Assessment and Identification of Improvement Areas for Facial Symmetry in Hemifacial Microsomia (Type IIB) Using Three-dimensional Measurements.

Background: Surgical planning for hemifacial microsomia (HFM) patients often involves planning the amount of maxillary movement and mandibular bone distraction from three-dimensional (3D) volumetric images constructed from computed tomography scans. By representing anatomical indicators for facial symmetry in X, Y, and Z coordinates, we identified the more challenging areas in correcting facial asymmetry. Methods: The study included five HFM patients with a mean age of 22.2 years, all diagnosed with HFM (type IIB). We established measurement points with high reproducible 3D coordinates on the 3D volumetric images obtained from computed tomography scans for before surgery, treatment objectives, and after surgery. We assessed the symmetry of measurement points between the affected side and nonaffected side at each time point. Results: In the before-surgery group, significant differences were observed between the affected side and nonaffected side in X,Y (excluding Palatine foramen, upper molar, canine) and Z coordinates for measurement items. In the treatment objectives group, no differences were observed between the affected side and nonaffected side in X, Y, and Z coordinates, resulting in facial symmetry. In the after-surgery group, significant differences were observed in Y coordinates in the mental foramen area, and significant differences were observed in z axis measurement items in the canine and mental foramen areas. Conclusions: It is evident that relying solely on a front view assessment is insufficient to achieve facial symmetry. Particularly, both anterior-posterior and vertical improvements in the area near the mental foramen on the affected side are necessary.

Real-time monitoring of vitamin C levels in trauma patients by electron-spin resonance spectrometry.

BACKGROUND: In critically ill patients, healthy vitamin C levels are important to avoid an imbalance in reactive oxygen species. To achieve this, oxidative stress levels in emergency patients need to be accurately measured in real-time. However, normally, reactive oxygen/nitrogen species are short-lived, rendering measurement difficult; moreover, measurement of relatively stable antioxidants and other oxidative stress markers in real-time is challenging. Therefore, we used electron-spin resonance spectrometry (ESR) to assess vitamin C levels, clarify their relationship with patients' severity, and establish more effective vitamin C therapy in critically ill patients. METHODS: We studied 103 severely ill emergency patients and 15 healthy volunteers. Vitamin C radical (VCR/dimethyl sulfoxide [DMSO]) values were analyzed in arterial blood samples by ESR at admission and once daily thereafter during the acute recovery phase. Severity scores were calculated. The relationship between these scores and VCR/DMSO values and chronological changes in VCR/DMSO values were analyzed. RESULTS: Serum VCR/DMSO values were significantly lower in critically ill patients than in healthy volunteers (0.264 ± 0.014 vs. 0.935 ± 0.052, p < 0.05), particularly in the severe trauma group and the cardiopulmonary arrest/post-cardiac arrest syndrome group. VCR/DMSO values and various severity scores did not correlate at admission; however, they correlated with SOFA scores from days 2-6. VCR/DMSO values remained low from the first measurement day through Day 6 of illness. CONCLUSIONS: Vitamin C levels were low at admission, remained low with conventional nutritional support, and did not correlate with the initial patient's severity; however, they correlated with patients' severity after admission. Some patients had normal vitamin C levels. Therefore, vitamin C levels should be measured in real-time and supplemented if they are below normal levels. TRIAL REGISTRATION: Retrospectively registered.

Influence of Lip Revision Surgery on Facial Growth in Patients With A Cleft Lip.

