Simultaneous Visualization of Microscopic Conductivity and Deformation in Conductive Elastomers

Conductive elastomers are promising for a wide range of applications in many fields due to their unique mechanical and electrical properties, and an understanding of the conductive mechanisms of such materials under deformation is crucial. However, revealing the microscopic conduction mechanism of conductive elastomers is a challenge. In this study, we developed a method that combines in situ deformation nanomechanical atomic force microscopy (AFM) and conductive AFM to successfully and simultaneously characterize the microscopic deformation and microscopic electrical conductivity of nanofiller composite conductive elastomers. With this approach, we visualized the conductive network structure of carbon black and carbon nanotube composite conductive elastomers at the nanoscale, tracked their microscopic response under different compressive strains, and revealed the correlation between microscopic and macroscopic electrical properties. This technique is important for understanding the conductive mechanism of conductive elastomers and improving the design of conductive elastomers.

Plant size, latitude, and phylogeny explain within-population variability in herbivory

Interactions between plants and herbivores are central in most ecosystems, but their strength is highly variable. The amount of variability within a system is thought to influence most aspects of plant-herbivore biology, from ecological stability to plant defense evolution. Our understanding of what influences variability, however, is limited by sparse data. We collected standardized surveys of herbivory for 503 plant species at 790 sites across 116° of latitude. With these data, we show that within-population variability in herbivory increases with latitude, decreases with plant size, and is phylogenetically structured. Differences in the magnitude of variability are thus central to how plant-herbivore biology varies across macroscale gradients. We argue that increased focus on interaction variability will advance understanding of patterns of life on Earth.

Phase II Clinical Trial of Hypofractionated Image-Guided Proton Therapy with 12 Fractions for Prostate Cancer

PURPOSE/OBJECTIVE(S)

Towards hypofractionated proton therapy for prostate cancer for improving convenience for patients to receive treatment and improving therapeutic efficacy, image-guided technique with hydrogel spacer solved the late gastrointestinal toxicity, but it is unclear whether acute genitourinary (GU) toxicity is acceptable. The aim of this phase II study was to evaluate the safety and efficacy of hypofractionated image-guided proton therapy (IGPT) with 12 fractions for prostate cancer.

MATERIALS/METHODS

Eligibility criteria were as follows: (1) histologically confirmed primary prostate cancer; (2) T1-T3bN0M0 staged by (UICC TNM8th); (3) ECOG-PS ≤ 2; (4) age ≥ 20 years; (5) no serious underlying disease or other cancers; (6) technically capable of proton therapy, and (7) written informed consent. Primary endpoint was the ratio of grade 2 or more acute genitourinary toxicity. We used the modified CTCAE grading of grade 2 GU toxicities, in which prescribing two and more types of drugs for dysuria within 3 months of the start of radiation was considered to indicate grade 2 GU toxicity. A phase II trial was planned based on the minimax Simon's two-stage design with a significance level of 0.05 and a power of 90%. The acceptable incidence is considered to be less than 5%, and the unacceptable incidence is considered to be more than 15%. A total of 83 patients is required for completion of the trial (7 patients or fewer). After evaluating the primary endpoint in 83 patients, 217 additional patients were registered and a total of 300 patients were registered in order to further examine the safety and efficacy. The prescribed dose to the isocenter was 51.6 GyRBE in 12 fractions (4 days a week).

RESULTS

From January 2020 to March 2021, 30, 53, and 217 patients (total 300) were enrolled. The patient characteristics were as follows: median age, 70 (48-83) years; low/intermediate/high risk, 44/132/124. Forty-nine and 38 patients had benign prostatic hyperplasia and diabetes mellitus, respectively. Grade 2 acute GU toxicities were observed in 1, 5 and 13 patients, respectively (total 6.3%). No grade 3 or higher acute GU toxicities were observed. However, urinary retention during IGPT, which was not previously observed, was observed in 3 cases, and temporary urethral catheterization was performed (Grade 2). Most of the acute GU toxicity tended to improve at 1 month after IGPT, and almost improved at 3 months. Mean score deteriorations beyond the minimum clinically important difference threshold (1/2 SD) were observed only at 1 month in the following scales: summary (-6.0), bother (-7.0), and irritative/obstructive (-6.3).

CONCLUSION

Hypofractionated IGPT with 12 fractions for prostate cancer is well tolerated in acute GU toxicities. Longer follow-up is necessary to evaluate the efficacy and late toxicities. Further investigation of hypofractionated IGPT with 12 fractions for prostate cancer is warranted. Since April 2021, an additional 1000 cases of prospective registration study have been conducted.

Quality of Palliative Radiation Therapy Assessed Using Quality Indicators: A Multicenter Survey

PURPOSE/OBJECTIVE(S)

Clinical practice is not always performed in accordance with guideline recommendations. Quality indicators (QIs) are valuable tools for evaluating the quality of healthcare systems. We sought to identify potential gaps between clinical practice and evidence using QIs previously developed using a modified Delphi method.

MATERIALS/METHODS

We used seven QIs (Table 1) to assess the quality of radiation therapy for bone (BoM) and brain metastases (BrM) at 29 centers; 13 (45%) were academic (12 university hospitals and 1 cancer center) and 16 (55%) were nonacademic hospitals. Compliance rate was calculated as the percentage of patients for whom recommended medical care was conducted. Random effects models were used to estimate pooled compliance rates. Mixed effects models with a Q test were used to compare compliance rates between academic and nonacademic centers.

RESULTS

The estimates of the compliance rates with 95% confidence intervals are presented in Table 1. For BoM-1, the compliance rate was higher in academic hospitals (100% [100-100%]) than in non-academic hospitals (96% [89-100%]) (P = 0.021). For BrM-3, the compliance rate was lower in academic hospitals (92% [81-99%]) than in nonacademic hospitals (100% [98-100%]) (P = 0.016).

