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In patients with sludge or severe spontaneous echo contrast (SEC) in the left atrial appendage (LAA), cases with isoproterenol loading transesophageal echocardiography (ISP-TEE) have been reported to identify the presence of thrombus in the LAA. This study aimed to assess the validity and hemodynamic changes of ISP-TEE in the LAA. We prospectively enrolled patients with atrial fibrillation (AF) who underwent ISP-TEE. The degree of sludge/SEC was categorized as being either absent (grade 0), mild SEC (grade 1), moderate SEC (grade 2), severe SEC or sludge (grade 3). The hemodynamic evaluation was performed by measuring LAA flow velocity, LAA tissue Doppler imaging (LAA-TDI) velocity, and pulmonary vein systolic forward flow velocity (PVS). In total, 35 patients (mean age 71 ± 7 years; 71% male) underwent ISP-TEE. Among 35 patients, 30 patients had grade 3 or 2 SEC, 5 patients had grade 1 SEC. After ISP loading, 23 patients (66% of all patients) showed improved sludge/SEC and one patient was diagnosed with thrombus in the LAA. There were 25 patients with grade 1 SEC, or no SEC (classified as Group1), 10 patients had residual sludge or grade 2 to 3 SEC (classified as Group2) after ISP administration. LAA flow, LAA-TDI, and PVS velocities were significantly higher in group 1 than in group 2 after ISP administration. There was no complication during the examination and after 24 h and 3 months. ISP infusion may be a potential tool to recognize LAA thrombus under the sludge/SEC during TEE in AF.

Despite recent advances in imaging for myocardial deformation, left ventricular ejection fraction (LVEF) is still the most important index for systolic function in daily practice. Its role in multiple fields (e.g., valvular heart disease, myocardial infarction, cancer therapy-related cardiac dysfunction) has been a mainstay in guidelines. In addition, assessment of LVEF is vital to clinical decision-making in patients with heart failure. However, notable limitations to LVEF include poor inter-observer reproducibility dependent on observer skill, poor acoustic windows, and variations in measurement techniques. To solve these problems, methods for standardization of LVEF by sharing reference images among observers and artificial intelligence for accurate measurements have been developed. In this review, we focus on the standardization of LVEF using reference images and automated LVEF using artificial intelligence.

The current study examined the older adults’ self-efficacy in computer use and explored the factors that impacted and mediated their self-efficacy. Older adults (N = 339) were recruited from a west...

Some cardiovascular (CV) risk factors, such as hypertension and diabetes mellitus, have been reported to reduce left ventricular (LV) longitudinal strain (LS) even in patients with preserved LV ejection fraction. We hypothesized that multiple CV risk factors might cause changes in myocardial strain. Our study aimed to assess the association between multiple CV risk factors and strain in patients without previous CV disease (CVD).We retrospectively evaluated 137 patients without CVD, who underwent echocardiography at our institution between May 2017 and February 2020. They were divided into four groups based on the number of risk factors (group 0: no risk factor, group 1: one risk factor, group 2: two risk factors, and groups 3: three or four risk factors). Risk factors were hypertension, dyslipidemia, diabetes mellitus, and chronic kidney disease. Absolute values of global LS (GLS) and relative apical LS ratio (RALSR) defined using the equation: average apical LS/(average basal LS + average mid LS) and was used as a marker of strain distribution.Out of 137 patients, group 0 had 35 patients, group 1 had 35 patients, group 2 had 32 patients, and group 3 had 35 patients. GLS was 22.4 ± 2.0%, 21.7 ± 2.1%, 21.3 ± 1.8%, 20.7 ± 2.2%, and RALSR was 0.64 ± 0.06, 0.66 ± 0.06, 0.68 ± 0.08, 0.69 ± 0.07 in groups 0-3, respectively. The one-way ANOVA detected significant differences between groups in GLS (p = 0.005) and RALSR (p = 0.037), respectively. Group 3 had a significantly lower GLS and higher RALSR than group 0 (p 0.05).In patients without previous CVD, LS decreased especially from the basal segment as the number of cardiovascular risks increased. The segmental LS may be markers of occult LV dysfunction in patients with CV risk factors.

