Antireflux Metal Stent for Initial Treatment of Malignant Distal Biliary Obstruction

Objectives. To compare the use of an antireflux metal stent (ARMS) with that of a conventional covered self-expandable metal stent (c-CSEMS) for initial stenting of malignant distal biliary obstruction (MDBO). Materials and Methods. We retrospectively investigated 59 consecutive patients with unresectable MDBO undergoing initial endoscopic biliary drainage. ARMS was used in 32 patients and c-CSEMS in 27. Technical success, functional success, complications, causes of recurrent biliary obstruction (RBO), time to RBO (TRBO), and reintervention were compared between the groups. Results. Stent placement was technically successful in all patients. There were no significant intergroup differences in functional success (ARMS [96.9%] versus c-CSEMS [96.2%]), complications (6.2 versus 7.4%), and RBO (48.4 versus 42.3%). Food impaction was significantly less frequent for ARMS than for c-CSEMS (P=0.037), but TRBO did not differ significantly between the groups (log-rank test, P=0.967). The median TRBO was 180.0 [interquartile range (IQR), 114.0–349.0] days for ARMS and 137.0 [IQR, 87.0–442.0] days for c-CSEMS. In both groups, reintervention for RBO was successfully completed in all patients thus treated. Conclusion. ARMS offers no advantage for initial stent placement, but food impaction is significantly prevented by the antireflux valve

凍結保存骨形成細胞シートの骨再建における有用性

Skeletal diseases, such as nonunion and osteonecrosis, are now treatable with tissue engineering techniques. Single cell sheets called osteogenic matrix cell sheets (OMCSs) grown from cultured bone marrow-derived mesenchymal stem cells show high osteogenic potential; however, long preparation times currently limit their clinical application. Here, we report a cryopreservation OMCS transplantation method that shortens OMCS preparation time. Cryopreserved rat OMCSs were prepared using slow- and rapid-freezing methods, thawed, and subsequently injected scaffold-free into subcutaneous sites. Rapid- and slow-frozen OMCSs were also transplanted directly to the femur bone at sites of injury. Slow-freezing resulted in higher cell viability than rapid freezing, yet all two cryopreservation methods yielded OMCSs that survived and formed bone tissue. In the rapid- and slow-freezing groups, cortical gaps were repaired and bone continuity was observed within 6 weeks of OMCS transplantation. Moreover, while no significant difference was found in osteocalcin expression between the three experimental groups, the biomechanical strength of femurs treated with slow-frozen OMCSs was significantly greater than those of non-transplant at 6 weeks post-injury. Collectively, these data suggest that slow-frozen OMCSs have superior osteogenic potential and are better suited to produce a mineralized matrix and repair sites of bone injury.博士（医学）・甲第650号・平成28年3月15日Copyright © 2016 by authors and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY). http://creativecommons.org/licenses/by/4.0

Cochlear implantation in patients with bilateral deafness caused by otitis media with ANCA-associated vasculitis (OMAAV): A report of four cases

Objective: Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) without systemic symptoms but with initial symptoms related to the ear, such as hearing loss, otalgia, and dizziness, has recently been reported. We have categorized this condition as otitis media with AAV (OMAAV), and have recently proposed its diagnostic criteria. Methods: To determine the effectiveness of cochlear implantation (CI) in patients with profound hearing loss due to OMAAV. We examined the language understanding ability of four patients with bilateral profound or total deafness due to OMAAV, who underwent CI. Results: In three of the four patients, the language understanding ability with CI was poor. These three patients with poor performance had characteristic features, including a short interval from the onset of ear symptoms to total deafness and clear enhancement of the cochlea on magnetic resonance imaging (MRI). Conclusion: The poor results observed in patients with a rapidly progressive history of hearing loss were attributed to possible severe and profuse intracochlear bleeding and/or destruction of structures, including the spiral ganglion. All the three patients showed contrast enhancement in the inner ear on MRI. We believe that preoperative evaluation of the history of hearing loss as well as the findings of contrast-enhanced MRI is important for predicting the prognosis after CI