CONCLUSION

A quality assessment based on these seven QIs is feasible. Overall, compliance rates were high; however, for BoM-3, the practice remains to be improved in some centers. Based on BoM-4 compliance rates, steroids are infrequently used concurrently with radiation therapy for malignant spinal cord compression. Extended fractionation for BoM was less frequently performed in academic than in nonacademic centers. The initiation of radiation therapy for brain metastases was more frequently delayed in academic than in nonacademic centers.

Insights into Mechanical Dynamics of Nanoscale Interfaces in Epoxy Composites Using Nanorheology Atomic Force Microscopy

Interfacial polymer layers with nanoscale size play critical roles in dissipating the strain energy around cracks and defects in structural nanocomposites, thereby enhancing the material's fracture toughness. However, understanding how the intrinsic mechanical dynamics of the interfacial layer determine the toughening and reinforcement mechanisms in various polymer nanocomposites remains a major challenge. Here, by means of a recently developed nanorheology atomic force microscopy method, also known as nanoscale dynamic mechanical analysis (nDMA), we report direct mapping of dynamic mechanical responses at the interface of a model epoxy nanocomposite under the transition from a glassy to a rubbery state. We demonstrate a significant deviation in the dynamic moduli of the interface from matrix behavior. Interestingly, the sign of the deviation is observed to be reversed when the polymer changes from a glassy to a rubbery state, which provides an excellent explanation for the difference in the modulus reinforcement between glassy and rubbery epoxy nanocomposites. More importantly, nDMA loss tangent images unambiguously show an enhanced viscoelastic response at the interface compared to the bulk matrix in the glassy state. This observation can therefore provide important insights into the nanoscale toughening mechanism that occurs in epoxy nanocomposites due to viscoelastic energy dissipation at the interface.

Simultaneous Force and Fluorescence Spectroscopy on Single Chains of Polyfluorene: Effect of Intra-Chain Aggregate Coupling

Conjugated polymer chains in compact conformations or in films exhibit spectral features that can be attributed to interactions between individual conjugated segments of the chain, including formation of aggregates or excimers. Here, we use atomic force microscopy (AFM) on single chains of the conjugated polymer polyfluorene (PFO) to control the intersegment interactions by mechanically unfolding the chain. Simultaneously with the force spectroscopy we monitor fluorescence from the single PFO chains using a fluorescence microscope. We found that mechanical stretching of the chain causes disappearance of the green emission band. This observation provides evidence that the green emission originates from an intrachain aggregated state on the self-folded chain, which is decoupled by the stretching. In addition, the stretching upon laser irradiation leads to the appearance of additional features in the force spectra, small force peaks in the initial stages of the unfolding. These features are attributed to a combination of excitonic and van der Waals coupling of a ground-state intrachain aggregate.

Effect of the Axle End Structure and Number of Through-Space Bonds on the Properties of Rotaxane Crosslinked Polymers

A rotaxane crosslinker (RC) is known to toughen the resulting rotaxane crosslinked polymer (RCP) via a stress dispersion effect that is attributed to the movable nature of the crosslinking structure. To evaluate this toughening mechanism in detail, a series of structure-definite RCs equipped with different axle end structures or different numbers of wheel components were synthesized, and subjected to free radical polymerization with a vinyl monomer to obtain RCPs. Analyses of the obtained RCPs revealed that the size of the axle end structure should be well-balanced to produce a strong toughening effect, and a [3]rotaxane crosslinker works more effectively than [2]rotaxane to toughen RCPs. The mobility of the crosslinking points, in terms of rotational and flipping movements, was more crucial to toughening the RCP than that of translational movement along the axle. The first observation of above crucial findings proved the utility of the systematic molecular design used in this study.

Nonspherical Epoxy Resin Polymer Particles Synthesized via Solvent-Free Polyaddition Reactions

Cubic liquid marbles (LMs) were fabricated by using various epoxy monomers as internal liquids and millimeter-sized polymer plates as stabilizers. Successively, cubic polymer particles were synthesized via solvent-free polyaddition reactions by exposing the cubic LMs to NH₃ vapor used as a curing agent. The effect of the solubility parameters (SPs) for the epoxy monomers on the formation of the cubic polymer particles was investigated. As a result, we succeeded in fabricating cubic polymer particles reflecting the shapes of the original LMs by using epoxy monomers with SP values of 23.70-21.66 (MPa)^1/2. Furthermore, the shapes of the LMs could be controlled on demand (e.g., pentahedral and rectangular) by control of the number of polymer plates per LM and/or coalescence of the LMs, resulting in fabrication of polymer particles with shapes reflecting those of the LMs.

Newborn screening for spinal muscular atrophy in Osaka -challenges in a Japanese pilot study

OBJECTIVE

This study aimed to establish an optional newborn screening program for spinal muscular atrophy (SMA-NBS) in Osaka.

METHODS

A multiplex TaqMan real-time quantitative polymerase chain reaction assay was used to screen for SMA. Dried blood spot samples obtained for the optional NBS program for severe combined immunodeficiency, which covers about 50% of the newborns in Osaka, were used. To obtain informed consent, participating obstetricians provided information about the optional NBS program to all parents by giving leaflets to prospective parents and uploading the information onto the internet. We prepared a workflow so that babies that were diagnosed with SMA through the NBS could be treated immediately.

RESULTS

From 1 February 2021 to 30 September 2021, 22,951 newborns were screened for SMA. All of them tested negative for survival motor neuron (SMN)1 deletion, and there were no false-positives. Based on these results, an SMA-NBS program was established in Osaka and included in the optional NBS programs run in Osaka from 1 October 2021. A positive baby was found by screening, diagnosed with SMA (the baby possessed 3 copies of the SMN2 gene and was pre-symptomatic), and treated immediately.

CONCLUSION

The workflow of the Osaka SMA-NBS program was confirmed to be useful for babies with SMA.

