High-risk imaging characteristics in left ventricular apex for the life-threatening arrhythmic events in Japanese hypertrophic cardiomyopathy patients.

Left ventricular (LV) apical aneurysm is known to be associated with the life-threatening arrhythmic events in hypertrophic cardiomyopathy (HCM). However, the current 2014 ESC guideline has not included apical aneurysm as a major risk factor for sudden cardiac death and 2018 JCS guideline includes it only as a modulator, while it has been included as a new major risk marker in 2020 AHA/ACC guideline. Therefore, we sought to identify high-risk imaging characteristics in LV apex which is associated with a higher occurrence of ventricular tachycardia/fibrillation (VT/VF). In 99 consecutive Japanese HCM patients (median age, 65 years; 59 males) undergoing implantable cardioverter-defibrillator (ICD) implantation for primary prevention following cardiac magnetic resonance including late gadolinium enhancement (LGE), the occurrence of appropriate ICD interventions for VT/VF was evaluated for 6.2 (median) years after ICD implantation. Overall, appropriate ICD interventions occurred in 43% with annual rates of 7.0% for appropriate interventions. Kaplan-Meier analysis demonstrated that the presence of LV apical aneurysm was significantly associated with a higher occurrence of appropriate interventions (annual rates 18.9% vs. 6.4%, P = 0.013). Similarly, patients with high LV mid-to-apex pressure gradient (annual rates 14.9% vs. 6.2%, P = 0.022) and presence of apical LGE (annual rates 10.9% vs. 4.0%, P = 0.001) experienced appropriate interventions more frequently. An aneurysm, high-pressure gradient, and LGE in an apex are associated with VT/VF. These characteristics in apex should be kept in mind when implanting ICD in Japanese HCM patients as a primary prevention.

Deep learning-based age estimation from chest X-rays indicates cardiovascular prognosis.

BACKGROUND: In recent years, there has been considerable research on the use of artificial intelligence to estimate age and disease status from medical images. However, age estimation from chest X-ray (CXR) images has not been well studied and the clinical significance of estimated age has not been fully determined. METHODS: To address this, we trained a deep neural network (DNN) model using more than 100,000 CXRs to estimate the patients' age solely from CXRs. We applied our DNN to CXRs of 1562 consecutive hospitalized heart failure patients, and 3586 patients admitted to the intensive care unit with cardiovascular disease. RESULTS: The DNN's estimated age (X-ray age) showed a strong significant correlation with chronological age on the hold-out test data and independent test data. Elevated X-ray age is associated with worse clinical outcomes (heart failure readmission and all-cause death) for heart failure. Additionally, elevated X-ray age was associated with a worse prognosis in 3586 patients admitted to the intensive care unit with cardiovascular disease. CONCLUSIONS: Our results suggest that X-ray age can serve as a useful indicator of cardiovascular abnormalities, which will help clinicians to predict, prevent and manage cardiovascular diseases.

Chest X-ray is one of the most widely used medical imaging tests worldwide to diagnose and manage heart and lung diseases. In this study, we developed a computer-based tool to predict patients' age from chest X-rays. The tool precisely estimated patients' age from chest X-rays. Furthermore, in patients with heart failure and those admitted to the intensive care unit for cardiovascular disease, elevated X-ray age estimated by our tool was associated with poor clinical outcomes, including readmission for heart failure or death from any cause. With further testing, our tool may help clinicians to predict outcomes in patients with heart disease based on a simple chest X-ray.

Additive prognostic significance of ejection fraction for ESC risk model in hypertrophic cardiomyopathy patients.