Although patients with cleft lip and palate often present with poor maxillary growth because of intrinsic and iatrogenic factors, the surgical influence of lip revision surgery, palatal fistula repair, and pharyngeal flap procedures remains uncertain in contrast to that of primary cleft lip repair and palatoplasty. Therefore, this study aimed to reveal factors inhibiting maxillary growth and inducing later orthognathic surgery. A retrospective analysis was conducted on the data of patients with cleft lip and palate who underwent a series of treatments at Keio University Hospital from 1990 to 2000. We collected data on patient sex, cleft type, number and timing of lip revision surgery, the incidence of palatal fistulae, history of pharyngeal flap procedures, and timing of a repeat bone graft, and reviewed whether these patients underwent orthognathic surgery later in life. Multivariate analysis was conducted using binary logistic regression to extract factors affecting later orthognathic surgery. A total of 52 patients were included in this study. Results showed that revision surgery conducted more than twice was the highest statistically significant predictor of later orthognathic surgery in patients with a cleft lip and palate ( P <0.05, odds ratio=43.3), followed by palatal fistula occurrence after cleft palate repair ( P <0.05, odds ratio=22.3). Therefore, primary surgical procedure is most important for these patients.

External Root Resorption of Second Molars Due to Impacted Mandibular Third Molars during Orthodontic Retention.

Whether there is a relationship between impaction of the third molars and the onset of crowding remains to be determined, and extraction of third molars after orthodontic treatment is left to the judgement of the practitioner. This report describes a case where a third molar caused external root resorption (ERR) of the mandibular second molar after orthodontic treatment. As ERR of the mandibular second molar was detected after non-extraction orthodontic treatment, the affected tooth was extracted and substituted with the third molar. External root resorption of the second molar occurred despite being determined as low risk given the state of the impacted third molar as observed on a panoramic radiograph obtained at the end of active treatment. The present results indicate that in cases where the mandibular third molar is present, the corpus length is short, and non-extraction treatment has been performed, it is necessary to obtain X-ray images on a regular basis or preventively extract the third molar to avoid ERR of the second molars.

Prehospital 12-Lead Electrocardiography System in Oita Assisted Transport of "True" Acute Coronary Syndrome Patients to Optimal Institutes.

BACKGROUND: Mobile cloud electrocardiography (C-ECG) can reduce the door-to-balloon time of acute coronary syndrome (ACS) patients, so we hypothesized it would also assist in transporting ACS-suspected patients to the optimal institutes.Methods and Results: Initially, 10 fire departments in Oita had 10 ambulances equipped with C-ECG. Ambulance crews recorded a 12-lead ECG from the patient at the first point of contact and transmitted them to 18 hospitals (13 institutions (PCII) with 24-h availability for percutaneous coronary intervention (PCI) and 5 regional core hospitals (RCH) without 24-h PCI) for analysis by a cardiologist. During 41 months, 476 ECGs suspected to be ACS were transmitted and analyzed. Of these, 24 ECGs transmitted to PCII were judged as not requiring PCI, and the patients were directly transported to a RCH (PCII-RCH); 35 ECGs sent to a RCH were judged as requiring PCI, and the patients were directly transported to a PCII (RCH-PCII). The prevalence of cardiovascular disease was significantly higher in the RCH-PCII group than in the PCII-RCH group (P<0.01). There was no significant difference in the door-to-balloon time between the RCH-PCII and the group in which the C-ECG was sent to a PCII and the patients were transported directly to PCII (PCII-PCII) (49±14 vs. 59±20 min, P=0.14). CONCLUSIONS: Prehospital 12-lead ECG can assist in transporting ACS-suspect patients to the optimal treatment facility.

Quercetin Reduces the Development of 2,3,7,8-Tetrachlorodibenzo-p-dioxin-Induced Cleft Palate in Mice by Suppressing CYP1A1 via the Aryl Hydrocarbon Receptor.

