Prevalence of Non-alcoholic Fatty Liver Disease Detected by Computed Tomography in the General Population Compared with Ultrasonography.

Objective To assess the prevalence and clinical correlates of non-alcoholic fatty liver disease (NAFLD) identified by computed tomography (CT) in the general population compared with ultrasonography (US). Methods Four hundred and fifty-eight subjects who received health checkups at Meijo Hospital in 2021 and underwent CT within a year of US in the past decade were analyzed. The mean age was 52.3±10.1 years old, and 304 were men. Results NAFLD was diagnosed in 20.3% by CT and in 40.4% by the US. The NAFLD prevalence in men was considerably greater in subjects 40-59 years old than in those ≤39 years old and in those ≥60 years old by both CT and US. The NAFLD prevalence in women was substantially higher in the subjects 50-59 years old than in those ≤49 years old or those ≥60 years old on US, while no significant differences were observed on CT. The abdominal circumference, hemoglobin value, high-density lipoprotein cholesterol level, albumin level, and diabetes mellitus were independent predictors of NAFLD diagnosed by CT. The body mass index, abdominal circumference, and triglyceride level were independent predictors of NAFLD diagnosed by the US. Conclusion NAFLD was found in 20.3% of CT cases and 40.4% of US cases among recipients of health checkups. An "inverted U curve" in which the NAFLD prevalence rose with age and dropped in late adulthood was reported. NAFLD was associated with obesity, the lipid profile, diabetes mellitus, hemoglobin values, and albumin levels. Our research is the first in the world to compare the NAFLD prevalence in the general population simultaneously by CT and US.

Tracheoarterial fistula in a patient with amyotrophic lateral sclerosis successfully managed by overinflation of the tracheostomy tube cuff alone: a case report.

BACKGROUND: Tracheoarterial fistula is the most devastating complication after tracheostomy, and its mortality, without definitive treatment, approaches 100%. In general, the combination of bedside emergency management, that is, overinflation of the tracheostomy tube cuff, and definitive treatment such as surgical or endovascular intervention is necessary to prevent the poor outcome. Patients with neuromuscular diseases such as amyotrophic lateral sclerosis are susceptible to tracheoarterial fistula because of long-term mechanical ventilation and muscle weakness. CASE PRESENTATION: We describe a case of tracheoarterial fistula in a Japanese 39-year-old patient with amyotrophic lateral sclerosis with long-term ventilator management. The patient was clinically diagnosed with a tracheoarterial fistula because of massive bleeding following sentinel hemorrhage. The massive hemorrhage was controlled by overinflation of the tracheostomy tube cuff alone, without definitive treatment. CONCLUSIONS: This case suggests overinflation of the tracheostomy tube cuff alone plays an important role, semi-permanently, in the management of tracheoarterial fistula, especially in cases where surgical or endovascular intervention is not indicated. Clinicians taking care of patients with tracheostomy undergoing long-term mechanical ventilation should be aware that tracheoarterial fistula might occur following tracheostomy.

Prevalence of nonalcoholic fatty liver disease and its association with age in patients with type 2 diabetes mellitus.

BACKGROUND: Type 2 diabetes mellitus (T2DM) is a risk factor for nonalcoholic fatty liver disease (NAFLD). AIM: To determine the prevalence and clinical correlates of NAFLD in a large cohort of patients with T2DM. METHODS: Four hundred thirty-seven participants with T2DM who consulted at Meijo Hospital from April 2019 to September 2020 and underwent computed tomography (CT) were assessed. The mean age was 74 ± 13 years, and 269 were men. Hepatic attenuation minus splenic attenuation (CTL-S) less than 1 Hounsfield unit was considered fatty liver. NAFLD was defined as fatty liver in the absence of significant alcohol consumption and hepatitis virus infection. A multiple logistic regression was used to assess the independent factors associated with NAFLD. RESULTS: NAFLD was identified in 25.2% of the participants. Young age (odds ratio [OR] = -0.945; 95% confidence interval [CI]: 0.922-0.969), higher hemoglobin levels (OR = 1.501, 95%CI: 1.278-1.764), lower high-density lipoprotein (HDL) cholesterol levels (OR = 0.971, 95%CI: 0.953-0.989), and the absence of dialysis (OR = 0.109, 95%CI: 0.014-0.856) were independent predictors of NAFLD. CONCLUSION: NAFLD was detected with CT in 25.2% of the participants. NAFLD was associated with younger age, higher hemoglobin levels, lower HDL cholesterol levels, and an absence of dialysis.

