm, low left ventricular wall motion ( Conclusions: The results from analyses of data from this multicenter registry demonstrated that patients with FMP are at a higher risk of death or heart transplantation in real-world settings. These observations inform which clinical and pathologic findings may be useful for prognostication in FMP. Registration: URL: https://www.umin.ac.jp/ctr ; Unique identifier: UMIN000039763.

Aims To examine the effects of a 24-month treatment with ipragliflozin on carotid intima-media thickness (IMT) in type 2 diabetes patients. Methods and results In this multicenter, prospective, randomized, open-label, and blinded-endpoint investigator-initiated clinical trial, adults with type 2 diabetes and haemoglobin A1C (HbA1c) of 6.0–10.0% (42–86 mmol/mol) were randomized equally to ipragliflozin (50 mg daily) and non-sodium-glucose cotransporter-2 (SGLT2) inhibitor use of standard-care (control group) for type 2 diabetes and were followed-up to 24 months. The primary endpoint was the change in mean common carotid artery IMT (CCA-IMT) from baseline to 24 months. A total of 482 patients were equally allocated to the ipragliflozin (N = 241) and control (N = 241) groups, and 464 patients (median age 68 years, female 31.7%, median type 2 diabetes duration 8 years, median HbA1c 7.3%) were included in the analyses. For the primary endpoint, the changes in the mean CCA-IMT from baseline to 24 months were 0.0013 [95% confidence interval (CI), −0.0155–0.0182] mm and 0.0015 (95% CI, −0.0155–0.0184) mm in the ipragliflozin and control groups, respectively, with an estimated group difference (ipragliflozin-control) of −0.0001 mm (95% CI, −0.0191–0.0189; P = 0.989). A group difference in HbA1c change at 24 months was also non-significant between the treatment groups [−0.1% (95% CI, −0.2–0.1); P = 0.359]. Conclusion Twenty-four months of ipragliflozin treatment did not affect carotid IMT status in patients with type 2 diabetes recruited in the PROTECT study, relative to the non-SGLT2 inhibitor-use standard care for type 2 diabetes.

The CARTOFINDER mapping system analyzes activation patterns using unipolar potentials during atrial fibrillation (AF), where isoproterenol (ISP) is conventionally used to induce non-pulmonary vein (PV) foci and confirm PV arrhythmogenicity. In 20 patients with persistent AF who underwent ablation at our hospital, arrhythmogenic foci were evaluated using both these methods.Before pulmonary vein isolation (PVI), PV and left atrium (LA) were analyzed during AF using CARTOFINDER, and the isolation line was determined based on the results. After PVI, ISP was loaded after return of sinus rhythm and confirmation of the presence of arrhythmogenic foci. The activation site in LA was ablated at the discretion of the surgeon.Focal activation sites detected by CARTOFINDER correlated with the arrhythmogenic foci induced by ISP in the PVs. The results also showed that a greater number of focal activation sites in the PVs correlated to an increased response to ISP administration. In one patient, it was observed that the focal activation site identified in the PV also coincided with the site of the origin of automaticity induced by ISP after PVI.CARTOFINDER and ISP both reliably determined the presence of arrhythmogenic foci in PV, in patients with persistent AF. Knowledge of the nature of arrhythmogenic foci in non-PV is considered to be a topic for future studies, and further data collection is required.

Ultra‐high‐resolution mapping is useful in the ablation of accessory pathways. However, in patients with accessory pathways in the coronary sinus (CS) diverticulum, treatment with endocardial ablation may be challenging. Patients suspected of having subepicardial accessory pathways may require the examination of the venous anomaly using CS angiography.

Cardiac involvement of malignant lymphoma is relatively common, although such a phenomenon has subclinical manifestations that are difficult to detect. We herein describe a patient with atrial fibrillation and sick sinus syndrome as the main symptoms. Computed tomography showed a mass in the right atrium extending into the superior vena cava (SVC). We implanted the patient with a leadless pacemaker. Transvenous biopsy revealed a diffuse large B-cell lymphoma. The patient was treated successfully with chemotherapy including rituximab. This case suggested that cardiac lymphoma may cause sick sinus syndrome, and leadless pacemaker implantation is a safe treatment option in patients with partial SVC obstruction.

We treated a patient with PCCD whose single left AT appeared as two different types on preoperative surface and intracardiac ECG from a pacemaker. The diagnosis was hindered by the fact that the conduction block encompassed interatrial block and the pacemaker A‐wave was captured at the right atrial appendage.

We present a patient with isolated bilateral external iliac artery dissections associated with emotional stress. The diagnosis should be kept in mind in young, fit patients presenting lower back pain occurring subsequent to emotional stress.