Quercetin is a flavonoid with a wide range of pharmacological activities, including anticancer, antioxidant, and anti-inflammatory effects. Since it is a nutrient that can be consumed with a regular diet, quercetin has recently garnered interest. Quercetin acts as a phytochemical ligand for the aryl hydrocarbon receptor (AhR). Cleft lip and palate are among the most frequently diagnosed congenital diseases, and exposure to 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) during pregnancy induces cleft palate via AhR. In this study, we investigated the preventive effect of quercetin intake on the TCDD-induced cleft palate and its mechanism of action. The in vivo results suggest that quercetin intake by pregnant mice can prevent cleft palate in fetal mice. In vitro, the addition of TCDD induced a reduction in cell migration and the proliferation of mouse embryonic palatal mesenchymal cells, which was mitigated by the addition of quercetin. The addition of quercetin did not alter the mRNA expression levels of the AhR repressor but significantly suppressed mRNA expression of CYP1A1. In addition, the binding of AhR to a xenobiotic responsive element was inhibited by quercetin, based on a chemically activated luciferase expression assay. In conclusion, our results suggest that quercetin reduces the development of TCDD-induced cleft palate by inhibiting CYP1A1 through AhR.

Septic shock due to Yersinia pseudotuberculosis infection in an adult immunocompetent patient: a case report and literature review.

BACKGROUND: Yersinia pseudotuberculosis infection can occur in an immunocompromised host. Although rare, bacteremia due to Y. pseudotuberculosis may also occur in immunocompetent hosts. The prognosis and therapeutic strategy, especially for immunocompetent patients with Y. pseudotuberculosis bacteremia, however, remains unknown. CASE PRESENTATION: A 38-year-old Japanese man with a mood disorder presented to our hospital with fever and diarrhea. Chest computed tomography revealed consolidation in the right upper lobe with air bronchograms. He was diagnosed with pneumonia, and treatment with intravenous ceftriaxone and azithromycin was initiated. The ceftriaxone was replaced with doripenem and the azithromycin was discontinued following the detection of Gram-negative rod bacteria in 2 sets of blood culture tests. The isolated Gram-negative rod bacteria were confirmed to be Y. pseudotuberculosis. Thereafter, he developed septic shock. Doripenem was switched to cefmetazole, which was continued for 14 days. He recovered without relapse. CONCLUSIONS: We herein report a case of septic shock due to Y. pseudotuberculosis infection in an adult immunocompetent patient. The appropriate microorganism tests and antibiotic therapy are necessary to treat patients with Y. pseudotuberculosis bacteremia.

A Thrombomodulin Promoter Gene Polymorphism, rs2239562, Influences Both Susceptibility to and Outcome of Sepsis.

Objective: Disseminated intravascular coagulation plays a key role in the pathophysiology of sepsis. Thrombomodulin is essential in the protein C system of coagulation cascade, and functional polymorphisms influence the human thrombomodulin gene (THBD). Therefore, we conducted a multicenter study to evaluate the influence of such polymorphisms on the pathophysiology of sepsis. Methods: A collaborative case-control study in the intensive care unit (ICU) of each of five tertiary emergency centers. The study included 259 patients (of whom 125 displayed severe sepsis), who were admitted to the ICU of Chiba University Hospital, Chiba, Japan between October 2001 and September 2008 (discovery cohort) and 793 patients (of whom 271 patients displayed severe sepsis), who were admitted to the five ICUs between October 2008 and September 2012 (multicenter validation cohort). To assess the susceptibility to severe sepsis, we further selected 222 critically ill patients from the validation cohort matched for age, gender, morbidity, and severity with the patients with severe sepsis, but without any evidence of sepsis. Results: We examined whether the eight THBD single nucleotide polymorphisms (SNPs) were associated with susceptibility to and/or mortality of sepsis. Higher mortality on severe sepsis in the discovery and combined cohorts was significantly associated with the CC genotype in a THBD promoter SNP (-1920*C/G; rs2239562) [odds ratio [OR] 2.709 (1.067-6.877), P = 0.033 and OR 1.768 (1.060-2.949), P = 0.028]. Furthermore, rs2239562 SNP was associated with susceptibility to severe sepsis [OR 1.593 (1.086-2.338), P = 0.017]. Conclusions: The data demonstrate that rs2239562, the THBD promoter SNP influences both the outcome and susceptibility to severe sepsis.

Three-Dimensional Measurements of Pharyngeal Airway in Patients with Unilateral Cleft Lip and Palate.