The current chapter examines the relationship between facets of cognitive abilities and relevant learning activities by drawing on literature pertaining to higher- and lower-order critical thinking. Specific discussions were made on cognitive architecture and deep learning, modality and information process, and cognitive abilities and levels of process in learning activities. The cognitive ability-learning activity matrix was proposed to (1) raise attention to the relationship between cognitive abilities and relevant learning activities in transversal critical thinking in game-based learning and (2) guide educators, teachers, and professional trainers to facilitate effective transversal of critical thinking skills across domains, disciplines, and learning communities. Discussions of the theoretical and practical significance of the proposed matrix were made. Recommendations for future research were proposed to guide the direction and practice in fostering transversal skills in game-based learning.

BackgroundCardiovascular diseases are the second most common cause of mortality among cancer survivors, after death from cancer. We sought to assess the impact of cancer on the short-term outcomes of acute myocardial infarction (AMI), by analysing data obtained from a large-scale database.MethodsThis study was based on the Diagnosis Procedure Combination database in the Japanese Registry of All Cardiac and Vascular Diseases and the Diagnosis Procedure Combination. We identified patients who were hospitalised for primary AMI between April 2012 and March 2017. Propensity Score (PS) was estimated with logistic regression model, with cancer as the dependent variable and 21 clinically relevant covariates. The main outcome was in-hospital mortality.ResultsWe split 1 52 208 patients into two groups with or without cancer. Patients with cancer tended to be older (cancer group 73±11 years vs non-cancer group 68±13 years) and had smaller body mass index (cancer group 22.8±3.6 vs non-cancer 23.9±4.3). More patients in the non-cancer group had hypertension or dyslipidaemia than their cancer group counterparts. The non-cancer group also had a higher rate of percutaneous coronary intervention (cancer 92.6% vs non-cancer 95.2%). Patients with cancer had a higher 30-day mortality (cancer 6.0% vs non-cancer 5.3%) and total mortality (cancer 8.1% vs non-cancer 6.1%) rate, but this was statistically insignificant after PS matching.ConclusionCancer did not significantly impact short-term in-hospital mortality rates after hospitalisation for primary AMI.

The patient with congenital hypogonadotropic hypogonadism (HH) shows low serum levels of androgen, which is a group of sex hormones including testosterone, caused by the decreased gonadotropin release in the hypothalamus. Recent reports showed androgens exert protective effects against insulin resistance or atherosclerotic diseases, such as diabetes mellitus or coronary artery disease. However, whether the juvenile hypogonadism affects the diabetes or cardiovascular disease is unclear. We report a case of a middle-aged man with congenital HH who had severe coronary artery disease complicated with metabolic disorders. J. Med. Invest. 68 : 189-191, February, 2021.

Background The prognosis of patients with cancer‐venous thromboembolism (VTE) is not well known because of a lack of registry data. Moreover, there is also no knowledge on how specific types are related to prognosis. We sought to evaluate the clinical characteristics and outcomes of patients with cancer‐associated VTE, compared with a matched cohort without cancer using real‐world registry data of VTE. Methods and Results This study was based on the Diagnosis Procedure Combination database in the JROAD‐DPC (Japanese Registry of All Cardiac and Vascular Diseases and the Diagnosis Procedure Combination). Of 5 106 151 total patients included in JROAD‐DPC, we identified 49 580 patients who were first hospitalized with VTE from April 2012 to March 2017. Propensity score was estimated with a logistic regression model, with cancer as the dependent variable and 18 clinically relevant covariates. After propensity matching, there were 25 148 patients with VTE with or without cancer. On propensity score‐matched analysis with 25 148 patients with VTE, patients with cancer had higher total in‐hospital mortality within 7 days (1.3% versus 1.1%, odds ratio [OR], 1.66; 95% CI, 1.31–2.11; P P P Conclusions Patients with cancer had a higher in‐hospital acute mortality for VTE than those without cancer, especially in pancreatic, biliary tract, and liver cancers.

