A case of lymphatic flow evaluation using indocyanine green fluorescence imaging for recurrence of anastomotic site after laparoscopic right hemicolectomy

BACKGROUND

Anastomotic recurrence of colorectal cancer is rare, but reoperation improves prognosis. However, there is no clear evidence regarding the extent of dissection, and there are few reports on the details of surgery. We used intraoperative lymphatic flow imaging with indocyanine green (ICG) fluorescence as a reference to determine the range of additional resection.

CASE PRESENTATION

The patient was a 75-year-old man who underwent laparoscopic right hemicolectomy and extracorporeal functional terminal anastomosis for ascending colon cancer 4 years ago. Histopathological examination revealed a well-differentiated tubular adenocarcinoma, T4aN0M0, pathological stageIIB. During follow-up, anemia was observed, and colonoscopy indicated anastomotic recurrence, so additional laparoscopic resection was performed. Intraoperatively, ICG was injected into the anastomotic site, and the operation proceeded under near-infrared light observation. Lymphatic vessels along the middle colonic artery were visualized down to the root of the vessel. Using this as an indicator, the vessel was ligated from the root. Using the fact that the lymphatic vessels were also depicted in the small intestinal mesentery on the oral side of the anastomosis as an indicator, the small intestine and mesentery were resected about 7 cm from the anastomosis.

CONCLUSIONS

The optimal surgical approach for anastomotic recurrence of colorectal cancer has not been defined. Intraoperative ICG fluorescence imaging can provide images of lymphatic flow from the site of recurrence and may be an indicator of lymph node dissection in the case of anastomotic recurrence.

Association Between Physician Empathy and Difficult Patient Encounters: a Cross-Sectional Study

BACKGROUND

Physicians frequently experience patients as difficult. Our study explores whether more empathetic physicians experience fewer patient encounters as difficult.

OBJECTIVE

To investigate the association between physician empathy and difficult patient encounters (DPEs).

DESIGN

Cross-sectional study.

PARTICIPANTS

Participants were 18 generalist physicians with 3-8 years of experience. The investigation was conducted from August-September 2018 and April-May 2019 at six healthcare facilities.

MAIN MEASURES

Based on the Jefferson Scale of Empathy (JSE) scores, we classified physicians into low and high empathy groups. The physicians completed the Difficult Doctor-Patient Relationship Questionnaire-10 (DDPRQ-10) after each patient visit. Scores ≥ 31 on the DDPRQ-10 indicated DPEs. We implemented multilevel mixed-effects logistic regression models to examine the association between physicians' empathy and DPE, adjusting for patient-level covariates (age, sex, history of mental disorders) and with physician-level clustering.

KEY RESULTS

The median JSE score was 114 (range: 96-126), and physicians with JSE scores 96-113 and 114-126 were assigned to low and high empathy groups, respectively (n = 8 and 10 each); 240 and 344 patients were examined by physicians in the low and high empathy groups, respectively. Among low empathy physicians, 23% of encounters were considered difficulty, compared to 11% among high empathy groups (OR: 0.37; 95% CI = 0.19-0.72, p = 0.004). JSE scores and DDPRQ-10 scores were negatively correlated (r = -0.22, p < 0.01).

CONCLUSION

Empathetic physicians were less likely to experience encounters as difficult. Empathy appears to be an important component of physician perception of encounter difficulty.

Lesser omental hernia through a defect in the posterior layer of the lesser omentum

BACKGROUND

In previously reported cases of lesser omental hernia, a rare clinical presentation, the herniated intestinal tract was passing through both peritoneal layers of the lesser omentum to herniate into the peritoneal cavity or bursa omentalis. Here we present a very rare case of lesser omentum hernia, where the transverse colon entered through only the posterior layer of the lesser omentum to form a hernia between the anterior and posterior layers.

CASE PRESENTATION

A 43-year-old man was admitted to the emergency department with acute abdominal pain. Plain abdominal computed tomography (CT) revealed a change in the caliber of the transverse colon between the stomach and pancreas, forming a closed loop on the cephaloventral side of the stomach. On contrast-enhanced CT images, vessels were observed in the contrast-enhanced lesser omentum surrounding the herniated intestine. The patient was diagnosed with a lesser omental hernia and underwent laparoscopic surgery. Intraoperatively, the transverse colon was covered by the anterior layer of the lesser omentum, and a defect was found in the posterior layer of the lesser omentum on the dorsal side of the stomach. A 2-cm incision was made in the posterior layer of the lesser omentum to widen the small defect. The herniated intestinal section was removed from the hernia sac, and the transverse colon was retained unresected. The postoperative course was uneventful.