The case of a liver-transplant recipient with severe acute respiratory syndrome coronavirus 2 infection who had a favorable outcome.

The outbreak of coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was identified in 2019; thereafter, the COVID-19 outbreak became a health emergency of international concern. The impact of COVID-19 on liver-transplant recipients is unclear. Thus, it is currently unknown whether liver-transplant recipients are at a higher risk of developing complications related to COVID-19. Here, we report the case of liver-transplant recipients who were infected with SARS-CoV-2. A 20-year-old man who had undergone living-donor liver transplantation from his father at 5 years of age because of congenital biliary atresia was referred to our hospital for SARS-CoV-2 infection. Chest computed tomography did not show any abnormalities; however, laboratory results revealed liver dysfunction. He received tacrolimus as maintenance therapy that was continued at the same dose. He has not developed severe pulmonary disease and was discharged after 10 days of hospitalization. Limited data are available on post-transplant patients with COVID-19, and this case of a young patient without metabolic comorbidities did not show any association of severe COVID-19 under tacrolimus treatment. The progression of COVID-19 in liver-transplant recipients is complex, and COVID-19 risk should be evaluated in each patient until the establishment of optimal guidelines.

Association between intensive care unit delirium and delusional memory after critical care in mechanically ventilated patients.

AIM: To determine the relationship between the delirium of patients with mechanical ventilation during intensive care unit (ICU) stay and delusional memory after ICU discharge. DESIGN: Prospective cohort study. METHODS: Delirium in adult patients who received mechanical ventilation for more than 24 hr was assessed twice daily using the Confusion Assessment Method for the ICU. Delusional memories were evaluated using the ICU Memory Tool 5-10 days after ICU discharge. The associations between the presence of delirium during the ICU stay and delusional memories were evaluated. RESULTS: Of 60 enrolled patients, 62% had delirium during their ICU stay, and 68% experienced delusional memories 5-10 days after discharge. Delirium during ICU stay was an independent factor to experience delusional memories following discharge. Preventing delirium during ICU stay might reduce delusional memory. We recommend that patients with delirium during their ICU stay should be carefully followed up after discharge from the ICU.

Effects of Manual Rib Cage Compressions on Mucus Clearance in Mechanically Ventilated Pigs.

BACKGROUND: Manual rib cage compression is a chest physiotherapy technique routinely used in clinical practice. However, scientific evidence remains scarce on the effects of manual rib cage compression on airway clearance and oxygenation in mechanically ventilated patients. METHODS: Anesthetized pigs were intubated via the trachea and mechanically ventilated. To create atelectasis, artificial mucus was infused into the airway. Each pig was randomly assigned to 1 of 2 groups: closed suctioning alone (control group, 7 pigs), or manual rib cage compression combined with closed suctioning (manual rib cage compression group, 8 pigs). Hard and brief rib cage compression synchronized with early expiratory phase was tested. Mucus clearance and oxygenation were assessed after the intervention. Sequential changes of hemodynamics were assessed after the intervention. RESULTS: During hard manual rib cage compression, the mean ± SD peak expiratory flow increased to 44 ± 7 L/min compared with 31 ± 7 L/min without treatment (P < .001). Manual rib cage compression combined with endotracheal suctioning increased mucus clearance compared with closed suctioning alone (mucus amounts, 5.5 [3.4-9.4] g vs 0.7 [0.5-2.0] g; P = .004); however, it did not improve gas exchange and radiologic findings. There were no significant differences in hemodynamic variables between the 2 groups. CONCLUSIONS: Our findings indicated that hard and brief manual rib cage compression combined with closed suctioning was safe and led to improvement of mucus clearance; however, no effectiveness was confirmed with regard to oxygenation and ventilation.

Influence of prolonged translaryngeal intubation on airway complications: a retrospective comparative analysis.