Background The overlap time of transmitral flow can be a novel marker of subclinical left ventricular dysfunction for predicting adverse events in heart failure (HF). We aimed to (1) investigate the role of overlap time of the E-A wave in association with clinical parameters and (2) evaluate whether the overlap time could add prognostic information with respect to other conventional clinical prognosticators in HF. Methods We prospectively evaluated 153 patients hospitalized with HF (mean age 68 ± 15 years; 63% male). The primary endpoint was readmission following HF or cardiac death. Results During a median period of 25 months, 43 patients were readmitted or died. Overlap time appeared to be associated with worse outcomes. After adjustment for readmission scores and ratios of diastolic filling period and cardiac cycle length in a Cox proportional-hazards model, overlap time was associated with event-free survival, independent of elevated left atrial pressure based on guidelines. When overlap time was added to the model based on clinical variables and elevated left atrial pressure, the C-statistic significantly improved from 0.70 (95% CI: 0.63–0.77) to 0.77 (95% CI: 0.69–0.83, compared) (P = 0.035). Conclusion This preliminary study suggested that prolonged overlap time may have potential for predicting readmission and cardiac mortality risk assessment in patients with HF.

How to personalize learners' learning with digital technology so that learners derive optimal experiences in learning is a key question facing learning scientists, cognitive psychologists, teachers, and professional instructional designers. One of the challenges surrounding personalization and digital technology is how to promote learners' cognitive processes at a deeper level so that they become optimally engaged in critical and creative thinking, making inferences in learning, transferring knowledge to new learning situations, and constructing new knowledge during innovative learning process. This chapter examines the literature relating to deep cognitive processes and the idiosyncratic features of digital technology that support learners' deep cognitive processes in learning. Guidelines pertaining to personalization with digital technology in regard to deep cognitive processing are proposed, followed by the discussions on future research with a focus on verifying the theoretical constructs proposed in the guidelines.

Advanced age, obesity, and muscle weakness are independent factors in the onset of deep vein thrombosis (DVT). Recently, an association between sarcopenia and DVT has been reported. We hypothesized that sarcopenia related factors, observed by ultrasonography, are associated with the regression effect on the thrombus following anticoagulation therapy. The present study focused on gastrocnemius muscle (GCM) thickness and the GCM's internal echogenic brightness. We examined the association with DVT regression following direct oral anticoagulants (DOACs) treatment.The prospective cohort study period was between October 2017 and August 2018. We enrolled 46 patients diagnosed with DVT by ultrasonography, who were aged >60 years old and treated with DOACs. Sarcopenia was evaluated using the Asian Working Group for Sarcopenia flowchart. The average DOACs treatment period was 94 days, and 29 patients exhibited thrombus regression. On univariate logistic regression analysis, sarcopenia, average GCM diameter index, and gastrocnemius integrated backscatter index were significantly associated with thrombus regression. In a multivariate model, only the average GCM diameter index correlated with thrombus regression.The average GCM diameter index is associated with DVT regression treated with DOACs. Considering the GCM diameter during DVT treatment can be a marker to make a decision for the treatment of DVT.

The current chapter focuses on the cognitive process relating to immersive technology in learning. By reviewing the cognitive theories in human architecture, the author argues that learners' learning can be significantly improved with technologies that promote deep processing through sensory immersive experience like virtual reality. Discussion of the features of immersive technologies is made in relation to human cognitive processing. Suggestions for future research and application of immersive technology in education are included to help educators and professionals to better integrate immersive technology in teaching and training.