CONCLUSIONS

As illustrated in this first case of a lesser omental hernia forming between the anterior and posterior layers, characteristic CT findings may play an active role in the diagnosis of this rare presentation.

Hybrid PBL and Pure PBL: Which one is more effective in developing clinical reasoning skills for general medicine clerkship?-A mixed-method study

This study aims to compare the effectiveness of Hybrid and Pure problem-based learning (PBL) in teaching clinical reasoning skills to medical students. The study sample consisted of 99 medical students participating in a clerkship rotation at the Department of General Medicine, Chiba University Hospital. They were randomly assigned to Hybrid PBL (intervention group, n = 52) or Pure PBL group (control group, n = 47). The quantitative outcomes were measured with the students' perceived competence in PBL, satisfaction with sessions, and self-evaluation of competency in clinical reasoning. The qualitative component consisted of a content analysis on the benefits of learning clinical reasoning using Hybrid PBL. There was no significant difference between intervention and control groups in the five students' perceived competence and satisfaction with sessions. In two-way repeated measure analysis of variance, self-evaluation of competency in clinical reasoning was significantly improved in the intervention group in "recalling appropriate differential diagnosis from patient's chief complaint" (F(1,97) = 5.295, p = 0.024) and "practicing the appropriate clinical reasoning process" (F(1,97) = 4.016, p = 0.038). According to multiple comparisons, the scores of "recalling appropriate history, physical examination, and tests on clinical hypothesis generation" (F(1,97) = 6.796, p = 0.011), "verbalizing and reflecting appropriately on own mistakes," (F(1,97) = 4.352, p = 0.040) "selecting keywords from the whole aspect of the patient," (F(1,97) = 5.607, p = 0.020) and "examining the patient while visualizing his/her daily life" (F(1,97) = 7.120, p = 0.009) were significantly higher in the control group. In the content analysis, 13 advantage categories of Hybrid PBL were extracted. In the subcategories, "acquisition of knowledge" was the most frequent subcategory, followed by "leading the discussion," "smooth discussion," "getting feedback," "timely feedback," and "supporting the clinical reasoning process." Hybrid PBL can help acquire practical knowledge and deepen understanding of clinical reasoning, whereas Pure PBL can improve several important skills such as verbalizing and reflecting on one's own errors and selecting appropriate keywords from the whole aspect of the patient.

Cryoballoon ablation of left atrial roof with a novel cryoballoon system

Introduction

A novel cryoballoon system (POLARx) has emerged and its efficacy regarding pulmonary vein isolation (PVI) has been already investigated. On the other hand, cryoballoon ablation of left atrial (LA) roof has been performed using a conventional cryoballoon system (Arctic Front Advance Pro [AFA-Pro]) in addition to PVI. However, cryoballoon ablation of LA roof with POLARx has not been investigated yet.

Methods

We performed cryoballoon ablation of LA roof with POLARx in 22 patients after we achieved PVI. After the cryoballoon ablation, complete conduction block at LA roof and isolation of all PVs were confirmed by creating an activation map during high right atrium pacing. If they could not be obtained with solely a cryoballoon, touch up ablation with radiofrequency ablation was permitted. The procedural data during ablation with POLARx was compared with those during ablation with AFA-Pro we had performed in a historical cohort of patients (n=46).