In Situ Nanostress Visualization Method to Reveal the Micromechanical Mechanism of Nanocomposites by Atomic Force Microscopy

An in situ atomic force microscopy (AFM) nanomechanical technique was used to directly visualize the micromechanical behaviors of polymer nanocomposites during compressive strain. We obtained a stress distribution image of carbon black (CB)-filled rubber at the nanoscale for the first time, and we traced the microscopic deformation behaviors of CB particles. Through this experiment, we directly revealed the microscopic reinforcement mechanisms of rubber composites. We found that CB-filled rubbers exhibited heterogeneous local microscopic deformations, which were related to the dispersion of CB particles in rubber matrices. The local stress distributions of the rubber composites showed heterogeneity, and the stresses were concentrated in the regions near the CB particles during compression. The area of stress concentration gradually expanded with increasing strain and eventually formed a stress network structure. This stress network bore most of the macroscopic stress and was considered the key reinforcement mechanism of CB-filled rubber. The stress transfer process in the rubber matrix was visualized in real space for the first time. Based on the image data from the AFM experiments, we used finite-element method (FEM) simulations to reproduce the microscopic deformation process of CB-filled rubber. The stress distribution images simulated by FEM showed heterogeneity consistent with AFM. In this study, an in situ visualization of material deformation confirmed the predictions of microscopic deformation behavior from previous theories and models; it also provided new insights into the microscopic reinforcement mechanisms of CB-filled rubber composites based on microscopic stress distribution images.

European Association for Endoscopic Surgery (EAES) consensus on Indocyanine Green (ICG) fluorescence-guided surgery

BACKGROUND

In recent years, the use of Indocyanine Green (ICG) fluorescence-guided surgery during open and laparoscopic procedures has exponentially expanded across various clinical settings. The European Association of Endoscopic Surgery (EAES) initiated a consensus development conference on this topic with the aim of creating evidence-based statements and recommendations for the surgical community.

METHODS

An expert panel of surgeons has been selected and invited to participate to this project. Systematic reviews of the PubMed, Embase and Cochrane libraries were performed to identify evidence on potential benefits of ICG fluorescence-guided surgery on clinical practice and patient outcomes. Statements and recommendations were prepared and unanimously agreed by the panel; they were then submitted to all EAES members through a two-rounds online survey and results presented at the EAES annual congress, Barcelona, November 2021.

RESULTS

A total of 18,273 abstracts were screened with 117 articles included. 22 statements and 16 recommendations were generated and approved. In some areas, such as the use of ICG fluorescence-guided surgery during laparoscopic cholecystectomy, the perfusion assessment in colorectal surgery and the search for the sentinel lymph nodes in gynaecological malignancies, the large number of evidences in literature has allowed us to strongly recommend the use of ICG for a better anatomical definition and a reduction in post-operative complications.

CONCLUSIONS

Overall, from the systematic literature review performed by the experts panel and the survey extended to all EAES members, ICG fluorescence-guided surgery could be considered a safe and effective technology. Future robust clinical research is required to specifically validate multiple organ-specific applications and the potential benefits of this technique on clinical outcomes.

Overcoming the entropy of polymer chains by making a plane with terminal groups: a thermoplastic PDMS with a long-range 1D structural order

Due to its unique physical and chemical properties, polydimethylsiloxane (PDMS) is widely used in many applications, in which covalent cross-linking is commonly used to cure the fluidic polymer. The formation of a non-covalent network achieved through the incorporation of terminal groups that exhibit strong intermolecular interactions has also been reported to improve the mechanical properties of PDMS. Through the design of a terminal group capable of two-dimensional (2D) assembly, rather than the generally used multiple hydrogen bonding motifs, we have recently demonstrated an approach for inducing long-range structural ordering of PDMS, resulting in a dramatic change in the polymer from a fluid to a viscous solid. Here we present an even more surprising terminal-group effect: simply replacing a hydrogen with a methoxy group leads to extraordinary enhancement of the mechanical properties, giving rise to a thermoplastic PDMS material without covalent cross-linking. This finding would update the general notion that less polar and smaller terminal groups barely affect polymer properties. Based on a detailed study of the thermal, structural, morphological and rheological properties of the terminal-functionalized PDMS, we revealed that 2D assembly of the terminal groups results in networks of PDMS chains, which are arranged as domains with long-range one-dimensional (1D) periodic order, thereby increasing the storage modulus of the PDMS to exceed its loss modulus. Upon heating, the 1D periodic order is lost at around 120 °C, while the 2D assembly is maintained up to ∼160 °C. The 2D and 1D structures are recovered in sequence upon cooling. Due to the thermally reversible, stepwise structural disruption/formation as well as the lack of covalent cross-linking, the terminal-functionalized PDMS shows thermoplastic behavior and self-healing properties. The terminal group presented herein, which can form a 'plane', might also drive other polymers to assemble into a periodically ordered network structure, thereby allowing for significant modulation of their mechanical properties.

Unraveling Nanoscale Elastic and Adhesive Properties at the Nanoparticle/Epoxy Interface Using Bimodal Atomic Force Microscopy

The addition of a small fraction of solid nanoparticles to thermosetting polymers can substantially improve their fracture toughness, while maintaining various intrinsic thermomechanical properties. The underlying mechanism is largely related to the debonding process and subsequent formation of nanovoids at a nanoscale nanoparticle/epoxy interface, which is thought to be associated with a change in the structural and mechanical properties of the formed epoxy network at the interface compared with the matrix region. However, a direct characterization of the local physical properties at this nanoscale interface remains significantly challenging. Here, we employ a recently developed bimodal atomic force microscopy technique for the direct mapping of nanoscale elastic and adhesive responses of an amine-cured epoxy resin filled with ∼50 nm diameter silica nanoparticles. The obtained elastic modulus and dissipated energy maps with high spatial resolution evidence the existence of a ∼20-nm-thick interfacial epoxy layer surrounding the nanoparticles, which exhibits a reduced modulus and weaker adhesive response in comparison with the matrix properties. While the presence of such a soft and weak-adhesive interfacial layer is found not to affect the architecture of structural heterogeneities in the epoxy matrix, it conceivably supports the toughening mechanism related to the debonding and plastic nanovoid growth at the silica/epoxy interface. The incorporation of this soft interfacial layer into the Halpin-Tsai model also provides a good explanation for the effect of the silica fraction on the tensile modulus of cured epoxy nanocomposites.