PURPOSE: Tracheostomy is usually suggested to facilitate airway management of intensive care unit (ICU) patients requiring prolonged translaryngeal intubation (PTLI). While it is not uncommon for physicians to hesitate and delay to perform it for more than 2 weeks, clinically recognizable airway adverse effects following PTLI are rarely discussed. Therefore, we compared retrospectively the PTLI group with control to assess them in adult patients. METHODS: During a period of 1991-2012, patients aged older than 15 years that were admitted to University of Tsukuba Hospital ICU, underwent translaryngeal intubation (TLI) for 14 days or longer, were retrospectively studied as Group P. Patients whose tracheas were intubated for 13 days or less were set up as a control group (Group C). Patients were excluded if they had undergone any procedures that might have affected recurrent laryngeal nerves. RESULTS: Ninety-eight patients (M:F = 58:40) (group P) and 88 patients (M:F = 58:30) (group C) were included. There were no differences in patients' characteristics. Durations of TLI were 20.8 ± 6.8 days in group P and 3.8 ± 3.0 days in group C. There were no differences in the occurrence rates of severe airway adverse events. Although we found higher incidence rates of dysphagia and dysphonia/hoarseness in group P, the symptoms were mild and they were not prolonged. There were no differences in other signs and symptoms. CONCLUSIONS: We found no difference in the occurrence rates of severe airway adverse events in both groups. Translaryngeal intubation may be tolerable in adults even if the duration exceeds 2 weeks.

Improving the neurological prognosis following OHCA using real-time evaluation of cerebral tissue oxygenation.

BACKGROUND: The neurological prognosis is poor for patients suffering from out-of-hospital cardiac arrest (OHCA), in the absence of bystander cardio pulmonary resuscitation (CPR), and showing asystole as the initial waveform. However, such patients have the potential of resuming social activity if cerebral tissue oxygen saturation can be preserved. CASE PRESENTATION: We recently encountered a 60-year-old man who had suffered an OHCA in the absence of bystander CPR, and who successfully resumed complete social activity despite initial asystole and requiring at least 75min of chest compressions before return of spontaneous circulation (ROSC). In this case, chest compression was appropriately performed concurrently with real-time evaluation of cerebral tissue oxygenation using near-infrared spectroscopy (NIRS). As a result, the cerebral tissue oxygenation was well maintained, leading to resumption of social activity. CONCLUSIONS: Improved neurological prognoses can be expected if OHCA patients with the potential for social activity resumption are identified, using NIRS, and effective cardiopulmonary and cerebral resuscitation is performed while visually checking CPR quality.

Descriptive epidemiology of traumatic spinal injury in Japan.

BACKGROUND: Spine injury epidemiology in Japan has not been studied since the 1990s when its incidence was 39.4-40.2 per million and the major cause of injury was motor vehicle crashes. We elucidate the current epidemiological state of spinal injury and spinal injury patients in Japan for the clinicians and public health prevention programs. METHODS: Spine injury patients were retrospectively selected from the Japan Trauma Data Bank (JTDB) from 2004 to 2013 for all ages and all spinal injuries. The Abbreviated Injury Scale codes (AIS98) were translated into injuries. The dataset was contributed by 241 hospitals nationwide. The data was analysed for the causes of spinal injury, injury severity, age, gender differences, injury types, survival, anatomic location, circumstances of injury and medical history. RESULTS: A total of 25,792 (M, 70.1%, F, 29.9%, mean age: 53.4 years) spinal injury patients were recorded in the JTDB from 2004 to 2013, when multiple injuries were included the number of cases swelled to 33,892 (M, 70.4%, F, 29.6%). The number of patients with spinal injuries as a percentage of all traumatic patients in the JTDB was observed to increase from 2004 (15.4%) to 2013 (17.6%). The aetiology of the injuries was mostly falls (52.4%) and motor vehicle crashes (39.8%). Most injuries occurred at the cervical spine level (49.7%). Medical histories of cardiovascular diseases were found, due mostly to hypertension (19.6%). In total, most of the injuries were associated with fractures (64.8%) and others (30.7%) involved the spinal cord. Suicides (12.0%) and industrial accidents (9.0%) caused spine injury were uniquely prevalent in the population. CONCLUSION: The number of spine injuries has increased in the JTDB between 2004 and 2013. Motor vehicle crashes have been replaced by falls due to various causes as the leading cause of spine injury. Suicides and industrial accidents are becoming a burden. More studies are needed to verify the actual incidence.

Cerebral Tissue Oxygenation Index Using Near-infrared Spectroscopy during Extracorporeal Cardio-pulmonary Resuscitation Predicted Good Neurological Recovery in a Patient with Acute Severe Anemia.

We herein report the clinical course of a patient who had a good neurological outcome despite severe anemia, high serum lactate levels, and a long period of time from cardiac arrest (CA) to extracorporeal cardio-pulmonary resuscitation (ECPR) establishment. During the period of resuscitation, the tissue oxygenation index (TOI) values were measured continuously by a near-infrared spectroscopy monitoring device and were kept within the normal range. The TOI seems to reflect cerebral perfusion and the balance between the oxygen supply and demand in the brain during ECPR, thereby predicting the neurological outcome. Continuous TOI monitoring is useful for predicting the neurological outcome during ECPR.