Results

Complete conduction block at LA roof without touch up ablation could be obtained in all the patients in POLARx group and 44 (95.7%) patients in AFA-Pro group. Total procedure time was almost similar in both groups (164.2±35.4 min for POLARx vs 180.3±35.4 min for AFA-Pro, p=0.10). During LA roof line ablation, nadir balloon temperature was significantly lower in POLARx group (right side: −53.6±4.4°C for POLARx vs −45.6±4.6°C for AFA-Pro, p&lt;0.01, central part: −56.4±4.3°C for POLARx vs −46.0±3.7°C for AFA-Pro, p&lt;0.01, left side: −55.1±3.5°C for POLARx vs −45.7±5.3°C for AFA-Pro, p&lt;0.01), and balloon temperature reached −40°C earlier in POLARx (right side: 30.7±8.9 sec for POLARx vs 78.0±39.8 sec for AFA-Pro, p&lt;0.01, central part: 30.6±9.3 sec for POLARx vs 65.9±33.3 sec for AFA-Pro, p&lt;0.01, left side: 30.4±4.2 sec for POLARx vs 78.8±49.6 sec for AFA-Pro, p&lt;0.01). Total freezing time required for LA roof line ablation was significantly shorter in POLARx group (589.3±163.6 sec for POLARx vs 877.5±191.7 sec for AFA-Pro, p&lt;0.01).The scar area created after LA roof line ablation was similar in both groups (9.3±4.1 cm2 for POLARx vs 11.0±4.8 cm2 for AFA-Pro, p=0.23).

Conclusion

Complete conduction block at LA roof could be obtained after cryoballoon ablation with POLARx, in the same way as AFA-Pro. Lower nadir balloon temperature could be expected in shorter freezing time during LA roof line ablation in using POLARx compared with AFA-Pro.

Funding Acknowledgement

Type of funding sources: None.

How to perform effective cryoballooon ablation of left atrial roof: considerations after experiences of more than 1000 cases

Introduction

Although pulmonary vein isolation is the cornerstone of atrial fibrillation (AF) ablation, concomitant cryoballoon ablation of left atrial (LA) roof has been expected to improve clinical outcomes after ablation. We demonstrate characteristics and efficacy of cryoballoon ablation of LA roof through our experiences from a large volume of procedures.

Methods

We had performed cryoballoon ablation of LA roof in 1036 procedures including 202 redo procedures in AF patients since June 2016. Among these procedures, we analyzed 834 patients (309 paroxysmal AF) who had undergone de novo ablation for AF. We confirmed whether the complete conduction block of LA roof line was obtained after the ablation.

Results

LA roof line block was obtained in 767 patients (92.0%) without touch up ablation with a radiofrequency catheter (Group A). LA diameter (LAD) was significantly smaller (43.6±6.6mm vs 47.4±7.5mm, p&lt;0.01) and body mass index (BMI) was significantly lower (24.9±4.0kg/m2 vs 26.3±4.6kg/m2, p=0.01) in those in Group A compared with those without LA roof line block after cryoballoon ablation (Group B). Compared with those in Group B, cryoballoon application number of LA roof (4.1±1.2 vs 4.5±1.6, p&lt;0.01) and mean nadir of cryoballoon temperature during cryoballoon ablation of LA roof (−44.5±5.6°C vs −40.5±7.5°C, p&lt;0.01) were significantly lower in those in Group A. Regarding cryoballoon application number, the number of the cryoballoon application in which a cryoballoon was applied to LA roof with the guiding catheter located in a left superior pulmonary vein (LSPV) was significantly lower in patients in Group A (1.3±0.8 vs 1.6±1.0, p=0.02), and when the number was less than 2, mean nadir of cryoballoon temperature was significantly lower compared with when it was 2 or more than 2 (−44.8±5.8°C vs −42.8±5.6°C, p&lt;0.01). Among those refer to first ablation procedures, one-year Kaplan-Meier atrial arrhythmias free rate estimates, 80.6% for those in Group A and 59.0% for those in Group B (p&lt;0.01). Multivariate analysis identified LA roof line block without touch up ablation as one of the predictors of atrial arrhythmias recurrences. Atrial tachycardia depending on LA roof occurred after cryoballoon ablation of LA roof in 8 patients, although LA roof line block without touch up ablation could be obtained in the index ablation procedure in 6 patients among them.

Conclusion

LA roof line block could be obtained by solely cryoballoon with a reasonable success rate, especially in those with smaller LAD and lower BMI. To obtaine LA roof line block, cryoballoon ablation with the guiding catheter located in LSPV is preferable. LA roof line block without touch up ablation brings better clinical outcomes in those who underwent cryoballoon ablation of LA roof.

Funding Acknowledgement

Type of funding sources: None.