The European Society of Cardiology (ESC) clinical risk model is reported in predicting sudden death of hypertrophic cardiomyopathy (HCM). We examined the validity of this model and investigated the significance of ejection fraction (EF) in predicting the prognosis using ESC risk model in HCM patients. 305 HCM patients (198 males) were followed (median follow-up 4.8 years) for life-threatening arrhythmic events (sudden death, aborted sudden death, sustained VT/VF, appropriate ICD intervention for VT/VF) and were divided using ESC risk model into low- (Group L), intermediate- (Group I) and high- (Group H) risk groups. There was a significant difference in the events rate among the 3 groups (L, 0.9%/year; I, 3.9%/year; H, 6.8%/year; log-rank p < 0.001) in all study patients. Reduced EF (<50%) was identified in 27 (8.9%) cases. There was a significant difference in the events rate among the 3 groups in patients with reduced EF (L, 2.4%/year; I, 4.9%/year; H, 16.1%/year; log-rank p = 0.025). There was a significant difference in the events rate among 2 groups in patients stratified as Group H (preserved EF, 3.1%/year vs. reduced EF, 16.1%/year; log-rank p = 0.041). ESC risk model precisely predicts life-threatening events in patients with HCM. Adding EF to ESC risk model are useful for further risk stratification of life-threatening arrhythmic events.

High Signal Intensity on T2-Weighted Cardiovascular Magnetic Resonance Imaging Predicts Life-Threatening Arrhythmic Events in Hypertrophic Cardiomyopathy Patients.

BACKGROUND: The prognostic value of high signal intensity on T2-weighted cardiovascular magnetic resonance imaging (T2 high signal) in hypertrophic cardiomyopathy (HCM) patients in a single-center cohort was investigated.Methods and Results:A total of 237 HCM patients (median age, 62 years; 143 male) underwent T2-weighted, cine and late gadolinium enhancement (LGE) imaging, and were followed (median duration, 3.4 years) for life-threatening arrhythmic events. The clinical and magnetic resonance imaging characteristics were extracted, and predictors of life-threatening arrhythmic events were assessed on multivariate analysis. LGE was present in 180 patients (75.9%). Median LGE score was 3 in a left ventricle 17-segment model. T2 high signal was present in 49 patients (20.7%). The annual events rate was significantly higher in patients with extensive LGE (score ≥4) than in those without (3.0%/year vs. 0.5%/year, P=0.011). On multivariate analysis, extensive LGE (hazard ratio, 5.650; 95% CI: 1.263-25.000, P=0.024) as an independent predictor for life-threatening arrhythmic events. In patients with extensive LGE, the annual events rate was significantly higher in patients with T2 high signal than in those without (5.8%/year vs. 0.9%/year, P=0.008). CONCLUSIONS: Extensive LGE was an independent predictor of life-threatening arrhythmic events in HCM patients. Furthermore, T2 high signal is useful for the risk stratification of serious arrhythmic events in patients with extensive LGE.

Prognostic value of cardiovascular magnetic resonance imaging for life-threatening arrhythmia detected by implantable cardioverter-defibrillator in Japanese patients with hypertrophic cardiomyopathy.

Implantable cardioverter-defibrillator (ICD) is effective to prevent sudden death in HCM patients. We reviewed ICD records to analyze the relation between life-threatening arrhythmia and late gadolinium enhancement (LGE) on cardiovascular magnetic resonance (CMR) in Japanese hypertrophic cardiomyopathy (HCM) patients. In 102 consecutive patients (median age 63 years, 63 males) implanted with an ICD after CMR with gadolinium enhancement (median follow-up 2.8 years), the outcome of life-threatening arrhythmic events (appropriate ICD interventions for ventricular tachycardia or ventricular fibrillation) was examined. Appropriate interventions rate were 10.3% per year for secondary prevention and 7.4% per year for primary prevention. The annualized ICD-related complication rate was 3.7%. 43/91 patients (47%) implanted ICD for primary prevention had maximum wall thickness ≥20 mm plus LGE in ≥4 of 17 left ventricular segments (cut-off value obtained from ROC curve); the appropriate ICD intervention rate was significantly higher in this group than in other patients group (annualized event rate, 11.1 vs. 4.6%; log-rank P = 0.038). A combination of myocardial hypertrophy and LGE is a useful outcome predictive factor for life-threatening ventricular arrhythmia in Japanese HCM patients.

Planimetry of the Orifice Area in Aortic Valve Stenosis Using Phase-Contrast Cardiac Magnetic Resonance Imaging.