Usefulness of 18F-FDG PET/computed tomography in differentiating between subacute and chronic aortic dissection: initial investigation

OBJECTIVES

In the selection of thoracic endovascular repair for aortic dissection (AD), it is important to distinguish between the subacute and chronic phases, but there is no reliable way to distinguish between them in patients with unknown onset of AD. The purpose of this study was to assess the diagnostic performance of 2-[18F] fluoro-2-deoxy-d-glucose (18F-FDG)-PET/computed tomography (PET/CT) for discriminating subacute AD from chronic AD.

METHODS

Thirteen patients with AD who were medically treated and followed up for 6 months were studied. 18F-FDG PET/CT images were obtained for each patient in the subacute phase (the first scan) and at 6 months (the second scan) after the onset. Target-to-background ratio (TBR) was measured as the maximum standardized uptake value (SUV) in the dissected aortic wall divided by blood pool SUV.

RESULTS

TBR was significantly higher in the first scan (mean ± SD, 1.97 ± 0.32) than in the second scan (1.69 ± 0.29, P = 0.007). The area under the receiver operating characteristic curve of TBR for discriminating subacute AD from chronic AD was 0.76. With a threshold of 1.74, the TBR showed the sensitivity, specificity, and positive and negative predictive value of 85%, 69%, 73%, and 82%, respectively, for the discrimination of subacute AD from chronic AD.

CONCLUSION

Metabolic assessment of dissected aortic wall by 18F-FDG PET/CT is useful in differentiating between subacute and chronic AD and can provide important information in determining the appropriate indication for treatment for patients with AD of unknown onset.

Insulating Polymer Blend Organic Thin-Film Transistors Based on Bilayer-Type Alkylated Benzothieno[3,2-b]naphtho[2,3-b]thiophene

Herein, we developed a practical method to produce high-performance organic thin-film transistors (OTFTs) based on highly layered crystalline organic semiconductors (OSCs) that form bilayer-type layered herringbone (b-LHB) packing and exhibit high intrinsic mobility. We applied the insulating polymer blend technique using a typical b-LHB OSC of 2-octyl-benzothieno[3,2-b]naphtho[2,3-b]thiophene (2-C8-BTNT) and fabricated polycrystalline thin-film transistors (TFTs) via short-duration spin coating and subsequent annealing. The use of blends and the choice of polymer additive strongly affected the performance of the polycrystalline TFTs, and poly(methyl methacrylate) (PMMA) blend TFTs exhibited a high mobility exceeding 4 cm²/(V s) and small device-to-device variations. Using extended techniques in atomic force microscopy (AFM), we investigated the thin-film morphologies by bimodal AFM and the carrier transport properties by Kelvin probe force microscopy (KPFM). We demonstrated that the PMMA blend system enables the formation of a well-ordered polycrystalline thin film induced by vertical phase separation between the OSC and PMMA over a large area, resulting in uniform TFT performance. These findings pave the way for obtaining high-performance TFTs using simple processes, representing a substantial advancement toward the realization of printed electronics.

Utility of psoas muscle area in selecting older patients feasible for thoracic endovascular aortic repair

BACKGROUND

The impact of psoas muscle mass index (PMI) on overall survival is unknown in older patients undergoing elective thoracic endovascular aortic repair (TEVAR).

METHODS

We retrospectively reviewed 105 patients 75 years and older who underwent elective TEVAR for descending thoracic aortic aneurysm between January 2010 and December 2019. Psoas muscle area was measured at the L3 level with preoperative computed tomography and adjusted by height² to derive PMI. The patients were stratified into two groups, Sarcopenia and Non-sarcopenia. Sarcopenia was defined as a PMI < 5.40 cm²/m² for male and < 3.56 cm²/m² for female. The overall survival was compared with the age- and sex-matched general population using the one-sample log-rank test. The propensity score adjusted-Cox proportional-hazard model was applied to determine the hazard ratio for all-cause mortality.

RESULTS

Twenty-three patients died during the follow-up period (median, 3.0 years). Thirty-eight (36%) patients were classified as Sarcopenia. The 5-year overall survival rate was 46% (95% confidence interval, 29-73) in Sarcopenia and 84% (95% confidence interval, 74-94) in Non-sarcopenia. The overall survival was significantly lower in Sarcopenia than in its matched general population (P = .004). Whereas, no statistically significant difference in overall survival was found between Non-sarcopenia and its matched general population (P = .417). Sarcopenia was an independent risk factor for all-cause mortality (adjusted hazard ratio, 2.64; 95% confidence interval, 1.02- 6.82; P = .045).

CONCLUSIONS

PMI may be a good predictor of mortality in older patients undergoing elective TEVAR for descending thoracic aortic aneurysm.

Direct Visualization of Interfacial Regions between Fillers and Matrix in Rubber Composites Observed by Atomic Force Microscopy-Based Nanomechanics Assisted by Electron Tomography

In order to explain or predict the macroscopic mechanical properties of polymer composites with complex nanostructures, atomic force microscopy (AFM)-based nanomechanics is one of the most appropriate tools because the local mechanical properties can be obtained by it. However, automatic force curve analysis based on contact mechanics would mislead us to the wrong conclusion. The purpose of this study is to elucidate this point by applying AFM nanomechanics on a carbon black (CB)-reinforced isoprene rubber (IR). The CB aggregates underneath the rubber surface prevent us from quantitatively evaluating the ratio of CB and interfacial polymer region (IPR), which is an important parameter to determine the macroscopic mechanical properties. In order to overcome this problem, transmission electron microtomography was incorporated to investigate the 3D structure in the same field of view as AFM nanomechanics. As a result, it was found that there are buried structures that do not appear in the AFM topographic image. In addition, we were able to reveal the existence of a force curve with an inflection point, which is characteristic of such "false" IPRs. To put it another way, we evidenced the existence of true IPRs for the first time by combining these state-of-the-art techniques.