Glycaemic management in a child with ornithine transcarbamylase deficiency undergoing cardiac surgery with hypothermic cardiopulmonary bypass

There is a lack of evidence regarding the optimal intra-operative glycaemic level of patients with ornithine transcarbamylase deficiency to prevent cerebral oedema due to protein catabolism and hyperammonemia. We describe a case of a two-year-old girl with ornithine transcarbamylase deficiency who underwent cardiac surgery requiring cardiopulmonary bypass. A high-dose dextrose infusion to prevent protein catabolism was given throughout surgery, which caused uncontrollable hyperglycaemia unresponsive to high-dose insulin administration. Factors contributing to the hyperglycaemia may have included surgical stress, steroid administration and hypothermia. During invasive surgery, anaesthetists should carefully adjust the rates of dextrose and insulin infusions, guided by close monitoring of blood ammonia, glucose and lactate.

The flipped classroom is effective for medical students to improve deep tendon reflex examination skills: A mixed-method study

Deep tendon reflexes (DTR) are a prerequisite skill in clinical clerkships. However, many medical students are not confident in their technique and need to be effectively trained. We evaluated the effectiveness of a flipped classroom for teaching DTR skills. We recruited 83 fifth-year medical students who participated in a clinical clerkship at the Department of General Medicine, Chiba University Hospital, from November 2018 to July 2019. They were allocated to the flipped classroom technique (intervention group, n = 39) or the traditional technique instruction group (control group, n = 44). Before procedural teaching, while the intervention group learned about DTR by e-learning, the control group did so face-to-face. A 5-point Likert scale was used to evaluate self-confidence in DTR examination before and after the procedural teaching (1 = no confidence, 5 = confidence). We evaluated the mastery of techniques after procedural teaching using the Direct Observation of Procedural Skills (DOPS). Unpaired t-test was used to analyze the difference between the two groups on the 5-point Likert scale and DOPS. We assessed self-confidence in DTR examination before and after procedural teaching using a free description questionnaire in the two groups. Additionally, in the intervention group, focus group interviews (FGI) (7 groups, n = 39) were conducted to assess the effectiveness of the flipped classroom after procedural teaching. Pre-test self-confidence in the DTR examination was significantly higher in the intervention group than in the control group (2.8 vs. 2.3, P = 0.005). Post-test self-confidence in the DTR examination was not significantly different between the two groups (3.9 vs. 4.1, P = 0.31), and so was mastery (4.3 vs. 4.1, P = 0.68). The questionnaires before the procedural teaching revealed themes common to the two groups, including “lack of knowledge” and “lack of self-confidence.” Themes about prior learning, including “acquisition of knowledge” and “promoting understanding,” were specific in the intervention group. The FGI revealed themes including “application of knowledge,” “improvement in DTR technique,” and “increased self-confidence.” Based on these results, teaching DTR skills to medical students in flipped classrooms improves readiness for learning and increases self-confidence in performing the procedure at a point before procedural teaching.

Does scoring patient complexity using COMPRI predict the length of hospital stay? A multicentre case-control study in Japan

OBJECTIVE

To clarify the factors associated with prolonged hospital stays, focusing on the COMplexity PRediction Instrument (COMPRI) score's accuracy in predicting the length of stay of newly hospitalised patients in general internal medicine wards.

DESIGN

A case-control study.

SETTING

Three general internal medicine wards in Chiba Prefecture, Japan.

PARTICIPANTS

Thirty-four newly hospitalised patients were recruited between November 2017 and December 2019, with a final analytic sample of 33 patients. We included hospitals in different cities with general medicine outpatient and ward facilities, who agreed to participate. We excluded any patients who were re-hospitalised within 2 weeks of a prior discharge.

PRIMARY AND SECONDARY OUTCOME MEASURES

Patients' COMPRI scores and their consequent lengths of hospital stay.

RESULTS

The 17 patients (52%) allocated to the long-term hospitalisation group (those hospitalised ≥14 days) had a significantly higher average age, COMPRI score and percentage of participants with comorbid chronic illnesses than the short-term hospitalisation group (<14 days). A logistic regression model (model A, comprising only the COMPRI score as the explanatory variable) and a multiple logistic regression model (model B, comprising variables other than the COMPRI score as explanatory variables) were created as prediction models for the long-term hospitalisation group. When age ≥75 years, a COMPRI score ≥6 and a physician with 10 years' experience were set as explanatory variables, model A showed better predictive accuracy compared with model B (fivefold cross-validation, area under curve of 0.87 vs 0.78). The OR of a patient with a COMPRI score of ≥6 joining the long-term hospitalisation group was 4.25 (95% CI=1.43 to 12.63).