Purpose Compared with conventional pulmonary vein isolation (PVI) with radiofrequency ablation, PVI with cryoballoon is an easier and shorter procedure without reconnection, particularly in the superior pulmonary vein. However, the durability of the cryoballoon may be reduced due to anatomical factors and the position of the pulmonary vein (PV). Further, inadequate isolation of the carina leads to recurrence of atrial fibrillation (AF). We aimed to determine whether using contrast-enhanced computed tomography (CT) for patient selection improves the early success rate and prevents the recurrence of AF in PVI with cryoballoon. Methods We evaluated patients who underwent ablation for paroxysmal atrial fibrillation in our hospital between July 2019 and November 2020. After excluding patients with contraindications for cryoablation, 50 patients were selected through visual inspection of the results of preoperative contrast-enhanced CT. A treatment plan was established, and the clinical course and outcomes were followed up. Results Of the 200 PVs of the 50 patients, only 8 PVs (4%) were incompletely isolated with a single cryoablation. Six of the eight PVs were successfully isolated with additional cryoablation. Only 2 patients (4%) underwent additional PVI with radiofrequency ablation. Four patients had AF recurrence within a mean follow-up period of 14.3 ± 5.1 months. The rate of sinus rhythm maintenance was 92%. PV reconnection was observed in 2 patients. None of the patients had postoperative atrial flutter. Conclusions Selecting patients for cryoablation according to contrast-enhanced CT findings made the procedure easier to perform, leading to improved early success rates and clinical course.

Background Catheter ablation for atrial fibrillation (AF) is an established therapy. However, postoperative recurrence is a serious issue caused by the reconduction of the isolated pulmonary veins (PV) and the onset of non-PV foci. The objectives of this study were to elucidate dormant conduction, confirm PV arrhythmia substrate, induce non-PV foci after PV isolation, and assess the acute efficacy of high dose isoproterenol (ISP) when administered in addition to adenosine. Methods The study consisted of 100 patients with drug-refractory AF (paroxysmal and persistent) who underwent ablation therapy (either radio-frequency or cryoballoon ablation) as the first-line of therapy at our hospital. All patients first underwent PV isolation (PVI) and were administered adenosine followed by ISP (6 μg × 5 min). The effects were observed, and the therapeutic strategy was evaluated. Results Persistent dormant conduction due to ISP administration was observed in 13 patients. In over half of the patients, arrhythmia substrates were identified in the PV. Ten patients presented with persistent PV firing. The ablation of non-PV foci was additionally performed in 23 patients. Conclusions We found that dormant conduction, as a result of ISP administration, is persistent and ISP is useful when performing an ablation. In addition, ISP administration is useful for the identification of PV arrhythmia substrates and induction of non-PV foci. However, the effectiveness of ISP may be partially due to the complementary effect of adenosine, and, therefore, a combination of the two drugs seems preferable.

Intraoperative identification of the parathyroid gland is very important during thyroid and parathyroid surgery.Recently, intrinsic fluorescence of the parathyroid gland was identified and reported.We report the case of a 45-year-old woman with thyroid papillary cancer.Before surgery, neck and chest CT showed a thyroid tumor(20mm)of the right lobe and an aberrant right subclavian artery.Her thyroid cancer(T1N1M0, Stage Ⅰ)was resected in December 2017(right lobectomy and lymph node dissection).During surgery, her parathyroid glands were visually inspected by the surgeon as well as by a ready-made photodynamic eye(PDE-neo)system.Diagnosis was performed using the intraoperative fast pathological method.Her inferior laryngeal nerve was non-recurrent(Toniato ⅡA).This photodynamic eye(PDE-neo)system is an effective and useful method that decreases the operation time and enables faster detection of the parathyroid gland.

Factor-Xa inhibitors (FXaIs) are widely used for the treatment of non-valvular atrial fibrillation (NVAF). Although we have previously reported the distribution of the anti-factor Xa activity (AXA) values of three different FXaIs in NVAF patients, the differences in the distribution of AXA values among the different FXaIs in patients with renal impairment (RI) have not been fully elucidated. Trough and peak AXA values were measured in 94 patients taking rivaroxaban, 124 patients taking apixaban, and 66 patients taking edoxaban. Of them, we identified 26 patients with moderate RI [creatinine clearance (CrCl) 30–49 mL/min] and 17 patients with severe RI (CrCl 15–29 mL/min) in the rivaroxaban cohort, 37 patients with moderate RI and 17 patients with severe RI in the apixaban cohort, and 21 patients with moderate RI and 9 patients with severe RI in the edoxaban cohort. AXA values were measured using chromogenic AXA assays. Both trough and peak AXA values were compared between patients with moderate RI and those with severe RI in each cohort, and differences in the peak-to-trough ratio among the different drugs were assessed. In the rivaroxaban cohort, the peak AXA value was significantly higher in patients with severe RI than in those with moderate RI. In the apixaban cohort, neither the trough nor peak AXA values significantly differed between patients with moderate RI and those with severe RI. In the edoxaban cohort, the trough AXA value was significantly higher in patients with severe RI than in those with moderate RI, and peak AXA tended to be higher in patients with severe RI. The peak-to-trough ratio of AXA values was significantly lower in patients taking apixaban than in those taking rivaroxaban and edoxaban. Among Japanese NVAF patients with RI, the peak or trough AXA values were higher in patients with severe RI than in those with moderate RI when taking rivaroxaban and edoxaban, whereas both the peak and trough AXA values were similar between patients with severe RI and those with moderate RI when taking apixaban. The peak-to-trough ratio of AXA values was the lowest in patients taking apixaban.