Longitudinal acquisition of endotracheal intubation skills in novice physicians

Little is known about the acquisition of intubation skills among novice physicians during their one-year clinical training. Our primary objective was to determine the changes in the intubation skills of novice physicians between prior to the clinical training and after completion of the clinical training. We used data of a prospective longitudinal multicenter data registry developed to investigate factors associated with the improvement of intubation skills among novice physicians. The study participants included 90 postgraduate year 1 physicians in 2015–2016. We used 4 simulation scenarios based on the devices used (direct laryngoscope [DL] and Airway scope [AWS]) and difficulty of intubation (normal and difficult scenarios). As a marker of the intubation skills, we used the force applied on the maxillary incisors and the tongue with each intubation. We compared the data obtained prior to clinical training with those obtained after completion of one-year clinical training. When using DL, compared to prior, significantly less force were applied on the maxillary incisors and the tongue after clinical training in the normal scenario (28.0 N vs 19.5 N, p < 0.001, and 11.1 N vs 8.4 N, p = 0.004). Likewise, when using AWS, compared to prior, significantly less force were applied on the tongue after clinical training in the normal scenario (22.0 N vs 0 N, p < 0.001). The force on the tongue decreased after clinical training but not significant. These associations persisted in the difficult airway scenario. These findings suggest that force applied on oral structures can be quantified as a marker of intubation skills by using high-fidelity simulators, and the assessment of procedural competency is recommended for all novice physicians prior to performing intubation in the clinical setting to improve the quality of emergency care

Human Adrenocortical Remodeling Leading to Aldosterone-Producing Cell Cluster Generation

Background. The immunohistochemical detection of aldosterone synthase (CYP11B2) and steroid 11β-hydroxylase (CYP11B1) has enabled the identification of aldosterone-producing cell clusters (APCCs) in the subcapsular portion of the human adult adrenal cortex. We hypothesized that adrenals have layered zonation in early postnatal stages and are remodeled to possess APCCs over time. Purposes. To investigate changes in human adrenocortical zonation with age. Methods. We retrospectively analyzed adrenal tissues prepared from 33 autopsied patients aged between 0 and 50 years. They were immunostained for CYP11B2 and CYP11B1. The percentage of APCC areas over the whole adrenal area (AA/WAA, %) and the number of APCCs (NOA, APCCs/mm2) were calculated by four examiners. Average values were used in statistical analyses. Results. Adrenals under 11 years old had layered zona glomerulosa (ZG) and zona fasciculata (ZF) without apparent APCCs. Some adrenals had an unstained (CYP11B2/CYP11B1-negative) layer between ZG and ZF, resembling the rat undifferentiated cell zone. Average AA/WAA and NOA correlated with age, suggesting that APCC development is associated with aging. Possible APCC-to-APA transitional lesions were incidentally identified in two adult adrenals. Conclusions. The adrenal cortex with layered zonation remodels to possess APCCs over time. APCC generation may be associated with hypertension in adults

ペピーノ（Solanum muricatum Aiton）ヲ ダイギ ニ モチイタ トマト ノ アオガレビョウ オヨビ トマトイチョウビョウ ノ ハツビョウ ヨクセイ コウカ

ペピーノを台木に用いたトマトの青枯病および萎凋病に対する発病抑制効果を検討した。青枯病Ⅰ～Ⅴ群菌にそれぞれ属する15菌株を接種したところ，ペピーノ‘ゴールドNo.1’およびペピーノ台接ぎ木トマト（‘大型福寿’/‘ゴールドNo.1’）では，外部病徴および導管褐変は認められなかった。トマト萎凋病レース1，2および3の菌株を接種したところ，ペピーノ‘ゴールドNo.1’およびペピーノ台接ぎ木トマト（‘大型福寿’/‘ゴールドNo.1’）では，外部病徴および導管褐変は認められなかった。以上，ペピーノ‘ゴールドNo.1’をトマトの台木として用いることで，青枯病およびトマト萎凋病に対する発病抑制効果が期待できる。Bacterial wilt caused by Ralstonia solanacearum and fusarium wilt caused by Fusarium oxysporum f. sp. lycopersici induce damage during the production of tomato. In this study, we investigated the control effect of these diseases by using pepino (Solanum muricatum Aiton) as a rootstock. In inoculation test of R. solanacearum of bacterial groupⅠ-Ⅴ and F. oxysporum f. sp. lycopersici races 1-3, own-rooted tomato ‘Ogata-fukuju’ was highly susceptible to all of the strains, whereas own-rooted pepino ‘Gold No.1’ and tomato ‘Ogatafukuju’ grafted on pepino ‘Gold No.1’ were completely resistant to all of the strains. Our results indicate that pepino ‘Gold No.1’ is resistant to the R. solanacearum bacterial groups and F. oxysporum f. sp. lycopersici races 1-3, and application of pepino as a rootstock can be an effective method for control of bacterial wilt and wilt diseases

Risk Factors for Bleeding After Endoscopic Submucosal Dissection for Gastric Cancer in Elderly Patients Older Than 80 Years in Japan.