This chapter presents a conceptual discussion on the roles of immersive technology relating to its past, present, and future. The underlying theories and assumptions pertinent to each stage of immersive technology are discussed by emphasizing the influences on pedagogical practices and assessment. An important focus of the chapter is to look at the function of present immersive technology in learning from the perspective of a technology taxonomy. Discussions on future immersive technologies are made by making a connection between immersive technology and other new technologies like artificial intelligence. The chapter concludes with suggestions for future research in immersive technology.

Enhancing the cognitive functionality of digital technology can be critical in learning complex topics like caregiving for older adults. This study examines the deployment of cognitive prompts in v...

Background: Echocardiography requires a high degree of skill on the part of the examiner, and the skill may be more improved in larger volume centers. This study investigated trends and outcomes associated with the use and volume of echocardiographic exams from a real-world registry database of heart failure (HF) hospitalizations. Methods: This study was based on the Diagnosis Procedure Combination database in the Japanese Registry of All Cardiac and Vascular Datasets (JROAD-DPC). A first analysis was performed to assess the trend of echocardiographic examinations between 2012 and 2016. A secondary analysis was performed to assess whether echocardiographic use was associated with in-hospital mortality in 2015. Results: During this period, the use of echocardiography grew at an average annual rate of 6%. Patients with echocardiography had declining rates of hospital mortality, and these trends were associated with high hospitalization costs. In the 2015 sample, a total of 52,832 echocardiograms were examined, corresponding to 65.6% of all HF hospital admissions for that year. We found that the use and volume of echocardiography exams were associated with significantly lower odds of all-cause hospital mortality in heart failure (adjusted odds ratio (OR): 0.48 for use of echocardiography and 0.78 for the third tertile; both p < 0.001). Conclusions: The use of echocardiography was associated with decreased odds of hospital mortality in HF. The volumes of echocardiographic examinations were also associated with hospital mortality.

The traditional view of linguistic-verbal intelligences focuses on individual linguistic abilities at the levels of phonology, syntax, and semantics. This chapter discusses the individual linguistic abilities from a text-comprehension perspective. The chapter examines the roles of multimedia and cognitive prompts in deep and surface verbal processing. Drawn from research in working memory, multimedia learning, and deep processing, a theoretical framework is proposed to promote learners' deep and surface learning in reading. Evidence from empirical studies are reviewed to support the underlying theoretical assumptions of the framework. The theoretical and practical significance of the theoretical framework is discussed with suggestions for future research.

In terms of valvular heart disease (VHD) imaging, transthoracic echocardiography (TTE) is the preferred first choice because of its widespread availability. Other modalities, such as transesophageal echocardiography, computed tomography and magnetic resonance imaging, have played a supplementary role in diagnosis for severity, deciding the timing/type of treatment, detection of post procedural complications, and prognostic predictions. However, there are few consensuses on how to employ these modalities, as the evidence is not extensive as that for TTE. On the other hand, these imaging modalities also have their own unique strengths. If employed properly, these modalities have the potential to play a more prominent role in clinical decision making. In this review, we focus on the potential, limitations and application of current imaging modalities in the management of left-sided VHD.

Primary non-Hodgkin bone lymphoma (PBL) can involve solitary or multiple destructive bone lesions such as those of the femur or pelvis humerus, and some cases have osteolytic lesions. PBL is a rare disease in adults. Thus, PBL is rarely considered a differential diagnosis of the osteolytic tumor. In addition, PBL can be underdiagnosed because patients do not experience symptoms or show objective abnormalities in the early stage. Here, we reported an elderly patient with PBL in multiple bones, including the cranial and femoral bones that were fractured due to falling. J. Med. Invest. 66 : 347-350, August, 2019.

This study investigated the redundancy effect on older and younger persons’ cognitive performance in a caregiver video training. Participants (N = 92) were recruited from one research-intensive university and three senior centers in a midsize city in the western United States. The mixed within- and between-subjects design was used. Participants watched the caregiving video with caption followed by a video without caption or vice versa depending on the condition. The results showed that older persons benefited from the redundancy learning whereas younger persons suffered from the redundancy learning. Implications of the findings are discussed with suggestions for future research.