Background:It is known that once heart failure occurs in older patients with diabetes, the overall prognosis is extremely poor. We investigated whether early initiation of SGLT2 inhibitor therapy after admission was beneficial for diabetic patients requiring inpatient treatment for acute heart failure.Methods:We retrospectively assessed consecutive patients with comorbid diabetes who were admitted to the Department of Cardiology in Tosei General Hospital for treatment of acute heart failure. Patients were divided into two groups: those who initiated SGLT2 inhibitor therapy (SGLT2 inhibitor group; mean age: 73 ± 9 years) and those who did not receive the inhibitors during hospitalization (conventional treatment group; mean age: 75 ± 10 years).Results:No intergroup differences were observed in the distribution of either the severity or classes of heart failure on admission. Glycosylated hemoglobin levels were significantly higher in the SGLT2 inhibitor group (HbA1c: 8.1% ± 0.8%) than in the conventional treatment group (HbA1c: 7.1% ± 0.8%) ( p = 0.003). After admission, patients in both groups recovered equally well, and in almost the same period of time, before discharge. The rate of diuretics use at the time of discharge in the SGLT2 inhibitor group ( n = 8, 67%) was significantly lower than that in the conventional treatment group ( n = 19, 100%) ( p = 0.016). In particular, the dose of loop diuretics in the conventional treatment group was 34 ± 4 mg/day while that in the SGLT2 inhibitor group was significantly lower at 13 ± 5 mg/day ( p = 0.008). During hospitalization, the incidence of acute kidney injury was significantly higher in the conventional treatment group ( n = 11, 58%) than in the SGLT2 inhibitor group ( n = 2, 16%) ( p = 0.031).Conclusions:For the treatment and management of heart failure in patients with diabetes, early initiation of SGLT2 inhibitor therapy appears to be effective.

Background: Dabigatran is a direct thrombin inhibitor used to decrease the risk of ischemic stroke in patients with non-valvular atrial fibrillation (NVAF). Its prodrug, dabigatran etexilate (DE) is often co-administrated with a proton pump inhibitor (PPI) because of its adverse effects on the gastrointestinal tract. Drug-drug interactions between DE and PPIs in daily clinical practice have not been fully elucidated. Methods: Changes in blood dabigatran concentration (DC) were investigated using the dilute thrombin time test in a randomized, open-label, two-period crossover study including 34 Japanese patients with NVAF receiving dabigatran therapy with or without PPI. Results: The average trough DC was significantly higher without PPI than with PPI (83 ± 42.3 vs. 55.5 ± 24.6 ng/mL, respectively; P < 0.001). Similarly, the average peak DC was significantly higher without PPI than with PPI (184.1 ± 107.7 vs. 124 ± 59.2 ng/mL, respectively; P = 0.0029). The average ratio of DC change at the trough and peak levels did not differ significantly among the three PPI types. Conclusions: PPI administration significantly decreased the trough and peak DCs in patients with NVAF. Therefore, when prescribing PPIs for patients with NVAF in a clinical setting, the possibility that the bioavailability of dabigatran may decrease should be considered. Keywords: Dabigatran, Proton pump inhibitor, Drugâdrug interaction

Aim Sodium–glucose cotransporter 2 (SGLT2) inhibitors are antidiabetic agents that act on the proximal renal tubules to lower blood glucose levels by inhibiting glucose reabsorption and promoting urinary glucose excretion. The present study assessed the long-term use of SGLT2 inhibitors in older patients with diabetes. Methods A total of 117 older patients with type 2 diabetes who were given SGLT2 inhibitors were enrolled from April 2014 to March 2016. Results The mean age of the patients was 73.7 ± 10.0 years. During the follow-up period (mean 289.3 days), there was no event associated with oral administration of SGLT2 inhibitors. These drugs significantly lowered fasting blood glucose and glycosylated hemoglobin levels at 6 months, and did not affect the creatinine level, blood urea nitrogen/creatinine ratio or estimated glomerular filtration rate during treatment. Although the treatment significantly increased hemoglobin and hematocrit levels, it did not affect the ultrasonographically determined diameter of the inferior vena cava, and no signs of intravascular collapse were observed. Changes in brain natriuretic peptide levels during the follow-up period were assessed in 78 patients with a brain natriuretic peptide level exceeding the normal upper limit before treatment with SGLT2 inhibitors. The brain natriuretic peptide levels significantly decreased after 6 months of treatment. Conclusions In older Japanese patients with diabetes, treatment with SGLT2 inhibitors for 6 months exerted a favorable hypoglycemic effect, while no sign of dehydration was observed. Geriatr Gerontol Int 2018; 18: 108–114.