The aim of this study was to investigate 3-dimensional (3D) airway volume in patients with unilateral cleft lip and palate (UCLP) using computed tomography (CT). The study population comprised 15 UCLP patients (UCLP group) scheduled to receive alveolar bone grafts and 15 with impacted teeth (control group). The clinical requirements for a CT scan were met in both groups. Measurements were recorded from 3D reconstructions of Digital Imaging and Communications in Medicine data obtained from the CT images. Airway volume, cross-sectional area, and linear and angular measurements were recorded. Airway volume and cross-sectional area showed no significant difference between the two groups. The narrowest section of the airway in the UCLP group was tighter than that in the control group, however (p=0.017). The results of this study suggest that this difference in the measurements of the narrowest section of the airway is involved in the particular maxillofacial morphology found in UCLP patients.

Interdental Distraction Osteogenesis in Unilateral Cleft Lip and Palate Patient with Wide Alveolar Cleft.

Alveolar bone grafting is routinely performed in repair of alveolar clefts. When the alveolar cleft is wider than 11 mm, however, the survival rate of the bone graft and prognosis are poor. Here, we describe successful orthodontic treatment using interdental distraction osteogenesis (IDO) with a tooth-tooth type distractor to reduce the width of the alveolar cleft in a patient with unilateral cleft lip and palate. The patient was a 12-year-old girl with unilateral cleft lip and palate, maxillary dentition midline deviation, congenitally missing maxillary lateral incisors, a palatally-displaced right upper first premolar, a wide alveolar cleft (20 mm), and mandibular prognathism due to maxillary hypoplasia. Treatment comprised a combination of orthodontic treatment and IDO. After treatment, appropriate occlusion, space closure in the maxillary arch, coincidence of the maxillary and facial midlines, and incorporation of the right maxillary first premolar into the arch were obtained. These results suggest that IDO is effective in treating cleft lip and palate patients with a wide alveolar cleft.

CAGE-seq analysis of osteoblast derived from cleidocranial dysplasia human induced pluripotent stem cells.

Non-coding RNAs (ncRNAs) comprise a major portion of transcripts and serve an essential role in biological processes. Although the importance of major transcriptomes in osteogenesis has been extensively studied, the function of ncRNAs in human osteogenesis remains unclear. Previously, we developed hiPSCs from patients with cleidocranial dysplasia (CCD) caused by runt-related transcription factor 2 (RUNX2) haploinsufficiency. To gain insight into ncRNAs in osteogenesis, we surveyed differential ncRNA expression profiling and promoter differences of RUNX2 using patient-specific iPSCs and cap analysis gene expression (CAGE) technology to define the promoter landscape. Revertant iPSCs (Rev1 iPSCs) edited by CRISPR/Cas9 system to harbor mutation-corrected RUNX2 exhibited increased proximal promoter expression of RUNX2, while CCD iPSCs did not. We identified 2271 ncRNA genes with altered expression levels before and after differentiation, 31 of which showed at least 20-fold higher expression in Rev1 iPSCs. Bioinformatic analysis also categorized AC007392.3, LINC00379, RP11-122D10.1, and RP11-90J7.2 as enhancer regulatory regions, and HOXA-AS2, MIR219-2, and RP11-834C11.3 as dyadic regulatory regions of these ncRNAs. In addition, two miRNAs, termed MIR199A2 and MIR152, were found to have high enrichment of osteogenic-related terms. Upon further examination of the role of MIR152 on osteoblast differentiation, we found that MIR152 knockdown induced upregulation of ALP and COL1A1 in Saos-2 cells. Thus, ncRNAs were found to regulate the osteogenic differentiation potentials of hiPSCs that are used for bone regeneration and repair owing to their differentiation potentials. These data allow understanding ncRNA profiles of hiPSCs during osteogenesis.

Survey on Condition and Orthodontic Treatment of Maxillary Lateral Incisors in Patients with Cleft Lip and Palate.