Renal contrast microangiography with synchrotron radiation: a novel method for visualizing structures within nephrons in vivo.

Background No non-invasive method of observing renal microcirculation in vivo has been established as yet. Although angiography is considered to be ideally suited for the purpose, conventional X-rays cannot be used to image structures smaller than 100 µm. Purpose To develop a method for visualizing the renal arterioles, glomeruli, and proximal tubules of rats in vivo making use of synchrotron radiation. Material and Methods Male Wistar rats were anesthetized, and a catheter was inserted via laparotomy into the abdominal aorta with its tip placed above the renal arteries. The rats were paralyzed with a neuromuscular blocking agent and mechanically ventilated. An inorganic iodine contrast medium was injected via the catheter. The SR derived X-rays transmitted through the subjects were recorded with a CCD camera. Two-dimensional images with a pixel size of 9 µm were obtained. The exposure time was fixed at 50 ms, with a maximum acquisition rate of three images/s. Results Renal arterioles as small as 18 µm in diameter, glomeruli with an average diameter of 173 ± 21 µm, as well as proximal tubules, were clearly visualized. In addition, glomerular density at the peripheral renal cortex was measurable. Conclusion Rat renal microcirculation could be successfully observed in real-time, without exteriorization of the kidney in this study.

Landiolol hydrochloride ameliorates acute lung injury in a rat model of early sepsis through the suppression of elevated levels of pulmonary endothelin-1.

Among the dysfunctions and pathologies associated with sepsis, the underlying molecular mechanisms of sepsis-induced acute lung injury (ALI) are poorly understood. Endothelin (ET)-1, a potent vasoconstrictor and pro-inflammatory peptide, is known to be involved in the pathogenesis of ALI in a rat model of sepsis. Here, we investigated whether landiolol hydrochloride, an ultra-short-acting ß-blocker, plays a crucial role in ameliorating and attenuating LPS-induced ALI through modulation of the ET-1 system. Male Wistar rats at 8weeks of age were administered with either saline or lipopolysaccharide (LPS) for three hours (3h) and some of the LPS-administered rats were continuously treated with landiolol for 3h. ALI was induced by LPS, including levels of both circulatory and pulmonary TNF-α and IL-6 but [PaO2] was significantly decreased. LPS also induced a significant increase in levels of pulmonary ET-1 and ET-A receptor, but levels of ET-B receptor, which has vasodilating effects, were remarkably diminished. Further, LPS administration upregulated the pulmonary expression of HIF-1α. Finally, the treatment of LPS-administered rats with landiolol for 3h ameliorated and prevented ALI, normalized the altered levels of pulmonary ET-1 and ET-A receptors. Landiolol also induced significant down-regulation of ET-B receptor in lung tissues in the early hours (phase) of sepsis. However, Landiolol treatment had no effect on the up-regulated inflammatory mediators (TNF-α, IL-6) in both plasma and lung tissues during sepsis, and expression of pulmonary HIF-1α also remained unchanged after landiolol treatment. Collectively, these data led us to conclude that landiolol may ameliorate sepsis-induced ALI via the pulmonary ET system.

Efficacy of concomitant use of dexmedetomidine and propofol in tetanus.

Tetanus is an infectious disease caused by Clostridium tetani, which manifests systemic convulsion and autonomic instability associated with high case fatality. Despite proper medical intervention, management of those symptoms is often difficult. We report a case of 67-year-old man with tetanus in which a concomitant use of dexmedetomidine, an adrenaline α-2 receptor agonist, and propofol, a GABA(A) receptor binding agent, was successful in the management of systemic convulsion and autonomic instability without necessitating conventional anticonvulsant, neuromuscular blocking agents, or tracheostomy.

Severity of delirium in the ICU is associated with short term cognitive impairment. A prospective cohort study.

OBJECTIVES: To examine the hypothesis that severity of delirium in the intensive care unit (ICU) is positively associated with cognitive impairment at the time of hospital discharge. DESIGN: A prospective cohort study. SETTING: Adult medical and surgical ICU of a tertiary-care teaching hospital in Japan in ICU patients who were enrolled and admitted for more than 48hours. METHODS: Severity of delirium was represented as a score of the Intensive Care Delirium Screening Checklist (ICDSC) during the patients' stay in the ICU under the assumption that higher ICDSC score indicated severe delirium. After discharge from the ICU, the patients were followed up for cognitive impairment using the Mini-Mental State Examination (MMSE). RESULTS: Of the 79 patients enrolled, 50 (63.3%) developed delirium during their stay in the ICU. Patients who developed delirium had higher rates of cognitive impairment (28.0% vs. 3.4%, p=0.03). After adjusting for covariates, the averaged ICDSC score during the ICU stay indicated a positive association between severity of delirium and cognitive impairment at the time of hospital discharge (adjusted odds ratio (OR) 1.6; 95% confidential interval (CI), 1.02-2.54; p=0.041). CONCLUSIONS: Our findings indicate that severity of delirium during ICU stay may be associated with cognitive impairment at the time of discharge from the hospital in ICU survivors.