CONCLUSIONS

Clinicians can use the COMPRI score when screening for complexity assessment to identify hospitalised patients at high risk of prolonged hospitalisation. Providing such patients with multifaceted and intensive care may shorten hospital stays.

Does a learner-centered approach using teleconference improve medical students' psychological safety and self-explanation in clinical reasoning conferences? a crossover study

During clinical reasoning case conferences, a learner-centered approach using teleconferencing can create a psychologically safe environment and help learners speak up. This study aims to measure the psychological safety of students who are supposed to self-explain their clinical reasoning to conference participants. This crossover study compared the effects of two clinical reasoning case conference methods on medical students’ psychological safety. The study population comprised 4^th-5^th year medical students participating in a two-week general medicine clinical clerkship rotation, from September 2019 to February 2020. They participated in both a learner-centered approach teleconference and a traditional, live-style conference. Teleconferences were conducted in a separate room, with only a group of students and one facilitator. Participants in group 1 received a learner-centered teleconference in the first week and a traditional, live-style conference in the second week. Participants assigned to group 2 received a traditional, live-style conference in the first week and a learner-centered approach teleconference in the second week. After each conference, Edmondson’s Psychological Safety Scale was used to assess the students’ psychological safety. We also counted the number of students who self-explained their clinical reasoning processes during each conference. Of the 38 students, 34 completed the study. Six out of the seven psychological safety items were significantly higher in the learner-centered approach teleconferences (p<0.01). Twenty-nine (85.3%) students performed self-explanation in the teleconference compared to ten (29.4%) in the live conference (p<0.01). A learner-centered approach teleconference could improve psychological safety in novice learners and increase the frequency of their self-explanation, helping educators better assess their understanding. Based on these results, a learner-centered teleconference approach has the potential to be a method for teaching clinical reasoning to medical students.

Preload stress echocardiography by using dynamic postural alteration can identify high risk patients with heart failure with reduced ejection fraction

Funding Acknowledgements

Type of funding sources: None.

Background

Haemodynamic assessment during stress testing is not commonly performed for patients with heart failure with reduced ejection fraction (HFrEF) due to its invasiveness, less feasibility, and safety concerns. Passive leg-lifting (PLL) manoeuvres have been introduced as a simple alternative for non-invasive preload stress testing; however, the haemodynamic load imposed on the cardiovascular system is unsatisfactory, which precludes the accurate assessment of the preload reserve for patients with HF.

Purpose

The purpose of this study was to assess the haemodynamic characteristics of patients with HFrEF in response to a preload stress during dynamic postural alterations by combining the semi-sitting position (SSP) and PLL. We also evaluated whether combined postural stress could be used for risk stratification for these patients.

Methods

For this study, 101 patients with HFrEF and 35 age- and sex-matched normal controls were prospectively recruited. At each postural position (i.e., baseline, SSP, and PLL), all standard echocardiographic and Doppler variables were obtained. Adverse cardiac events were prespecified as the combined endpoints of death from or hospitalisation for deteriorated HF, or sudden cardiac death. Clinical follow-up was conducted for a median of 7 months.

Results

During PLL stress, the stroke volume index (SVi) significantly increased in both controls (from 40 ± 6 to 43 ± 6 mL/m², P = 0.03) and HFrEF patients (from 31 ± 9 to 34 ± 10 mL/m², P = 0.03). Conversely, during SSP stress, the SVi significantly decreased for both controls (from 40 ± 6 to 37 ± 6 mL/m², P = 0.03) and HFrEF patients (31 ± 9 to 28 ± 8 mL/m², P = 0.03). During the follow-up period, 16 patients developed cardiac events. In patients without events, the Frank-Starling mechanism was well preserved (Fig. A). Namely, the SVi significantly increased from 31 ± 9 to 35 ± 10 mL/m² (P = 0.02) during PLL stress, while the SVi significantly decreased from 31 ± 8 to 28 ± 8 mL/m² (P = 0.02) during SSP stress. In contrast, for patients with cardiac events, the SVi did not change during postural alterations (n.s), which indicated that the failing heart operates on the flat portion of the Frank-Starling curve (Fig. A). When patients were divided into three equal sub-groups based on the total difference in the SVi during dynamic postural stress, patients with impaired preload reserve (third trimester, ΔSVi ≤ 3.0 mL/m²) showed significantly worse event-free survival than the other two sub-groups (Fig. B; P &lt; 0.001). In a Cox proportional-hazard analysis, baseline LVEF (hazard ratio 0.93; P = 0.04), and ΔSVi during postural stress (hazard ratio 0.76; P = 0.004) were predictors of future cardiac events.