Treatment Strategies for Improving the Surgical Outcomes of Ruptured Abdominal Aortic Aneurysm: Single-Center Experience in Japan

Objective: We aimed to examine the surgical outcomes of ruptured abdominal aortic aneurysm cases at our hospital and considered strategies for improvement.

Material and Methods: We examined the preoperative characteristics of hospital mortality, postoperative complications, and long-term outcomes of 91 surgical cases of ruptured abdominal aortic aneurysm performed between January 2009 and December 2020 at our hospital.

Results: Of the 91 cases, 24 died at the hospital (mortality, 26.3%). Mortality was mostly due to hemorrhage/disseminated intravascular coagulation and intestinal necrosis. Ten patients required preoperative aortic clamp by thoracotomy or insertion of intra-aortic balloon occlusion, and eight of them died. Ten patients required open abdominal management due to abdominal compartment syndrome, and five of them died. There was no significant difference between the two groups in terms of the long-term results of the open repair and abdominal endovascular aneurysm repair (EVAR).

Conclusion: To improve the surgical outcomes of ruptured abdominal aortic aneurysms, it is necessary to start surgery immediately. Therefore, the choice of surgical method (open surgery or EVAR) should be based on the resources and discretion of the hospital. To prevent postoperative intestinal necrosis, risk factors for acute compartment syndrome should be considered, and open abdominal management should be introduced.

Liver Cirrhosis Complicated by Spontaneous Bacterial Peritonitis Caused by the Burkholderia cepacia Complex

A 79-year-old man with underlying alcoholic liver cirrhosis presented with complaints of a fever, abdominal pain, and difficulty walking. A diagnostic work-up revealed liver atrophy and chylous ascites, and spontaneous bacterial peritonitis (SBP) was diagnosed based on the cell and neutrophil counts. The Burkholderia cepacia complex (Bcc) was detected on blood and ascitic fluid cultures. Although broad-spectrum antibiotic therapy was initiated, the infection was difficult to control, and the patient died of multiple organ failure. Bcc is often multidrug-resistant and difficult to treat. SBP caused by Bcc has been rarely reported and may have a serious course, thus necessitating caution.

Topology-transformable block copolymers based on a rotaxane structure: change in bulk properties with same composition

The topology of polymers affects their characteristic features, i.e., their microscopic structure and macroscopic properties. However, the topology of a polymer is usually fixed during the construction of the polymer chain and cannot be transformed after its determination during the synthesis. In this study, topology-transformable block copolymers that are connected via rotaxane linkages are introduced. We will present systems in which the topology transformation of block copolymers changes their 1) microphase-separated structures and 2) macroscopic mechanical properties. The combination of a rotaxane structure at the junction point and block copolymers that spontaneously form microphase-separated structures in the bulk provides access to systems that cannot be attained using conventional covalent bonds.

Therapeutic window for obtaining favorable remodeling after thoracic endovascular aortic repair of type B aortic dissection

OBJECTIVE

The purpose of the present study was to determine the most appropriate timing for thoracic endovascular aortic repair (TEVAR) of type B aortic dissection (TBAD) in terms of remodeling of the aorta.

METHODS

A total of 41 patients who had undergone TEVAR for the treatment of aortic dissection were included in the present study. The patients were divided into two groups: those who had undergone TEVAR in the acute or subacute phase (group A) and those who had undergone TEVAR in the chronic phase (group B). The indications for TEVAR as the treatment of TBAD were the presence of aortic rupture or malperfusion of the aortic branches, a maximum aortic diameter of ≥40 mm on the initial diagnostic computed tomography scan, and/or expansion of the aorta of ≥5 mm within 3 months for acute and subacute TBAD. The indication was a maximum aortic diameter of ≥50 mm or expansion of the aorta of ≥5 mm within 1 year for chronic TBAD. The diameters of the aorta, true lumen, and false lumen were measured at the level of the most dilated part of the descending aorta (level M) and at the diaphragm (level D) on the computed tomography scan obtained before TEVAR and at the 2-year follow-up examination.

RESULTS

The median interval between TEVAR and the onset of TBAD was 0.2 month (interquartile range, 0.03-0.7 month) in group A (n = 21) and 32 months (interquartile range, 4.7-35.2 months) in group B (n = 20). Except for the aortic diameter at level D in group B, favorable remodeling was obtained at both levels in both groups. The diameter change ratio of the aorta at level D was significantly greater in group A than in group B (P = .02). Receiver operating characteristic curve analysis of the interval for a significant decrease in the aortic diameter at level D yielded 4.2 months as the optimal threshold for performing TEVAR (area under the curve, 0.859; 95% confidence interval, 0.7-1.0).

CONCLUSIONS

TEVAR for TBAD will result in favorable outcomes, irrespective of the timing of the procedure. However, it might be more effective to perform TEVAR within 4.2 months of the onset of TBAD, provided that the TEVAR procedure can be performed safely.

High spatial-density, cladding-pumped 6-mode 7-core fiber amplifier for C-band operation

We present a C-band 6-mode 7-core fiber amplifier in an all-fiberized cladding-pumped configuration for space division multiplexed transmission supporting a record 42 spatial channels. With optimized fiber components (e.g. passively cooled pump laser diode, pump coupler, pump stripper), high power multimode pump light is coupled to the active fiber without any noticeable thermal degradation and an average gain of 18 dB and noise figure of 5.4 dB are obtained with an average differential modal gain of 3.4 dB.