Manual planimetry is a well-established method using transesophageal echocardiography (TEE) to assess the severity of aortic stenosis (AS). TEE, however, is a less than optimal approach in patients with calcified valves. Even when using cine-cardiac magnetic resonance (CMR), it is often difficult to evaluate the true border of the aortic orifice because of jet turbulence. With phase-contrast sequences of CMR, high flow signals at the aortic orifice can be clearly visualized, even in cases with severe calcification and jet turbulence. Therefore, the aims of the present study were to compare the utility of CMR using phase-contrast imaging with TEE and cine-CMR for the performance of planimetry of the aortic valve. The study cohort consisted of 30 consecutive patients with moderate or severe aortic valve stenosis documented by TEE who had undergone phase-contrast and cine-CMR for the evaluation of AS. Manual planimetry of the area of high flow signal was traced over the phase-contrast images at systolic peak, when the aortic valve is maximally opened. The results showed that the aortic valvular area (AVA) value derived from TEE correlated better with phase-contrast planimetry (r2 = 0.84, P < 0.05) than cine-mode planimetry (r2 = 0.57, P < 0.05). Bland-Altman plots indicated that the variation of measuring AVA was greater using the cine-mode method than the phase-contrast method. In conclusion, phase-contrast CMR offers a tool for evaluating the severity of aortic valve stenosis noninvasively. Phase-contrast CMR has the potential to become a routine clinical option as an alternative to TEE, at least in selected cases.

Amino acid residues critical for DNA binding and inducer recognition in CbnR, a LysR-type transcriptional regulator from Cupriavidus necator NH9.

CbnR, a LysR-type transcriptional regulator from Cupriavidus necator NH9, activates the transcription of chlorocatechol-degradative enzymes. To activate the transcription, CbnR needs to bind not only to the cbnA promoter but also to the inducer. In this study, the transcriptional activity and DNA-binding activity of twenty-five mutants of CbnR were analyzed. Of the 17 mutants of the DNA-binding domain, 11 mutants lost their ability to activate transcription. While most mutants without transcriptional activation did not show DNA-binding activity, Asn17Ala, Gln29Ala, and Pro30Ala retained DNA-binding activity, suggesting that transcriptional activation by CbnR requires more than its binding to promoter DNA. Of the 8 mutants of the regulatory domain, 6 mutants changed their responses to the inducer, when compared with wild-type CbnR. Interestingly, Arg199Ala and Val246Ala induced constitutive expression of the cbnA promoter without the inducer, suggesting that these mutations brought about a conformational change mimicking that induced by the inducer molecule.

Extent of Late Gadolinium Enhancement on Cardiac Magnetic Resonance Imaging in Japanese Hypertrophic Cardiomyopathy Patients.

BACKGROUND: In addition to the presence of late gadolinium enhancement (LGE) on cardiovascular magnetic resonance (CMR), the extent of LGE is considered clinically important in hypertrophic cardiomyopathy (HCM). We evaluated the extent of LGE on CMR in a large series of Japanese HCM patients. METHODS AND RESULTS: CMR was performed in 317 HCM patients (147 male). The extent of LGE was scored as the sum of LGE-positive segments in a left ventricle (LV) 17-segment model. LGE was present in 246 patients (77.6%). LGE was detected in 3.5±3.1 segments on average. When the patients were divided according to maximum wall thickness (mild, <20 mm; moderate, 20-29 mm; severe, ≥30 mm), median LGE score increased as wall thickness increased (mild, 2 vs. moderate, 4 vs. severe, 5; P=0.000). When the patients were divided according to ejection fraction (EF) (reduced, <50%; low-normal, 50-65%; normal, >65%), median LGE score increased as EF decreased (reduced, 7 vs. low-normal, 4 vs. normal, 2; P=0.000). On multivariate analysis, reduced EF (OR, 0.947, P=0.015), pressure gradient <30 mmHg (OR, 0.359, P=0.000) and increased maximum wall thickness (OR, 1.236, P=0.000) were independent factors associated with extensive LGE. CONCLUSIONS: Progression of LGE was related to increased wall thickness, decreased contractility, and reduced intraventricular pressure gradient.

Construction of nanoantennas on the bacterial outer membrane.