The aim of this study was to investigate the condition of the maxillary lateral incisors and evaluate the methods used for cleft closure in patients with cleft lip and palate, including the treatment of the maxillary lateral incisors. A total of 214 patients (260 clefts) with alveolar clefts who had started Phase II treatment and entered the maintenance period at the Department of Orthodontics at Tokyo Dental College, Chiba Hospital, between 1975 and 2014 were included. Panoramic, intraoral, and occlusal radiographs, as well as intraoral photographs and medical records, were used to investigate cleft classification, the presence or absence and location of maxillary lateral incisors, and frequency and treatment method for peg lateral incisors in the cleft region. There were more unilateral cleft cases (78.5%) than bilateral cleft cases. The prevalence of congenital absence of the maxillary lateral incisors was similar between unilateral (53.0%) and bilateral cases (53.3%). Peg laterals occurred frequently, with 89.9% occurring in unilateral cases. The maxillary lateral incisors were more commonly found in the secondary than in the primary palate. The number of non-extraction cases was larger than that of extraction cases, regardless of cleft type or the location of the peg laterals. In many cases, the peg laterals were treated with non-extraction and space closure or crown modification. These results suggest that, depending on their condition, the peg laterals should be preserved as much as possible in devising a treatment plan.

Three-Dimensional Evaluation of Change in Maxillary Alveolar Arch after Expansion in Unilateral Cleft Lip and Palate Patients.

Narrowing of the maxillary dental arch is a major cause of occlusal abnormalities in cleft lip and palate patients. Although the dental arch may be expanded in such cases, relapse will often occur during the subsequent retention period. In this study, the stability of expansion of the maxillary arch was investigated by examining 3-dimensional change in the maxillary arch during the treatment and post-retention periods. Three-dimensional measurements was performed on maxillary plaster models obtained from 8 unilateral cleft lip and palate patients (mean age, 12.5 years) who had undergone maxillary arch expansion using an edgewise appliance and quad helix (CLP group). The controls consisted of 8 unilateral cleft lip and alveolus patients (mean age, 12.9 years). Measurements were made during the pretreatment, post-treatment, and post-retention periods. In the CLP group, horizontal relapse was observed in the alveolar and dental arches between the second premolars, together with vertical relapse on the cleft side of the central incisor, lateral incisor, and canine. The sites where relapse occurred demonstrated decreased growth before orthodontic treatment. A correlation was observed between the extents of expansion and relapse. These findings suggest that excessive horizontal or vertical tooth movement in areas showing developmental failure should be avoided in order to increase stability after orthodontic treatment.

Successful treatment of left subclavian artery penetration due to ingestion of a safety pin by an elderly person.

BACKGROUND: Ingestion cases are increasing in elderly persons. Herein, we report a rare case of ingestion of a safety pin by an elderly person. CASE PRESENTATION: The patient was an 87-year-old bedridden woman who had fever with left pleural effusion. Chest X-ray revealed a foreign body, confirmed to be a safety pin, in the cervical esophagus. A contrast multidetector row computed tomography scan revealed that the opened safety pin penetrated the left subclavian artery, leading to the diagnosis of an esophageal foreign body penetrating the left subclavian artery. The safety pin was removed, and the subclavian artery aneurysm caused by the penetration was embolized by interventional radiology. After treatment, she was returned to the nursing home on postoperative day 8. CONCLUSION: Penetration by ingestion of a safety pin is rare; in this case, safe treatment was possible due to a team of certified specialist physicians and surgeons.

Three-dimensional Coordinate System for Hemifacial Microsomia.