40 Years Anniversary of Cardiac 123I-mIBG Imaging: State of the Heart

Purpose of Review

This narrative review reflects on the body of evidence on cardiac 123I-mIBG imaging that has accumulated since the introduction in the late 1970s and focusses on to what extent cardiac 123I-mIBG imaging has fulfilled its potential in cardiology especially.

Recent Findings

In contrast to the linear relationship between 123I-mIBG-derived parameters and overall prognosis in heart failure, there seems a “bell-shape” curve for 123I-mIBG-derived parameters and arrhythmic events. In addition, there is a potential clinical role for cardiac 123I-mIBG in optimizing patient selection for expensive devices (i.e., ICD and CRT). This needs of course to be established in future trials.

Summary

Cardiac 123I-mIBG imaging is, despite the numerous of studies, sometimes mistakenly seen as a nice to have technique rather than a must have imaging modality. Although cardiac 123I-mIBG imaging has grown and matured over the years, its full clinical potential has still not been tested to the maximum.

The relation between cardiac 123I-mIBG scintigraphy and functional response 1 year after CRT implantation

Aims 

Cardiac resynchronization therapy (CRT) is a disease-modifying therapy in patients with chronic heart failure (CHF). Current guidelines ascribe CRT eligibility on three parameters only: left ventricular ejection fraction (LVEF), QRS duration, and New York Heart Association (NYHA) functional class. However, one-third of CHF patients does not benefit from CRT. This study evaluated whether ¹²³I-meta-iodobenzylguanidine (¹²³I-mIBG) assessed cardiac sympathetic activity could optimize CRT patient selection.

Methods and results 

A total of 78 stable CHF subjects (age 66.8 ± 9.6 years, 73% male, LVEF 25.2 ± 6.7%, QRS duration 153 ± 23 ms, NYHA 2.2 ± 0.7) referred for CRT implantation were enrolled. Subjects underwent ¹²³I-mIBG scintigraphy prior to implantation. Early and late heart-to-mediastinum (H/M) ratio and ¹²³I-mIBG washout were calculated. CRT response was defined as either an increase of LVEF to >35%, any improvement in LVEF of >10%, QRS shortening to <150 ms, or improvement in NYHA class of >1 class. In 33 patients LVEF increased to >35%, QRS decreased <150 ms in 36 patients, and NYHA class decreased in 33 patients. Late H/M ratio and hypertension were independent predictors of LVEF improvement to >35% (P = 0.0014 and P = 0.0149, respectively). In addition, early H/M ratio, LVEF, and absence of diabetes mellitus (DM) were independent predictors for LVEF improvement by >10%. No independent predictors were found for QRS shortening to <150 ms or improvement in NYHA class.

Conclusion 

Early and late H/M ratio were independent predictors of CRT response when improvement of LVEF was used as measure of response. Therefore, cardiac ¹²³I-mIBG scintigraphy may be used as a tool to optimize selection of subjects that might benefit from CRT.

Prognostic value of myocardial MIBG scintigraphy in acute ischemic stroke

Funding Acknowledgements

Type of funding sources: None.

Background Autonomic dysfunction is a common complication of acute ischemic stroke and has been associated with poor functional outcome and increased mortality. We investigated the potential relation between the myocardial washout rate (WOR) of 123I-meta-iodobenzylguanidine (123I-mIBG), as a measure of cardiac sympathetic activity, and functional outcome in acute ischemic stroke. 

Methods 38 patients with ischemic stroke (11 females, 72 years old [61-81)), underwent myocardial 123I-mIBG scintigraphy within the first week after stroke onset. Early (10 minutes post-injection (pi)) and late (4 hours pi) planar scans of the thoracic region were made. Regions of interest (ROI) were drawn over the mediastinum and the heart, and heart-to-mediastinum ratio (HMR) was calculated. Myocardial WOR was calculated as follows: (ROI heart early – ROI heart late)/ (ROI heart early) x 100%. Counts were corrected for background and counts in ROI heart late were corrected for decay. Patients were divided in 2 groups: those with a good functional outcome, defined as modified Rankin Scale (mRS) ≤ 2 at 3 months after stroke (i.e., patient is functionally independent), and those with a poor functional outcome, defined as a mRS &gt; 2. 

Results Median WOR was 27,4 % (IQR 10,4-43,6). In univariate analysis, poor functional outcome after stroke was associated with age, stroke severity on admission (measured by the National Institutes of Health Stroke Scale (NIHSS)), beta-blocker use before and during hospitalization, WOR and late HMR. In subsequent multivariate analysis WOR (OR 1.087; 95% CI 1.003-1.177, p = 0.042) was an independent predictor of poor stroke outcome even after adjustment for age and NIHSS.

Conclusions In patients with acute ischemic stroke, myocardial washout of 123I-mIBG predicts stroke outcome, even after adjustment for age and stroke severity on admission.

Radiomics analysis of myocardial perfusion SPECT images in patients with cardiomyopathy and heart failure

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): JSPS KAKENHI Grants

Background

Although myocardial perfusion heterogeneity due to focally damaged cardiomyocytes is observed in single−photon emission computed tomography (SPECT) imaging, a current perfusion defect scoring system does not allow us to provide sufficient diagnostic information for heterogeneity.

Purpose

The aim of this study was to perform radiomics analysis of myocardial perfusion SPECT (MPS) images to investigate the potential to detect myocardial perfusion heterogeneity.

Methods

Patients with hypertrophic cardiomyopathy (n = 3), heart failure (n = 9), and with a low likelihood of coronary artery disease (n =15) (Figure 1), who underwent a rest 99mTc-MIBI myocardial perfusion SPECT, were assessed using a LIFEx software. Four shape−based features, 6 histogram−based features, and 32 textural features were computed. The relevant features for the classification of the patients were selected using the Boruta algorithm, and hierarchical clustering of the selected features using the Spearman correlation coefficient was also performed for the feature reduction. The receiver operating characteristics (ROC) analysis was performed by the support vector machine to calculate the area under the ROC curve (AUC) for the selected features.