We demonstrate a simple manipulation of gold nanoparticles that creates a structure-dependent nanometer-scale antenna on the surface of bacteria. Our studies illuminate the concept of the "effective use of light" based on the absorption and emission of light by antennas formed on bacteria.

Prognostic value of late gadolinium enhancement on cardiac magnetic resonance imaging in Japanese hypertrophic cardiomyopathy patients.

BACKGROUND: The prognostic value of late gadolinium enhancement (LGE) on contrast-enhanced cardiovascular magnetic resonance (CMR) in Japanese hypertrophic cardiomyopathy (HCM) patients in a large, single-center cohort was investigated. METHODS AND RESULTS: A total of 345 HCM patients (mean age, 59±17 years; 214 male) underwent CMR with gadolinium enhancement, and were followed (mean duration, 21.8 months) for cardiovascular events. Patients were divided into event-positive and event-negative groups. The clinical and CMR characteristics were compared between the 2 groups, and predictors of cardiovascular events assessed on multivariate analysis. LGE was positive in 252 patients (73%). The annual cardiovascular events rate was significantly higher in patients with LGE than in those without (6.2%/year vs. 0.6%/year, P=0.003). On multivariate analysis, LGE (hazard ratio [HR], 7.436; 95% confidence interval [CI]: 1.001-55.228, P=0.050), increased myocardial mass index (HR, 1.013; 95% CI: 1.002-1.023, P=0.018), reduced left ventricular ejection fraction (HR, 0.965; 95% CI: 0.945-0.985, P=0.001), and atrial fibrillation (HR, 2.257; 95% CI: 1.024-4.976, P=0.043) were significantly associated with cardiovascular events. CONCLUSIONS: The presence of LGE, increased myocardial mass index, reduced left ventricular ejection fraction and atrial fibrillation were independent predictors of adverse prognosis in Japanese HCM patients.

High signal intensity on T2-weighted cardiac magnetic resonance imaging correlates with the ventricular tachyarrhythmia in hypertrophic cardiomyopathy.

Late gadolinium enhancement (LGE) with cardiac magnetic resonance (CMR) can predict ventricular arrhythmia and poor prognosis in hypertrophic cardiomyopathy (HCM) patients. Although myocardial T2-high signal has been reported to appear within LGE in those patients, its clinical significance remains unclear. We investigated the relationship between the T2-high signal and nonsustained ventricular tachycardia (NSVT) in HCM patients. Eighty-one HCM patients who underwent Holter ECG and CMR including T2-weighted and LGE imaging were retrospectively recruited. They were divided into NSVT-positive and NSVT-negative groups. We compared the clinical and CMR characteristics between both of the groups, and assessed predictors of NSVT with multivariate analysis. Myocardial T2-high signal was observed in 15/81 (18.5 %) patients. Each T2-high signal was localized within LGE. Significantly in the NSVT-positive group, the prevalence of atrial fibrillation [5/17 (29.4 %) vs. 2/64 (3.1 %), p = 0.0006] and T2-high signal [9/17 (52.9 %) vs. 6/64 (9.4 %), p < 0.0001] and the left ventricular (LV) end-systolic volume index (32.2 ± 15.9 ml/m(2) vs. 23.3 ± 14.9 ml/m(2), p = 0.034) and the number of segments with LGE (5.8 ± 3.3 vs. 2.7 ± 2.7, p < 0.0001) was increased, and the LV ejection fraction (54.8 ± 10.9 % vs. 65.1 ± 10.6 %, p = 0.0007) was decreased, compared to the NSVT-negative group. On multivariate analysis, the presence of atrial fibrillation (OR 29.49, p = 0.0025) and DM (OR 7.36, p = 0.0455) and T2-high signal (OR 14.96, p = 0.0014) and reduced LV ejection fraction (OR 0.93, p = 0.0222) were significantly associated with NSVT. The presence of myocardial T2-high signal is a significant independent predictor of NSVT in HCM patients.

Assessment of pharmacy students' communication competence using the Roter Interaction Analysis System during objective structured clinical examinations.