Background Anti-Xa activity (AXA) in patients with nonvalvular atrial fibrillation (NVAF) and relationship to bleeding events remains unclear. Methods We evaluated AXA in 94 patients at both trough and peak rivaroxaban concentrations. Rivaroxaban dosage was determined according to creatinine clearance (CrCl): 10 and 15 mg once daily for patients with CrCl 15–49 and CrCl ≥50 mL/min, respectively. AXA value distribution and its association with bleeding events were examined in enrolled subjects. Results The mean peak AXA level was significantly higher than the mean trough level (1.98 ± 0.81 vs. 0.16 ± 0.15 IU/mL; p

BackgroundLentinan (LNT) is a purified β-1, 3-glucan that augments immune responses. The present study was conducted to assess the efficacy of LNT in combination with S-1 as a first-line treatment for unresectable or recurrent gastric cancer.Patients and methodsEligible patients were randomly assigned to receive S-1 alone or S-1 plus LNT. The primary end-point was overall survival (OS). Secondary end-points were time-to-treatment failure (TTF), overall response rate (ORR), safety, quality of life (QOL), and biomarker. The percentages of LNT-binding monocytes in peripheral blood prior to treatment were analysed for the biomarker assessment.ResultsOne hundred and fifty-four and 155 patients were randomly assigned to receive S-1 alone or S-1 plus LNT, respectively. The median OS was 13.8 and 9.9 months (P = 0.208), the median TTF was 4.3 and 2.6 months (P

BackgroundRivaroxaban is currently used to prevent stroke in patients with atrial fibrillation. Measuring coagulation function may help clinicians to understand the effects of this drug and the associated risk of bleeding.Methods and resultsRivaroxaban was given to 136 patients with non-valvular atrial fibrillation. Mean age was 74.5±9.0 years (men: 63.2%) and mean CHADS2 score (±SD) was 1.8±1.2. Prothrombin times (PTs) and plasma soluble fibrin (SF) levels were examined in 84 out of 136 patients at baseline and at least 2 weeks thereafter. In 48 patients we were able to collect blood at exact times, namely just before and 3h after rivaroxaban administration, corresponding to the trough and peak concentrations. Mean peak PT in 48 patients was 17.1±3.6s and median peak SF level was 1.46μg/mL. Multiple regression analysis showed that female sex, high brain natriuretic peptide, and high dose were independent factors prolonging the peak PT. Patients with peak PTs ≥20s experienced significantly more bleeding events. Among 29 of 46 patients newly treated with rivaroxaban without any previous anticoagulant, we examined coagulation function at the exact trough and peak times. In 29 patients, peak PT was significantly more prolonged than the baseline or trough PT (p

BACKGROUND Chromogenic anti-factor Xa activity (AXA) assay is reported to be the most appropriate method to measure the pharmacodynamics of apixaban, but the distribution of AXA in non-valvular atrial fibrillation (NVAF) patients on apixaban therapy has not been fully elucidated. METHODS AND RESULTS Steady-state trough and peak AXA were measured in 124 NVAF patients taking apixaban. In 25 patients, baseline, first peak, and trough AXA were also examined, and were 0.01±0.02 IU/ml, 0.83±0.43 IU/ml, and 0.34±0.17 IU/ml, respectively. First trough AXA was significantly lower than steady-state trough AXA, although it was significantly higher than baseline (P

Background The distribution of anti-factor Xa activity (AXA) values in non-valvular atrial fibrillation (NVAF) patients on edoxaban therapy has not been fully elucidated. Methods and results The steady-state trough and peak AXA values were measured in 66 NVAF patients. The trough AXA value did not differ significantly between the 60-mg and the 30-mg OD groups (0.17±0.13 IU/ml vs. 0.12±0.11 IU/ml, respectively; P=0.17). Similarly, the peak AXA value did not differ significantly between the 2 groups (1.45±0.81 IU/ml vs. 1.25±0.48 IU/ml, respectively; P=0.26). Conclusions Recommended dosing should be followed for sufficient efficacy of edoxaban. (Circ J 2016; 80: 745-747).