Results

Of 40 features, 17 were selected by the classification analysis, and these features were classified into 7 classes by the correlation analysis (Figure 2). The ROC AUCs for 7 features extracted from each class were 0.99, 0.97, 0.96, 0.92, 0.90, 0.86, and 0.83 for the contrast of NDGLDM, the entropy of histogram, ZLNU of GLZLM, the energy of GLCM, the energy of histogram, SZLGE of GLZLM, and the correlation of GLCM, respectively, as compared to 0.39 for a summed rest score.

Conclusions

Radiomics analysis successfully determined the myocardial perfusion heterogeneity in patients with cardiomyopathy and heart failure. It might be promising for the evaluation of myocardial damages that cannot be analyzed by the conventional scoring method.

Creation of mortality risk calculator using a I-123 mIBG-based machine learning model: differential prediction of arrhythmic death and heart-failure death

Funding Acknowledgements

Type of funding sources: None.

Background

Although I-123 meta-iodobenzylguanidine (mIBG) has been applied to patients with chronic heart failure (CHF), a diagnostic tool for differential prediction of fatal arrhythmic events (ArE) and heart-failure death (HFD) has been pursued. 

Purpose

The aim of this study was to create a calculator of mortality risk for differentiating mode of cardiac death using a machine learning (ML) method, and to test the accuracy in a new cohort of patients with CHF.

Methods

A total of 529 patients with CHF was used as the training database for ML. The ArE group consisted of patients with arrhythmic death, sudden cardiac death and appropriate therapy by implantable cardioverter defibrillator. A heart-to-mediastinum ratio (H/M) standardized to the medium-energy collimator condition was calculated with a planar anterior mIBG scintigram. The best classifier models for predicting HFD and ArE were determined by four-fold cross validation. Input variables included age, sex, New York Heart Association (NYHA) functional class, left ventricular ejection fraction, ischemic etiology, mIBG H/M and washout rate, and b-type natriuretic peptide (BNP) or NT Pro BNP, estimated glomerular filtration rate, hemoglobin, and complications such as diabetes and hypertension. After creating the ML-based model, the constructed classifier functions for ArE, HFD, and survival were exported for subsequent use. A new cohort of patients (n = 312, age 67 ± 13 years, 2015 or later) was used to test the ML-based model.

Results

The training database included 141 events (27%) with ArE (7%) and HFD (20%). Receiver-operating characteristic analysis by four-fold validation showed area under the curve value of 0.90 for HFD and 0.73 for ArE. Among various ML methods, the logistic regression method demonstrated the most stable calculation of the probability of ArE followed by random forest and gradient boosted tree methods. Therefore, the logistic-regression method was used for calculating both HFD and ArE probabilities. In the test cohort, patients with a high HFD probability &gt;8% resulted in 6.3-fold higher HFD than those with low probability (≤ 8%). Patients with high ArE probability &gt;8% showed 2.5-fold higher ArE than those with low probability (≤ 8%).

Conclusion

The ML-based mortality risk calculator could be used for stratifying patients at high and low risks, which might be useful for estimating appropriate treatment strategy.

INFLUENCE OF MASTICATION ON THE MICROSTRUCTURE AND PHYSICAL PROPERTIES OF RUBBER

The effects of the masticated state of isoprene rubber (IR) at the carbon black (CB) addition stage on subsequent mixing, microstructure, and physical properties in the case of a kneader with a characteristic large-diameter shaft are investigated by examining the mastication-time dependence. A sufficiently masticated IR shows a shorter black incorporation time, which results in an improved dispersion of CB and better physical properties. Observing the microstructure of a rubber compound using the atomic force microscope–based nanomechanical technique, poor CB dispersion is revealed for insufficient mastication. Specifically, large CB agglomerations surrounded by the interfacial rubber region with higher elastic modulus than that of a rubber matrix are formed. Such a large CB agglomeration, on the other hand, does not appear in rubber compounds with longer mastication times. The thickness of the interfacial region becomes shorter in these cases. These observations are further discussed by the concept of “rheological unit” introduced by Mooney et al. This study demonstrates that the microstructure of a rubber compound is highly heterogenous with rubber regions of different microscopic elastic moduli and that the microstructure has an influence on CB dispersion and the physical properties of rubber.

Lead-free MCP to improve coincidence time resolution and reduce MCP direct interactions

Achieving direct imaging of the annihilation position of a positron on an event-by-event basis using an ultrafast detector would have a great impact on the field of nuclear medicine. Cherenkov emission is the most attractive physical phenomenon for realizing such an ultrafast timing performance. Moreover, a microchannel-plate photomultiplier tube (MCP-PMT) is one of the most promising photodetectors for fully exploiting the fast timing properties of Cherenkov emission owing to its excellent single photon time resolution of 25 ps full width at half maximum (FWHM). However, as the MCP structure generally contains a lead compound, the gamma rays frequently and directly interact with the MCP, resulting in the degradation of its timing performance and generation of undesirable side peaks in its coincidence timing histogram. To overcome this problem, we have developed a new MCP-PMT based on an MCP consisting of borosilicate glass, thus drastically reducing the probability of the photoelectric effect occurring in the MCP. To evaluate its insensitivity to gamma rays and its timing performance, a coincidence experiment was performed and showed that the probability of direct interactions was reduced by a factor of 3.4. Moreover, a coincidence time resolution of 35.4 ± 0.4 ps FWHM, which is equivalent to a position resolution of 5.31 mm, was obtained without any pulse height/area cut, improving to 28.7 ± 3.0 ps when selecting on the highest amplitude events by careful optimization of the voltage divider circuit of the new MCP-PMT. The timing performance of this new MCP-PMT presents an important step toward making direct imaging possible.