OBJECTIVE: To determine the value of using the Roter Interaction Analysis System during objective structured clinical examinations (OSCEs) to assess pharmacy students' communication competence. METHODS: As pharmacy students completed a clinical OSCE involving an interview with a simulated patient, 3 experts used a global rating scale to assess students' overall performance in the interview, and both the student's and patient's languages were coded using the Roter Interaction Analysis System (RIAS). The coders recorded the number of utterances (ie, units of spoken language) in each RIAS category. Correlations between the raters' scores and the number and types of utterances were examined. RESULTS: There was a significant correlation between students' global rating scores on the OSCE and the number of utterances in the RIAS socio-emotional category but not the RIAS business category. CONCLUSIONS: The RIAS proved to be a useful tool for assessing the socio-emotional aspect of students' interview skills.

Case of anaphylaxis due to tetracycline hydrochloride.

A 17-year-old Japanese woman showed anaphylaxis after taking tetracycline hydrochloride, pyridoxal phosphate, flavin adenine dinucleotide sodium and ascorbic acid. Prick tests were performed for these suspicious drugs and anaphylaxis due to tetracycline hydrochloride was diagnosed.

Reliability of evaluation for communication competency in pharmaceutical objective structured clinical examination (OSCE).

In the objective structured clinical examination (OSCE), which for pharmaceutical students training, adequate methods should be used for evaluating a student's skill and aptitude for good communication in a medical interview. However, the reliability of the evaluation methods used in the pharmaceutical OSCE has not been investigated sufficiently. In this study, we reviewed the evaluation scores and video recordings obtained in a pharmaceutical OSCE trial, and examined the reasons for disagreement in the scores between two raters. We had two experienced raters in medical communication re-evaluate the students using the vide images, and compared their scores with those on the examination day. The ratio of disagreement was 14.5% (87/600 items in 30 students), and the reason for disagreement could not be identified for 63 items that evaluated communication skills such as 'actively listen' and 'empathy'. A comparison of the scores on examination day and those on re-evaluation revealed a possible reason for the disagreement; the use of a checklist, i.e. binary scores, with criteria that differed between the raters. We suggest that the items used for a detailed performance evaluation be selected carefully and that rating scales be used in order to perform an adequate evaluation, especially regarding communication skill and aptitude.

Effects of BLS training on factors associated with attitude toward CPR in college students.

AIM: In order to elucidate the factors for willingness to perform CPR, we evaluated the responses of college students to questionnaires before and after basic life support (BLS) training. METHODS: Before and after participating in a small group BLS course, 259 students completed questionnaires. A logistic regression model was used to elucidate independent factors for their willingness to attempt resuscitation. RESULTS: Factors associated with willingness to perform BLS for strangers were "anxiety for a bad outcome" (odds ratio (OR) 0.08) and "having knowledge of automated external defibrillator (AED)" (OR 4.5) before training. The proportion of students showing willingness to perform BLS increased from 13% to 77% after the training even when the collapsed person is a stranger. After training, "anxiety for being sued because of a bad outcome" (OR 0.3), and "anxiety for infection" (OR 3.8) were significant factors. Those who preferred to perform BLS without ventilation increased from 40% to 79% (p<0.0001). CONCLUSION: The proportion of students showing willingness to perform BLS increased after the training. Significant association between "anxiety for infection" and willingness to perform BLS might indicate that those who wish to perform BLS developed their awareness of risk of infection more than the counterparts. For future guidelines for resuscitation and the instruction consensus, the reluctance of bystanders to perform CPR due to the hesitation about mouth-to-mouth ventilation should be reconsidered with other recent reports indicating the advantage of compression-only CPR.

Public perception of and willingness to perform bystander CPR in Japan.