Introduction:As the aging of people in a society advances, the number of elderly patients older than 80 years in Japan with gastric cancer continues to increase. Although delayed ulcer bleeding is a major adverse event after endoscopic submucosal dissection (ESD), little is known about characteristic risk factors for bleeding in elderly patients undergoing ESD. This study aimed to evaluate risk factors for delayed bleeding after ESD for gastric cancer in elderly patients older than 80 years.Methods:We retrospectively evaluated the incidence of delayed bleeding after ESD in 10,320 patients with early-stage gastric cancer resected by ESD between November 2013 and January 2016 at 33 Japanese institutions and investigated risk factors for delayed bleeding in elderly patients older than 80 years.Results:The incidence of delayed bleeding in elderly patients older than 80 years was 5.7% (95% confidence interval [CI]: 4.6%-6.9%, 95/1,675), which was significantly higher than that in nonelderly (older than 20 years and younger than 80 years) patients (4.5%, 4.1%-5.0%, 393/8,645). Predictive factors for ESD-associated bleeding differed between nonelderly and elderly patients. On multivariate analysis of predictive factors at the time of treatment, risk factors in elderly patients were hemodialysis (odds ratio: 4.591, 95% CI: 2.056-10.248, P < 0.001) and warfarin use (odds ratio: 4.783, 95% CI: 1.689-13.540, P = 0.003).Discussion:This multicenter study found that the incidence of delayed bleeding after ESD in Japanese patients older than 80 years was high, especially in patients receiving hemodialysis and taking warfarin. Management of ESD to prevent delayed bleeding requires particular care in patients older than 80 years

A type system with subtyping for WebAssembly’s stack polymorphism

Post-print (lokagerð höfundar)We propose a new type system for WebAssembly. It is a refinement of the type system from the language specification and is based on type qualifiers and subtyping. In the WebAssembly specification, a typable instruction sequence gets many different types, depending in particular on whether it contains instructions such as br (unconditional branch) that are stack-polymorphic in an unusual way. But one cannot single out a canonical type for a typable instruction sequence satisfactorily. We introduce qualifiers on code types to distinguish between the two flavors of stack polymorphism that occur in WebAssembly and a subtyping relation on such qualified types. Our type system gives every typable instruction sequence a canonical type that is principal. We show that the new type system is in a precise relationship to the type system given in the WebAssembly specification. In addition, we describe a typed functional-style big-step semantics based on this new type system underpinned by an indexed graded monad and prove that it prevents stack-manipulation related runtime errors. We have formalized our type system, inference algorithm, and semantics in Agda.This work was supported by the Icelandic Research Fund grant no. 196323-053.Peer reviewed (ritrýnd grein

High-Resolution Laser-Assisted Magnetic Nanoparticle Imaging Using a High-TC SQUID Magnetometer

A new type of magnetic nanoparticle imaging (MPI) system has been proposed and developed. The spatial resolution of MPI systems is generally determined and limited by the size of the magnetic sensors used and the magnetic properties of the nanoparticles detected. Here, high-resolution imaging of magnetic particles was realized by combining the MPI system with a high-TC SQUID magnetometer and laser scanning system. The spatial resolution of this system was not determined by the properties of the magnetic nanoparticles but was determined by the laser spot size focused on samples. Thus, the higher spatial resolution imparted by conventional MPI systems could be expected. As a demonstration of the imaging system, two cylindrical containers filled with magnetic particles solutions were fabricated and measured. Although the containers were spaced only 2 mm apart, they could be clearly distinguished by the obtained signals. A knife-edge analysis was also applied to the obtained signals, and the spatial resolution of our system was estimated to be approximately 0.9 mm

Atraumatic Anterior Dislocation of the Hip Joint

Dislocation of the hip joint in adults is usually caused by high-energy trauma such as road traffic accidents or falls from heights. Posterior dislocation is observed in most cases. However, atraumatic anterior dislocation of the hip joint is extremely rare. We present a case of atraumatic anterior dislocation of the hip joint that was induced by an activity of daily living. The possible causes of this dislocation were anterior capsule insufficiency due to developmental dysplasia of the hip, posterior pelvic tilt following thoracolumbar kyphosis due to vertebral fracture, and acetabular anterior coverage changes by postural factor. Acetabular anterior coverage changes in the sagittal plane were measured using a tomosynthesis imaging system. This system was useful for elucidation of the dislocation mechanism in the present case