Pregnancy outcome after first trimester exposure to domperidone-An observational cohort study

Aim

To assess the teratogenic risk of domperidone by comparing the incidence of major malformation with domperidone to a control.

Methods

Pregnancy outcome data were obtained for women at two Japanese facilities that provide counseling on drug use during pregnancy between April 1988 and December 2017. The incidence of major malformation was calculated among infants born to women taking domperidone (n = 519), nonteratogenic drugs (control, n = 1673), or metoclopramide (reference, n = 241) during the first trimester of pregnancy. Using the control group as reference, the crude odds ratio (OR) of the incidence of major malformation in the domperidone and metoclopramide groups was calculated using univariable logistic regression analysis. Adjusted OR was also calculated using multivariable logistic regression analysis adjusted for various other factors.

Results

The incidence of major malformation was 2.9% (14/485, 95% confidence interval [CI]: 1.6–4.8) in the domperidone group, 1.7% (27/1554, 95%CI: 1.1–2.5) in the control group, and 3.6% (8/224, 95%CI: 1.6–6.9) in the metoclopramide group. The adjusted multivariable logistic regression analysis showed no significant difference in incidence between the control and domperidone groups (adjusted OR: 1.86 [95%CI: 0.73–4.70], p = 0.191) or between the control and metoclopramide groups (adjusted OR: 2.20 [95%CI: 0.69–6.98], p = 0.183).

Conclusions

This observational cohort study showed that domperidone exposure during the first trimester was not associated with increased risk of major malformation in infants. These results may help alleviate the anxiety of patients who took domperidone during pregnancy.

Epilepsy in patients with advanced Fukuyama congenital muscular dystrophy

BACKGROUND

Recent advances in respiratory management have improved survival for patients with Fukuyama congenital muscular dystrophy (FCMD), characterized by congenital muscular dystrophy and brain malformation. Previous studies reported that more than half of patients exhibit seizures in childhood. However, little is known about epilepsy after childhood.

METHODS

To elucidate the long-term clinical course of epilepsy, we retrospectively reviewed all medical records in nine patients (6 males, mean age 20.7 years) with FCMD diagnosed between 1981 and 2019.

RESULTS

The follow-up periods ranged from 6 to 30 years (mean 18.4 years). A total of 75 EEG recordings were available from nine patients. In some patients, EEGs were normal during early childhood but tended to show paroxysmal discharges with age. Overall, epileptic seizures were observed in six patients. Except for one presenting with afebrile seizure at one year of age, the remaining five patients developed epilepsy between 13 and 22 years of age. The most common seizure type was focal impaired awareness seizure. After adolescence, four patients exhibited status epilepticus. Their convulsive movements of the seizures became less prominent with progression of the disease. At the last evaluation, most patients (5/6) had uncontrolled seizures.

CONCLUSIONS

Despite presence of distinct brain malformation, epileptic seizures may develop after childhood in FCMD patients. Our experience suggests that clinicians should be careful not to overlook epileptic seizures, especially in advanced-stage patients who had profound muscle weakness.

REACTOR PHYSICS EXPERIMENT IN A GRAPHITE-MODERATION SYSTEM FOR HTGR

The Japan Atomic Energy Agency (JAEA) started the Research and Development (R&D) to improve nuclear prediction techniques for High Temperature Gas-cooled Reactors (HTGRs). The objectives are to introduce a generalized bias factor method to avoid full mock-up experiment for the first commercial HTGR and to introduce reactor noise analysis to High Temperature Engineering Test Reactor (HTTR) experiment to observe sub-criticality. To achieve the objectives, the reactor core of graphite-moderation system named B7/4”G2/8”p8EUNU+3/8”p38EU(1) was newly composed in the B-rack of Kyoto University Critical Assembly (KUCA). The core is composed of the fuel assembly, driver fuel assembly, graphite reflector, and polyethylene reflector. The fuel assembly is composed of enriched uranium plate, natural uranium plate and graphite plates to realize the average fuel enrichment of HTTR and it’s spectrum. However, driver fuel assembly is necessary to achieve the criticality with the small-sized core. The core plays a role of the reference core of the bias factor method, and the reactor noise was measured to develop the noise analysis scheme. In this study, the overview of the criticality experiments is reported. The reactor configuration with graphite moderation system is rare case in the KUCA experiments, and this experiment is expected to contribute not only for an HTGR development but also for other types of a reactor in the graphite moderation system such as a molten salt reactor development.

Relevance of Aortic Dissection Chronicity to the Development of Stent Graft-induced New Entry

BACKGROUND

The relevance of aortic dissection chronicity to the development of stent graft-induced new entry (SINE) is unknown.

METHODS

This study enrolled 69 patients who underwent thoracic endovascular aortic repair (TEVAR) for chronic aortic dissection from January 2006 to December 2017 and were followed up for ≥6 months. Their medical records were reviewed retrospectively. Patients were stratified according to TEVAR timing into an early group (≤6 months from the onset of aortic dissection) and a late group (>6 months after the onset). The incidence of SINE as well as the interval between TEVAR and the development of SINE was compared between these groups.

RESULTS

During the follow-up period, SINE occurred in 12% (3/26) and 35% (15/43) of patients in the early and late groups, respectively (P = .029). The interval between TEVAR and SINE development was significantly longer in the late group than the early group (median, 92 days vs 1144 days, respectively; P = .002). According to the multivariate analysis results, the late group (hazard ratio, 3.667; 95% confidence interval, 1.037-12.968; P = .044) and the distal oversizing ratio (hazard ratio, 1.492; 95% confidence interval, 1.071-2.080; P = .018) were the independent predictors for SINE development.

CONCLUSIONS

TEVAR should be performed in the early period of the chronic phase to prevent SINE. Close and lifelong follow-up is mandatory for patients who undergo TEVAR >6 months after onset because SINE can develop several years after TEVAR in those patients.