The insulin-sensitizing agent troglitazone ((+/-)-5-[4-(6-hydroxy-2,5,7,8-tetramethylchroman-2-ylmethoxy++ +)benzyl]-2,4- thiazolidinedione, CAS 97322-87-7), has been reported to reduce vascular tone in the rat tail artery. This study was designed to examine whether troglitazone could relax the precontracted canine coronary artery in vitro. Isometric tension of coronary arterial rings was measured, and analysis by Mann-Whitney U-test revealed that significant relaxation was induced even with 1 mumol/l troglitazone. This relaxation was not affected by blocking of NO synthase, cyclooxygenase, the large and intermediate conductance Ca(2+)-activated K+ channel, the ATP-sensitive K+ channel, or the Na(+)-K+ pump. The exact mechanism of the reduction of vascular tone by troglitazone remains unclear. However, the finding that troglitazone acts as a vasorelaxant in the coronary artery may be clinically useful, since troglitazone is mainly used for type II diabetic patients with insulin resistance, which is associated with increased risk for coronary artery disease.

各種剪定材（カキ，クワ，サクラ，ウメ，ナラ，ブドウおよびリンゴ）を菌床に用いて栽培した鹿角霊芝子実体の水抽出物の差異について検討した．子実体から抽出した水溶性画分（WS）は，菌床の違いで収量（全糖量）が異なり，WSから得られた水溶性多糖画分（WS-H）でも収量に差異が認められた．WS-Hの全糖量はカキで最も多く，次いでリンゴとクワが多かった．構成糖組成の比較を行ったところ，カキおよびクワではアラビノースおよびキシロースが顕著に多く見られた．他のものではガラクトース，マンノースおよびグルコースが多く含まれていた．糖結合様式について検討したところ，ガラクタン系多糖およびグルカン系多糖で構成されていた．一方，カキおよびクワではガラクタン系多糖の他に，キシラン系多糖も多く含まれていた．したがって，異なる剪定材を菌床に用いて栽培した鹿角霊芝の子実体より抽出した水溶性多糖には違いがあることがわかった．今回の結果から，菌床を変えることで，異なる効能を備えた鹿角霊芝子実体の栽培が期待できるとともに，本来廃棄物として処理されている剪定材を有効に利用する可能性が示唆された．

Bacteria isolated from surgical infections during the period from April 2010 to March 2011 were investigated in a multicenter study in Japan, and the following results were obtained. In this series, 631 strains including 25 strains of Candida spp. were isolated from 170 (81.7%) of 208 patients with surgical infections. Four hundred and twenty two strains were isolated from primary infections, and 184 strains were isolated from surgical site infection. From primary infections, anaerobic Gram-negative bacteria were predominant, followed by aerobic Gram-negative bacteria, while from surgical site infection aerobic Gram-positive bacteria were predominant, followed by anaerobic Gram-negative bacteria. Among aerobic Gram-positive bacteria, the isolation rate of Enterococcus spp. such as Enterococcus faecalis, Enterococcus faecium, and Enterococcus avium was highest, followed by Streptococcus spp. such as Streptococcus anginosus and Staphylococcus spp. such as Staphylococcus aureus, in this order, from primary infections, while Enterococcus spp. such as E. faecalis and E. faecium was highest, followed by Staphylococcus spp. such as S. aureus from surgical site infection. Among aerobic Gram-negative bacteria, Escherichia coli was the most predominantly isolated from primary infections, followed by Klebsiella pneumoniae, Klebsiella oxytoca, Enterobacter cloacae, and Pseudomonas aeruginosa in this order, and from surgical site infection, E. coli and R aeruginosa were most predominantly isolated, followed by E. cloacae and K. pneumoniae. Among anaerobic Gram-positive bacteria, the isolation rates of Parvimonas micra, Eggerthella lenta, Streptococcus constellatus, Gemella morbillorum, and Collinsella aerofaciens were the highest from primary infections, and the isolation rate from surgical site infection was generally low. Among anaerobic Gram-negative bacteria, the isolation rate of Bilophila wadsworthia was the highest from primary infections, followed by, Bacteroides fragilis and Bacteroides ovatus, and from surgical site infection, B. fragilis was most predominantly isolated, followed by Bacteroides thetaiotaomnicron, in this order. In this series, vancomycin-resistant MRSA (methicillin-resistant S. aureus), vancomycin-resistant Enterococcus spp. and multidrug-resistant P. aeruginosa were not observed.

経皮的人工心肺補助(percutaneous cardiopulmonary support, PCPS)により救命し得た電撃型脂肪塞栓症候群の1例を経験した。症例は18歳,男性。交通事故で左大腿骨骨折を受傷した。入院後より急激に呼吸不全が進行し,受傷17時間後に気管挿管,人工呼吸を開始したが,人工呼吸のみでは酸素化の改善が得られず,さらに血圧の低下もあり,PCPSを導入した。胸部X線写真上の吹雪様陰影や意識障害を認め,脂肪塞栓症候群と診断した。また,経胸壁心エコーにて下大静脈内を流れる多数の高輝度物質を5日間検出した。ステロイドパルス療法,シベレスタットナトリウムなどの薬物療法を併用し,翌日にはPCPSの離脱に成功した。第9病日に大腿骨創外固定術を施行し,第10病日には人工呼吸器から離脱した。意識障害はほとんど後遺症なく回復し,4ヶ月後には独歩にて退院した。重症呼吸不全と循環不全を合併する脂肪塞栓症候群では,PCPSが治療手段の一つとして有用と考えられる。