Conclusions

The combined assessment of dynamic postural stress during PLL and SPP is a simple, time-saving, and easy-to-use clinical tool for the assessment of preload reserve for patients with HFrEF. Moreover, postural stress echocardiography proved to contribute to the risk stratification for these patients.

Abstract Figure.

The Clinical Key Features of Persistent Postural Perceptual Dizziness in the General Medicine Outpatient Setting: A Case Series Study of 33 Patients

Objective This case series aimed to investigate the clinical and pathological characteristics of persistent postural perceptual dizziness (PPPD). Methods We retrospectively examined the medical records of patients with chronic dizziness in our department, and tracked the percentage of PPPD, the age and sex, disorder duration, exacerbating factors for dizziness, and duration of momentary worsening dizziness. We also examined the duration of momentary worsening dizziness in cases of depression, anxiety disorder, and somatic symptom disorder. Results Among 229 patients with chronic dizziness, 14.4% (33/229) met the diagnostic criteria for PPPD. PPPD was the second most common disorder of patients with chronic dizziness after depression. The median age of patients with PPPD was 75 (75.8% female) and the median duration of the disorder was 60 months (range: 3-360 months). The exacerbating factors were motion without regard to direction or position (90.9%), upright posture (66.7%), and exposure to moving visual stimuli or complex visual patterns (30.3%). While the duration of momentary worsening dizziness was less than 10 minutes in 93.9% of patients with PPPD, the duration in patients with depression, anxiety disorder, and somatic symptom disorder were 3.6 % (2/55), 16.1% (5/31), and 0% (0/11), respectively. When the duration was less than 10 minutes, the odds ratios of PPPD for depression and anxiety disorder were 46.5 (95% CI: 6.1-362.0) and 40.3 (95% CI: 7.4-219.3), respectively. Conclusion Short episodes of momentary worsening dizziness constitute a distinctive feature of PPPD that may be useful for differentiating PPPD from other types of psychogenic dizziness.

Influence of psychiatric or social backgrounds on clinical decision making: a randomized, controlled multi-centre study

BACKGROUND

Frequent and repeated visits from patients with mental illness or free medical care recipients may elicit physicians' negative emotions and influence their clinical decision making. This study investigated the impact of the psychiatric or social background of such patients on physicians' decision making about whether to offer recommendations for further examinations and whether they expressed an appropriate disposition toward the patient.

METHODS

A randomized, controlled multi-centre study of residents in transitional, internal medicine, or emergency medicine was conducted in five hospitals. Upon randomization, participants were stratified by gender and postgraduate year, and they were allocated to scenario set 1 or 2. They answered questions pertaining to decision-making based on eight clinical vignettes. Half of the eight vignettes presented to scenario set 1 included additional patient information, such as that the patient had a past medical history of schizophrenia or that the patient was a recipient of free care who made frequent visits to the doctor (biased vignettes). The other half included no additional information (neutral vignettes). For scenario set 2, the four biased vignettes presented to scenario set 1 were neutralized, and the four neutral vignettes were rendered biased by providing additional information. After reading, participants answered decision-making questions regarding diagnostic examination, interventions, or patient disposition. The primary analysis was a repeated-measures ANOVA on the mean management accuracy score, with patient background information as a within-subject factor (no bias, free care recipients, or history of schizophrenia).