Hyperinflation deteriorates arterial oxygenation and lung injury in a rabbit model of ARDS with repeated open endotracheal suctioning.

BACKGROUND: Hyperinflation (HI) is performed following open endotracheal suctioning (OES), whose goals include: to stimulate a cough, recover oxygenation and improve compliance. However, it may also induce unintended consequences, including: lung stress and strain, failure to maintain high distending pressure, and subsequently cycling recruitment and derecruitment. Here, our aim was to investigate the effects of hyperinflation after repeated OES on sequential alteration of arterial oxygenation and lung injury profile using a saline lavage-induced surfactant depleted ARDS rabbit model. METHODS: Briefly, 30 Japanese White Rabbits were anesthetized and ventilated in pressure-controlled setting with a tidal volume of 6-8 ml/kg. Animals were divided into four groups, i.e.; Control, ARDS, OES, and HI. Saline-lavage-induced lung injury was induced except for Control group. Thereafter, rabbits were ventilated with positive-end expiratory pressure (PEEP) at 10 cm H2O. The ARDS group received ventilation with the same PEEP without derecruitment. As intervention, OES and HI were performed in ARDS animals. OES was performed for 15 seconds at 150 mm Hg, whereas HI was performed with PEEP at 0 cm H2O and peak inspiratory pressure at +5 cm H2O for a minute. Total duration of the experiment was for 3 hours. OES and HI were performed every 15 minutes from beginning of the protocol. RESULTS: PaO2 was maintained at about 400 mm Hg in both control and ARDS groups for the duration of this study, while in both OES and HI groups, PaO2 decreased continuously up to 3 hours, dropped to a mean (±SD) of 226 ± 28.9 and 97.0 ± 30.7 mmHg at 3 h, respectively. HI group had the lowest PaO2 in the present investigation. Histological lung injury score was the highest in HI group than other three groups. Pulmonary TNF-α and IL-8 levels were the highest in HI group compared to other groups, but without significant alterations at circulatory level in all the experimental groups. CONCLUSIONS: We show in the present study that hyperinflation following repeated OES deteriorate arterial oxygenation and the severity of lung injury in a rabbit model of ARDS undergoing mechanical ventilation.

Higher circulatory level of endothelin-1 in hypertensive subjects screened through a cross-sectional study of rural Bangladeshi women.

Endothelin-1 (ET-1) is a potential marker of the endothelial dysfunction, which has been shown to be elevated in hypertensive subjects. No previous study has investigated the circulatory level of ET-1 and hypertension in a South Asian country. The present study assessed the circulating levels of ET-1 in subjects with or without hypertension and further examined the association of ET-1 with clinical and metabolic parameters. A total of 2543 rural Bangladeshi women with a mean age of 44.5 years were studied using a cross-sectional survey. Multiple regressions were used to examine the association between the circulatory ET-1 levels and hypertension. The prevalence of hypertension was 29.3%. The ET-1 levels were significantly higher in the hypertensive (mean 3.08 pg ml(-1), s.e. (0.19)) than in the non-hypertensive subjects (mean 2.01 pg ml(-1), s.e. (0.03)) (P = 0.001). After adjusting for age, the ET-1 level had significant positive associations with the diastolic blood pressure (P = 0.002), systolic blood pressure (P = 0.001), mean arterial pressure (P = 0.002) and fasting blood glucose (P = 0.002). In a tertile analysis, we found that hypertension in the subjects was significantly increased as the levels of ET-1 increased (P for the trend = 0.001). In a stepwise multiple regression analysis, after adjusting for age and all other potential variables, we found that the mean arterial pressure and the fasting plasma levels have significant associations with the ET-1 level. The present study demonstrates that there is a higher concentration of ET-1 among the hypertensive subjects in an apparently healthy population of Bangladeshi rural women. The relationship between ET-1 and hypertension requires further investigation to define the clinical utility and predictive value of serum ET-1 levels for hypertension for a South Asian population.