Although reports suggest that tolvaptan does not reduce survival or subsequent hospitalization rates in heart failure patients, its continuous use has shown good outcomes in some patients who cannot be effectively managed with high doses of loop diuretics. Therefore, we investigated the association of patient characteristics and continued tolvaptan use in heart failure patients with changes in the frequency and annual duration of patient hospitalization due to heart failure. We carefully reviewed the medical records of patients hospitalized due to heart failure who began tolvaptan therapy and continued with outpatient treatment between December 2010 and November 2013 (tolvaptan group); patients hospitalized for heart failure between May 2008 and March 2009 served as controls. We set the reference dates as the start of tolvaptan therapy (tolvaptan group) or as the date of admission (control group). The changes in hospitalization frequency and total hospitalization time due to heart failure, before and after the reference dates, were not significantly different between the tolvaptan and control groups. In the tolvaptan group, a high estimated glomerular filtration rate was a predictor of decreased hospitalization. Continuous tolvaptan use did not decrease hospitalization duration in all heart failure patients, but good renal function was predictive of a good response.

気腹式胆嚢摘出術の麻酔管理にラリンジアルマスク(LM)が使用できるか検討するために,6mmHgの低気腹圧下で,気管チューブ(TT)との無作為比較試験を行った.1回換気量7～10ml・kg-1で陽圧換気を行い,気腹中のPETCO2が45mmHgを超えないように換気回数で調節した.換気回数はLM群がTT群より有意に多くなったが,PETCO2は両群間に差がなかった.気道内圧は両群とも25cmH2Oを超えなかった.LM群で低換気をきたすような換気漏れはなかった.術後の肺合併症はみられず,PaO2も両群で差がなかった.低気腹圧での腹腔鏡下胆嚢摘出術に対してLMを用いて麻酔をしても臨床的に問題ないと考えられた.

Our objective was 1) to assess postischemic vasodilatation using simultaneous intravascular two-dimensional and Doppler ultrasound, and 2) to clarify whether plasma nitrite and nitrate (NOx-) levels change during postischemic vasodilatation. The vascular cross-sectional area (GSA) was evaluated in 18 mongrel dogs, and the average instantaneous peak velocity (APV) in the iliac arteries after the 5-min occlusion of blood flow was determined. Plasma NOx- levels were measured at the baseline, during the occlusion of blood flow, and 1.5, 3, and 10min after recanalization. The %CSA significantly increased from 30s to 7 min after the recanalization, and maximal vasodilatation was observed at 1.5min after the recanalization (14.1±0.9 to 15.8±1.0mm2, p

This study was designed to compare the effects of prostacyclin synthase (PCS) gene transfer with those of a systemic infusion of beraprost sodium (BPS), a prostacyclin analogue, on vascular smooth muscle cell (VSMC) proliferation and neointimal formation after arterial injury.PCS gene (3 or 30 micrograms) was transfected into rat balloon-injured carotid arteries by a non-viral lipotransfection method. BPS (100 or 300 micrograms/kg/day) was subcutaneously infused with osmotic pumps after the injury. LacZ gene (30 micrograms) was used as a control. VSMC proliferation was estimated by the bromodeoxyuridine (BrdU) index (BrdU-positive nuclei/total nuclei) at day 7. Neointimal formation was evaluated at day 14. Each treatment group had six rats.PCS gene transfer prevented the increase in intimal/medial area ratio (3 micrograms: 46.6%, 30 micrograms: 61.1% reduction; P0.05, P0.01, respectively), as did BPS 300 micrograms/kg/day (49.8% reduction; P0.05). BPS 100 micrograms/kg/day, however, had no effects on the ratio. PCS gene transfer and BPS 300 micrograms/kg/day significantly suppressed the BrdU index. BPS 300 micrograms/kg/day group had more frequent hematoma and longer bleeding time. There were no significant differences in blood pressure, heart rate, or urinary volume among all groups.Both PCS gene transfer and BPS 300 micrograms/kg/day reduced neointimal formation after arterial injury by inhibiting VSMC proliferation. PCS gene transfer may be a safer therapeutic modality against neointimal formation than a systemic infusion of BPS because the former method resulted in fewer bleeding complications.