This research project included two studies that investigated (a) differences between technology use in tech-knowledgeable and less tech-knowledgeable older persons, (b) cognitive and affective variables and their association with the application of technology, and (c) the implications of these variables on the design of remote-delivered caregiver education. Study 1 findings suggested that high technology (e.g., Internet delivered education) reduced stress among the tech-knowledgeable group. In Study 2, which focused on the less tech-knowledgeable group, neither high technology (e.g., telehealth-delivered education) nor low technology (e.g., phone-delivered education) was associated with the cognitive and affective measures used in the study. Implications in the training of older caregivers with digital technology are discussed for negotiating the affective and cognitive features in remote delivered caregiver eduational protocols.

A broad range of chronic conditions, including heart failure (HF), have been associated with vitamin D deficiency. Existing clinical trials involving vitamin D supplementation in chronic HF patients have been inconclusive. We sought to evaluate the outcomes of patients with vitamin D supplementation, compared with a matched cohort using real-world big data of HF hospitalization. This study was based on the Diagnosis Procedure Combination database in the Japanese Registry of All Cardiac and Vascular Datasets (JROAD-DPC). After exclusion criteria, we identified 93,692 patients who were first hospitalized with HF between April 2012 and March 2017 (mean age was 79 &plusmn, 12 years, and 52.2% were male). Propensity score (PS) was estimated with logistic regression model, with vitamin D supplementation as the dependent variable and clinically relevant covariates. On PS-matched analysis with 10,974 patients, patients with vitamin D supplementation had lower total in-hospital mortality (6.5 vs. 9.4%, odds ratio: 0.67, p &lt, 0.001) and in-hospital mortality within 7 days and 30 days (0.9 vs. 2.5%, OR, 0.34, and 3.8 vs. 6.5%, OR: 0.56, both p &lt, 0.001). In the sub-group analysis, mortalities in patients with age &lt, 75, diabetes, dyslipidemia, atrial arrhythmia, cancer, renin-angiotensin system blocker, and &beta, blocker were not affected by vitamin D supplementation. Patients with vitamin D supplementation had a lower in-hospital mortality for HF than patients without vitamin D supplementation in the propensity matched cohort. The identification of specific clinical characteristics in patients benefitting from vitamin D may be useful for determining targets of future randomized control trials.

Cognitive load can play a key role in learners’ abilities to solve complex problems like mathematics. Many factors can affect the presence of cognitive load in learning including instructional strategy, task difficulty and prior knowledge. To understand the interaction of above factors and their influence on learner cognitive load and performance, a three-way interaction study was conducted with worked example (full- vs. completion-worked examples), task difficulty (easy vs. difficult) and prior knowledge (high vs. low) serving as independent variables, and cognitive load and performance as dependent variables. One hundred and sixty participants were recruited who were randomly assigned into one of eight learning conditions. Results revealed a significant three-way interaction by posttest. It was found that higher-prior knowledge learners performed better with completion-worked examples than full-worked examples whereas lower-prior knowledge learners performed better with full-worked examples than completion-worked examples. Significant positive correlation was found between intrinsic and germane cognitive load implying that interest in the instructional domain is an important determinant in effecting germane cognitive load.

Background Evaluation of diastolic dysfunction is crucial in determining elevated left atrial pressure. However, a validation of the long-term prognostic value of the newly proposed algorithm updated in 2016 has not been performed. The aim of the present study was to investigate the relative value of the updated 2016 diastolic dysfunction grading system for the incidence of readmission in patients with heart failure (HF) with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF). Methods Two hundred thirty-two patients hospitalized with HF were retrospectively evaluated. Subjects were divided into two subgroups: those with HFrEF (n = 127) and those with HFpEF (n = 105). Readmission risk scores were calculated using the Yale Center for Outcomes Research and Evaluation HF, LACE index, and HOSPITAL scores. The primary end point was readmission following HF and cardiac death. Results Over a period of 24 months, 86 patients were either readmitted or died. Multivariate Cox analysis was performed on both the HFrEF and HFpEF groups. In the HFrEF group, both the 2009 and 2016 algorithms had superior incremental value for the association of the primary end point to several readmission risk scores. In the HFpEF group, only the 2016 algorithm led to significant improvement in association with the primary end point. The 2016 algorithm had incremental value over several readmission risk scores alone. Conclusions The recommendations of the 2016 algorithm can be useful for readmission and cardiac mortality risk assessment in patients with HFrEF and HFpEF. The use of echocardiography to estimate elevated left atrial pressure appears to identify a higher risk group and may allow a more tailored approach to therapy.