AIM: Immediate bystander cardiopulmonary resuscitation (CPR) is the most essential factor for life saving in out-of-hospital cardiac arrest patients. We investigated the characteristics associated with willingness to attempt CPR among the Japanese general population. METHODS: We randomly selected 2400 persons from all over Japan and conducted a questionnaire survey regarding their knowledge, experiences of and attitudes toward CPR. We performed descriptive statistics followed by multivariable logistic regression analyses. RESULTS: A total of 1132 persons (47%) completed the questionnaire. Only 13% of the subjects were willing to attempt bystander CPR for their families and friends, and 7% were willing to attempt bystander CPR for strangers. Willingness to attempt CPR was independently associated with office workers or skilled workers [odds ratio (OR) 1.8; 95% confidence interval (CI): 1.1-2.7], having trained in CPR [OR: 3.1; 95% CI: 2.1-4.6], actual experience with CPR [OR: 3.8; 95% CI: 1.7-8.3], and having friends with heart diseases [OR: 1.8; 95% CI: 1.05-3.0]. Having trained in CPR was independently associated with younger age [OR: 1.6; 95% CI: 1.2-2.1], office workers or skilled workers [OR: 1.5; 95% CI: 1.1-2.0], having driver's license [OR: 1.7; 95% CI: 1.2-2.4] and awareness of AED placement in a public space [OR: 2.1; 95% CI: 1.4-3.1]. CONCLUSION: Experience of CPR training closely associated with willingness to attempt CPR, and awareness of AED in a public space are significant factors in CPR training. AED placement might call attention to CPR training and develops willingness to attempt CPR.

Divergence of contact hypersensitivity in vivo compared with hapten-specific lymphocyte proliferation and interferon-gamma production in vitro following ultraviolet B irradiation: the possibility that UVB does not affect the sensitizing phase of contact hypersensitivity.

A hapten-specific lymphocyte proliferation assay, which measures the in vitro stimulation of DNA synthesis (as assessed by [3H]thymidine incorporation), was used to determine systemic immunization induced by an epicutaneously applied hapten in addition to the more commonly used method which measures ear (or footpad) swelling. 2,4-Dinitrofluorobenzene (DNFB) was painted on the shaved backs of C57BL/6 mice for two consecutive days after ultraviolet B (UVB) irradiation (at 1000 J/m2), and DNFB-sensitized lymph node cells (LNC) were obtained from the regional lymph nodes 4 days later. Although the ear swelling response (ESR) was suppressed by UVB radiation, as previously reported, analysis of LNC culture supernatants showed that the production of interferon-gamma, a Tc1-type cytokine, was not inhibited by the UVB irradiation. In addition, contact dermatitis was induced (at levels similar to those of non-irradiated mice) by painting DNFB on the abdomen as a secondary response. We then examined the effect of UVB exposure alone on the ESR by injecting a mast cell degranulator, compound 48/80, 7 days after irradiation. Both the ESR and the percentage of degranulated mast cells were significantly reduced in UVB-irradiated mice. These results demonstrate that UVB irradiation does not affect the sensitizing phase of contact hypersensitivity, but modulates the elicitation phase and reduces the ESR primarily by suppressing the degranulation of mast cells. Therefore, suppression of the ESR alone cannot always be considered as hapten-specific immunotolerance.

[Bispectral index monitoring is useful to reduce total amount of propofol and to obtain immediate recovery after propofol anesthesia].

Bispectral index (BIS) is a processed EEG parameter for assessment of hypnotic effects of anesthetics. We studied whether BIS monitoring can improve recovery from propofol anesthesia and decrease the total amount of propofol needed. Forty-six patients without hypertension and obesity were studied. In the BIS group (n = 20), propofol infusion rate was adjusted to achieve a target BIS value between 40-60, increasing to 65 during the final 10 min of the surgical procedure. In the control group (n = 19), propofol infusion rate was adjusted based only on standard clinical signs. Compared with the control group, patients in the BIS group required lower propofol infusion rates(4.3 +/- 1.1 vs 4.9 +/- 0.8 mg.kg-1.h-1; P < 0.05), and the total amount of propofol decreased significantly (709 +/- 210 vs 914 +/- 326 mg; P < 0.05). BIS monitoring led to immediate recovery after propofol anesthesia. There were no significant differences in the incidence of intraoperative responses between the two groups. BIS monitoring decreased the total amount of propofol and led to immediate recovery after propofol anesthesia. These findings indicate that the use of BIS monitoring may be useful in controlling the infusion rate of propofol during surgery.