This study was performed to clarify the mechanism of vasoconstriction induced by oxygen-derived free radicals in spontaneously hypertensive rats. The isometric tension of aortic rings from spontaneously hypertensive rats and Wistar-Kyoto rats was measured in Krebs-Henseleit solution. Oxygen-derived free radicals were generated by mixing xanthine and xanthine oxidase. The removal of endothelium enhanced the contractions induced by oxygen-derived free radicals. The inhibition of nitric oxide production with N G -nitro-L-arginine methyl ester (10 -4 M) enhanced the contractions. Treatment with the thromboxane A 2 (TXA 2 ) synthetase inhibitor OKY-046 (10 -4 M) or RS-5186 (10 -4 M) markedly reduced the contractions. Treatment with the cyclooxygenase inhibitor indomethacin (10 -5 M) and a TXA 2 /prostaglandin H 2 (PGH 2 ) receptor antagonist. ONO-3708 (10 -6 M), completely abolished the oxygen-derived free radical-induced contractions. In contrast, treatment with the PGI 2 synthetase inhibitor tranylcypromine (10 -4 M) did not attenuate the oxygen-derived free radical-induced contractions. Whether endothelium was present or not, the release of TXB 2 , PGE 2 , and 6-keto-PGF 1α . but not PGF 2α . was increased by the production of oxygen-derived free radicals. Catalase and the hydroxyl radical scavenger deferoxamine plus mannitol markedly inhibited the oxygen-derived free radical-induced contractions. These results suggest that oxygen-derived free radical-induced vasoconstriction in spontaneously hypertensive rat aorta is caused by TXA 2 and PGH 2 released in smooth muscle.

Primary extranodal malignant lymphoma frequently occurs in the gastrointestinal tract: however, it is rarely encountered in the rectum. We report herein the case of an 85-year-old man who underwent abdominoperineal resection for primary malignant lymphoma of the rectum, and 1 year later, developed hematemesis caused by gastric metastasis. To our knowledge this is the first case report of such distant metastasis developing from malignant lymphoma of the rectum.

We report a very rare case of splenic hamartoma found incidentally. A 47-year-old asymptomatic woman was pointed out a splenic mass by screening ultrasound. Further examinations revealed a round, well-demarcated and homogenous 4cm mass which appeared as hyperechoic area on ultrasound, low density area on plain CT with faint enhancement on enhanced CT. The mass was demonstrated as an area of slightly high intensity on T1-weighted MRI images and as an area of isointensity on T2-weighted images. Selective angiogram showed irregular stretching of the arteries in the mass. There was no neovascularity or pooling. Tumormarkers were within normal limits. As it was difficult to differentiate it from other malignant lesions, a splenectomy was subsequently performed. The excised spleen showed a well-defined and gray-whitish mass in the inferior spleen. Microscopically, the tumor was noncapsulated and was mainly consisted of dilated vessels with an overgrowth of endothelial cells and mature lipocytes, which was coincident with the diagnosis of splenic hamartoma.

Bacteria isolated from surgical infections during the period from April 2009 to March 2010 were investigated in a multicenter study in Japan, and the following results were obtained. In this series, 671 strains including 16 strains of Candida spp. were isolated from 174 (79.1%) of 220 patients with surgical infections. Four hundred and eleven strains were isolated from primary infections, and 244 strains were isolated from surgical site infection. From primary infections, anaerobic Gram-negative bacteria were predominant, followed by aerobic Gram-negative bacteria, while from surgical site infection aerobic Gram-positive bacteria were predominant, followed by anaerobic Gram-negative bacteria. Among aerobic Gram-positive bacteria, the isolation rate of Enterococcus spp. was highest, followed by Streptococcus spp., and Staphylococcus spp. in this order, from primary infections, while Enterococcus spp. was highest, followed by Staphylococcus spp. from surgical site infection. Among aerobic Gram-negative bacteria, Escherichia coli was the most predominantly isolated from primary infections, followed by Klebsiella pneumoniae, Enterobacter cloacae and Pseudomonas aeruginosa, in this order, and from surgical site infection, E. coli was most predominantly isolated, followed by P. aeruginosa and E. cloacae. Among anaerobic Gram-positive bacteria, the isolation rate of Eggerthella lenta was the highest from primary infections, followed by Parvimonas micra, Streptococcus constellatus and Finegoldia magna, and from surgical site infection, E. lenta was most predominantly isolated. Among anaerobic Gram-negative bacteria, the isolation rate of Bilophila wadsworthia was the highest from primary infections, followed by Bacteroides fragilis, Bacteroides ovatus and Bacteroides thetaiotaomicron, and from surgical site infection, B. fragilis was most predominantly isolated, followed by B. ovatus, B. wadsworthia and B. thetaiotaomicron, in this order. In this series, we noticed no vancomycin-resistant Gram-positive cocci, nor multidrug-resistant P. aeruginosa. We should carefully follow up B. wadsworthia which was resistant to various antibiotics, and also Bacteroides spp. which was resistant to many beta-lactam antibiotics.