How to design computer interface that facilitates learners' creative thinking can be challenging. This chapter discusses the cognitive processes, the types of divergent thinking, visualization, and brain-functions in relation to human learning. Informed by the research in previous areas, the authors examine the features of computer interface that aligns with brain-functions to support various types of creative thinking. An example is included to demonstrate, at the conceptual level, how computer interface can be leveraged to support learners' creativity, imagination, originality, and expressiveness in learning. Discussions are made with respect to the implication and limitation of the chapter. The chapter concludes with suggestions for future research and studies.

Middle-aged marathon runners have an increased risk of developing atrial fibrillation (AF). A previous study described that repetitive marathon running was associated with left atrial (LA) dysfunction. However, whether this change is common in marathon runners and which runners are at risk of LA dysfunction remain unknown. The purpose of this study was to determine which factors could predict LA dysfunction. We prospectively examined 12 healthy amateur volunteers (9 males, 31 ± 8 years old) who participated in a full marathon. All echocardiographic measurements and speckle-tracking echocardiography were performed before and after the marathon. The endpoint was defined as reduced LA reservoir strain 1 day after the marathon (non-responder group). Seven participants were in the non-responder group. Age (35 ± 9 vs. 26 ± 2 years, p = 0.020), augmentation index (76 ± 12 vs. 55 ± 8, p = 0.002), and diastolic blood pressures (83 ± 11 vs. 70 ± 7 mmHg, p = 0.021) in the non-responder group were significantly higher compared with the responder group. In multivariate linear regression analysis, only the augmentation index was an independent predictor of reduced LA reservoir function after the marathon (β = − 0.646, p = 0.023). The augmentation index was a predictive marker for reduction in LA reservoir function after a marathon in healthy amateur volunteers.

This chapter examines college students' perceptions on personalized learning with digital technology. Five hundred and five college students were recruited from American and Chinese institutions of higher education. Participants were given a survey questionnaire on digital technology and personalized digital learning. Using factor analysis, three conceptual constructs were perceived by college students as critical to personalized digital learning. In addition to the critical factors identified, the results also revealed significant relationships between the variables of demographic and computer experience and the constructs perceived by college students. These findings can inform the design and implementation of personalized digital learning in higher education. Recommendations for future research include focusing on the verification of the constructs in both theoretical and practical fields.

This chapter focuses on the cognitive and affective factors that may influence learners' performance in visual learning. Both cognitive and affective factors were identified with cognitive factors aiming to reduce cognitive load, making meaningful learning through schema connection and activation. The affective factors focused on meeting the psychological and self-fulfillment needs in visual learning. Discussions were made on the implications of the chapter in terms of supporting professionals and educators in their design of effective visual learning in education.

The current study examined factors related to older adults’ perceptions of Internet use. Three hundred ninety five older adults participated in the study. The factor analysis revealed four factors perceived by older adults as critical to their Internet use: social connection, self-efficacy, the need to seek financial information, and the need to seek health information. Key differences were found between previous research and the factors extracted in this study. The regression analysis demonstrated that variables like health condition, financial status, computer experience, and life satisfaction significantly predict, at various levels, factors perceived by the older adults to affect Internet use. The significance of the study as well as its implications for research and practice are discussed. Suggestions are made for future research and practice.