RESULTS

A total of 207 questionnaires were collected. Repeated-measures ANOVA showed that additional background information had influence on mean accuracy score (F(7, 206) = 13.84, p <  0.001 partial η2 = 0.063). Post hoc pairwise multiple comparison test, Sidak test, showed a significant difference between schizophrenia and no bias condition (p <  0.05). The ratings for patient likability were lower in the biased vignettes compared to the neutral vignettes, which was associated with the lower utilization of medical resources by the physicians.

CONCLUSIONS

Additional background information on past medical history of schizophrenia increased physicians' mistakes in decision making. Patients' psychiatric backgrounds should not bias physicians' decision-making. Based on these findings, physicians are recommended to avoid being influenced by medically unrelated information.

P4704The efficacy of intravascular ultrasound for patients with peripheral artery diseases presenting aorto-iliac artery disease

Background

The use of intravascular ultrasound (IVUS) promotes better clinical outcomes for intervention in complex lesions. However, the data demonstrating whether use of IVUS improves primary patency following stenting for aorto-iliac lesions in patients with peripheral artery disease (PAD) are limited.

Purpose

The purpose of the current study was to investigate the impact of IVUS use on primary patency 12 months after stent implantation for aorto-iliac lesions.

Methods

We analyzed a clinical database of the OMOTENASHI registry (Observational prospective Multicenter registry study on Outcomes of peripheral arTErial disease patieNts treated by AngioplaSty tHerapy in aortoIliac artery), registering symptomatic PAD patients (Rutherford category 2, 3, or 4) undergoing endovascular therapy for aorto-iliac lesions between January 2014 and April 2016 in Japan. The current study analyzed 803 patients who underwent self-expandable stent implantation at 61 centers with the institutional volume known. The primary endpoint was 12-month restenosis, defined as ≥50% stenosis on computed tomography or angiography, or a peak systolic velocity ratio ≥2.5 on duplex ultrasound. When treatment strategies, endovascular procedures and clinical outcomes were compared between the patients treated with IVUS use and those treated without IVUS use, the propensity score matching was performed to minimize the inter-group difference in baseline characteristics.

Results

A total of 545 patients (67.9%) underwent IVUS-supported stent implantation. Patients treated with IVUS use had a lower prevalence of regular dialysis, whereas they had a higher prevalence of TASC II class D and chronic total occlusion. In patients treated with IVUS use, carbon dioxide contrast agent were more often used, and 0.035-inch guidewire was less frequently selected. Implanted stents in these patients were longer and smaller in diameter. The propensity score matching extracted 138 pairs, with no remarkable intergroup difference in baseline characteristics. Procedure time ≤1 hour was less frequent in patients treated with IVUS use; their radiation time was longer. Endovascular strategies, as well as postoperative medication were not significantly different between patients with and without IVUS use. The 12-month restenosis risk was not significantly different between patients with and without IVUS use (10.2% [6.9 to 14.9%] versus 10.3% [5.4 to 18.6%], P=0.99).

Conclusion

IVUS use in aorto-iliac stenting for patients with PAD was not associated with primary patency at 12 months.

Acknowledgement/Funding

None

Enhancement of the spin polarization of an Fe3O4(100) surface by nitric oxide adsorption

The geometric, electronic and magnetic properties of a nitric oxide (NO) adsorbed Fe3O4(100) surface have been investigated using density functional theory (DFT) calculations. NO molecules preferentially bond with surface Fe(B) atoms via their N atoms. The generalized gradient approximation (GGA) is not recommended to be used in such a strongly correlated system since it provides not only an overestimation of the adsorption energy and an underestimation of the Fe(B)-N bond length, but also magnetic quenching of the adsorbate and the bonded Fe(B) atoms. In contrast, a tilted geometry and magnetization of the adsorbate and the bonded Fe(B) atom are obtained after including the strong on-site Coulomb interactions through a Hubbard term (GGA+U). The spin-down 2π* states of the NO molecule are filled and broadened due to the adsorbate-substrate interaction and the molecule-molecule interaction. The surface spin polarization close to the Fermi level is expected to be greatly enhanced by the NO adsorption which has significance for interface design in spintronic devices.