Bacteria isolated from infections in abdominal surgery during the period from April 2008 to March 2009 were investigated in a multicenter study in Japan, and the following results were obtained. In this series, 712 strains including 18 strains of Candida spp. were isolated from 173 (80.5%) of 215 patients with surgical infections. Three hundred and sixty-six strains were isolated from primary infections, and 346 strains were isolated from postoperative infections. From primary infections, anaerobic Gram-negative bacteria were predominant, followed by aerobic Gram-negative bacteria, while from postoperative infections aerobic Gram-positive bacteria were predominant, followed by anaerobic Gram-negative bacteria. Among aerobic Gram-positive bacteria, the isolation rate of Enterococcus spp. was highest, followed by Streptococcus spp., and Staphylococcus spp. in this order, from primary infections, while Enterococcus spp. was highest, followed by Staphylococcus spp. from postoperative infections. Among aerobic Gram-negative bacteria, Escherichia coli was the most predominantly isolated from primary infections, followed by Klebsiella pneumoniae and Pseudomonas aeruginosa, in this order, and from postoperative infections, P aeruginosa was most predominantly isolated, followed by E. coli, Enterobacter cloacae, and K. pneumoniae. Among anaerobic Gram-positive bacteria, the isolation rate of Eggerthella lenta was the highest from primary infections, followed by Parvimonas micra, Streptococcus constellatus and Gemella morbillorum, and from postoperative infections, E. lenta was most predominantly isolated. Among anaerobic Gram-negative bacteria, the isolation rate of Bacteroides fragilis was the highest from primary infections, followed by Bacteroides thetaiotaomicron, Bacteroides ovatus and Bilophila wadsworthia, and from postoperative infections, B. fragilis was most predominantly isolated, followed by B. thetaiotaomicron, B. wadsworthia and B. ovatus, in this order. In this series, we noticed no vancomycin-resistant methicillin-resistant S. aureus, and Enterococcus spp., nor multidrug-resistant P aeruginosa. We should carefully follow up B. wadsworthia which was resistant to various antibiotics, and also Bacteroides spp. which was resistant to many beta-lactam antibiotics.

Influence of obesity as a risk factor of breast cancer was assessed by analysing data of 411 women with primary breast cancer who had been operated on for the past 7 years (1982-88) at our department. It has been inferred that a recent increase in the incidence of breast cancer would be associated with the secular trend for obesity in the elderly women. Moreover, obesity would positively correlate with the metastasis to regional lymphnodes, staging, and redical mastectomy either of the standard or the extended one. These findings were more clearly observed in the group of postmenopausal cancer patients. Although the positive rate either to estrogen receptors or progesterone receptors in obese patients was not different from that in non-obese patients, the positive rate to progesterone receptors was significantly lower among older patients. It is suggested that avoidance from getting obese may prevent from breast cancer primarily, secondarily, and even tertiarily.

Background— Circulating endothelial progenitor cells (EPCs) are known to be involved in vasculogenesis and mobilized after acute myocardial infarction (AMI). To test the hypothesis that the angiogenic function of EPCs affects post-myocardial infarction (MI) myocardial salvage, we evaluated the number and potential differentiation of EPCs and compared these data with clinical parameters 6 months after MI. Methods and Results— Consecutive 51 patients (age, 61±8 years, mean±SD) with primary AMI who were successfully treated with stenting were enrolled. EPC identified as CD45 low , CD34 + , CD133 + , and VEGFR2 + was quantified by a flow cytometry. The potential of EPCs to differentiate into endothelial cells (EPC differentiation) was also confirmed by the upregulation of CD31 and VEGFR2 after 7 days of culture. According to the proportion of EPC fraction, patients were divided into 2 groups (cut-off value=median). Although no difference was seen in myocardial damage shown by mean peak CK leakage and mean area at risk between the differentiated group (n=26) and nondifferentiated group (n=25), the number of attached cell was greater in differentiated group than in the nondifferentiated group ( P =0.023). Left ventricular function and ischemic damaged area were assessed by scintigraphic images of 123 I-BMIPP in the acute phase and 99m Tc-tetrofosmin in the chronic phase. We found that a greater increase in myocardial salvage ( P =0.0091), decrease in end-systolic volume ( P =0.012), and recovery of ejection fraction ( P =0.011) occurred in the group with differentiated EPCs than in the nondifferentiated group. Conclusions— In patients with primary AMI, the capability of EPCs to differentiate influences the functional improvement and infarct size reduction, indicating that manipulation of EPCs could be a novel therapeutic target to salvage ischemic damage.

Objective: Prostacyclin synthase (PGIS) gene transfer have been shown to accelerate re-endothelialization and prevent neointimal formation in balloon-injured arteries. The aim of this study is to evaluate how overexpression of endogenous prostacyclin exerts those beneficial effects in atheromatous arteries. Methods: New Zealand White Rabbits fed a 0.5% cholesterol diet underwent balloon injury and Palmaz–Schatz stent implantation in the iliac arteries followed PGIS gene (pCMV-PGIS, 200 μg) delivery by the lipotransfection method via Dispatch catheter ( n = 6 each). Results: One week after transfection, arterial segments of pCMV-PGIS produced higher levels of 6-keto-PGF1α than those of control, pCMV-LacZ ( p