Interactions between Respiratory, Cardiac and Stepping Rhythms in Decerebrated Cats: Functional Hierarchical Structures of Biological Oscillators

Interactions are described of central origin between respiratory, cardiac and stepping rhythms during fictive locomotion in paralyzed, vagotomized, and decerebrated cats. Fictive locomotion was induced by tonic electrical stimulation of the mesencephalic locomotor region (MLR). The coherence between heart beat fluctuation, the efferent discharges of the phrenic, and the lateral gastrocnemius nerves was used to evaluate the strength of the coupling between those three rhythms. The heart beat rhythm was modulated by the centrally generated respiratory and stepping rhythms. The central respiratory rhythm was modulated by the centrally generated stepping rhythm. Based on the present findings, we have proposed a new model concerning the functional hierarchical structures of the three biological oscillators.

Reversible switching of the spin state in a manganese phthalocyanine molecule by atomic nitrogen

Reversible control of the spin state of an organic molecule is significant for the development of molecular spintronic devices. Here, density functional theory calculations have been performed to study the adsorption of atomic nitrogen on a single manganese phthalocyanine (MnPc) molecule, three-layered MnPc, and MnPc on an Fe(100) surface. For all three cases, the N atom strongly adsorbs on top of the Mn atom and induces a significant variation of the geometric, electronic and magnetic properties. After N adsorption, an energy gap appears and the electronic states become unpolarized. Different functionals including three hybrid functionals are used in these calculations, and all yield a switchable spin state.

Factors that predict in-hospital mortality in eosinophilic granulomatosis with polyangiitis

BACKGROUND

Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare systemic small-vessel vasculitis associated with asthma, eosinophilia, and necrotizing vasculitis. EGPA is potentially life-threatening and often involves peripheral neuropathies, peptic ulcers, cerebral vessel disease, and cardiovascular disease. However, there is limited understanding of the prognostics factors for patients with EGPA. We investigated the clinical features and factors affecting patients' in-hospital mortality, using a national inpatient database in Japan.

METHODS

We retrospectively collected data of EGPA patients who required hospitalization between July 2010 and March 2013, using the Diagnosis Procedure Combination database. We evaluated EGPA patients' characteristics and performed multivariate logistic regression analyses to assess the factors associated with in-hospital mortality.

RESULTS

A total of 2195 EGPA patients were identified. The mean age was 61.9 years, 42.1% (924/2195) were male, and 41.6% (914/2195) had emergent admission. In-hospital deaths occurred in 97/2195 patients (4.4%). Higher in-hospital mortality was associated with age older than 65 years, disturbance of consciousness on admission, unscheduled admission, respiratory disease, cardio-cerebrovascular disease, renal disease, sepsis, and malignant disease on admission. Lower mortality was associated with female gender and peripheral neuropathies.

CONCLUSIONS

Our study revealed the clinical features of EGPA patients who required hospitalization and the factors associated with their mortality. These results may be useful for physicians when assessing disease severity or treatments for hospitalized EGPA patients.

Half-metallicity induced by boron adsorption on an Fe3O4(100) surface

Spin polarization of the Fe₃O₄(100) surface is enhanced by B adsorption through the opening of the spin-up band gap.

Increasing testicular temperature by exposure to elevated ambient temperatures restores spermatogenesis in adult Utp14b (jsd) mutant (jsd) mice

Because mutations in the human UTP14C gene are associated with male infertility, we sought to develop a method for fertility restoration in azoospermic mice with a mutation in the orthologous Utp14b(jsd) (jsd) gene that have spermatogonial arrest. The method is based on our observation that elevation of testicular temperatures restores spermatogonial differentiation in jsd mutant mice. To non-surgically raise intrascrotal temperatures we placed these mice in incubators at different elevated ambient temperatures. Exposure of jsd/jsd mice to ambient temperatures of 34.5 °C or 35.5 °C for 24 days increased the proportion of tubules with spermatocytes from 0% in untreated controls to over 80%. As those higher temperatures interfere with spermatid differentiation, the mice were then transferred to incubators at 32-32.5 °C for the next 24 days. These environments allowed differentiation to progress, resulting in up to 42% of tubules having late spermatids and about half of the mutant mice having spermatozoa in testicular suspensions. When these spermatozoa were used in intracytoplasmic sperm injection, all gave rise to viable healthy offspring with normal weight gain and fertility. The successful restoration of fertility in Utp14b mutant mice suggests that transient testicular warming might also be useful for spermatogenesis recovery in infertile men with UTP14C gene mutations.