BACKGROUND: Hemifacial microsomia (HFM) is a congenital disorder characterized by facial asymmetry, but no midline reference has been established for evaluating facial morphology in patients with HFM. The purpose of this study was to develop a 3-dimensional coordinate system unaffected by the deformity of the external acoustic aperture or orbital circumference and to quantitatively evaluate craniofacial morphology in such patients. METHODS: We quantitatively evaluated craniofacial morphology using 3-dimensional measurements with the skull base as a reference. Using computed tomography data from 15 patients with HFM and 15 controls, a coordinate system was created for each patient, and left-right differences between measurement points were compared. RESULTS: When mandibular deformity was severe, the deformity of the posterior part of the palatine bone and lateral part of the orbit increased, but this trend was not evident for other measurement points. Thus, craniofacial deformity in HFM was not always related to mandibular deformity. Moreover, no difference was evident in the position of the hypoglossal canal between controls and patients with HFM. CONCLUSIONS: Quantitative assessments are possible using the coordinate system devised in this study, irrespective of the severity of HFM. The degree of mandibular deformity detailed in the Pruzansky classification was associated with the superoinferior deformity of the posterior part of the palatine bone and anteroposterior deformity of the lateral part of the orbit.

Le Fort III Distraction Osteogenesis Without Bicoronal Incision.

PURPOSE: Recently, midfacial hypoplasia for syndromic craniosynostosi has been corrected by Le Fort III distraction osteogenesis. During conventional Le Fort III osteotomy, osteotomy is performed via bicoronal incision. In contrast, the authors have developed a technique for performing Le Fort III osteotomy using internal devices but without bicoronal incision. PATIENTS AND METHODS: The authors performed the Le Fort III distraction technique in 22 patients. Of these, 17 patients underwent an approach using conventional coronal incision; the others underwent an approach without coronal incision. This new approach was performed using a McCord incision, a brow incision, and gingivo-buccal sulcus incisions. We then performed osteotomy and attached the internal device. RESULTS: The age of patients ranged from 6 to 21 years (mean: 14.1 ±â€Š5.0 years) and 6 to 38 years (mean: 19.6 ±â€Š11.5 years) in the groups with or without coronal incision, respectively. Mean operative time was 410 ±â€Š196 minutes in the group with coronal incision and 357 ±â€Š121 minutes in the group without coronal incision. Mean blood loss (per unit of body weight) was 51.3 ±â€Š38.5 and 33.9 ±â€Š9.9 ml/kg) in the groups with or without coronal incision, respectively. There were no complications, except in the case of a 38-year-old patient, the oldest patient, who lost vision in the left eye after surgery. CONCLUSION: A direct facial approach for Le Fort III distraction was useful because of its reduced operative time and blood loss. However, down fracture following incomplete osteotomy or inadequate dissection of the orbit may cause blindness. Consequently, this technique requires careful attention.

An internal distraction device for midface distraction osteogenesis: The NAVID system type Z'gok.

Midface advancement with distraction osteogenesis is more routinely used for faciocraniosynostosis. Distraction devices are generally classified into external and internal types. Compared with external distractors, internal distractors are smaller and better tolerated, but their removal is complicated. Here, we introduce a refined internal distraction device and describe its applicability. Unlike the previous anterior fixation plate that utilises screws, the refined internal distraction (type Z'gok) has 3 claws. This anterior point of the distractor is positioned behind the malar eminence, or the lateral orbital wall. Eight patients with syndromic craniosynostosis underwent midface distraction osteogenesis using the type Z'gok between 2016 and 2017 (Z'gok group). Twelve patients were treated using conventional internal distractors (control group). Patient age ranged from 6 to 21 years. Among them, 4 patients underwent Le Fort III distraction osteogenesis, while the others underwent Le Fort IV distraction osteogenesis. The operative time to remove the distractors in the Z'gok group was 65 ± 18 min, shorter than 89 ± 12 min in the control group. The blood loss per kilogram of body weight in the Z'gok and control groups was 3.6 ±â€¯3.3 mL/kg and 4.7 ±â€¯1.7 mL/kg, respectively. In conclusion, the type Z'gok is a reliable and effective internal distractor for midface distraction osteogenesis.

Assessment of Bioabsorbable Hydroxyapatite for Secondary Bone Grafting in Unilateral Alveolar Clefts.

PURPOSE: To evaluate the utility and efficacy of bioabsorbable hydroxyapatite and collagen complex (HA/Col) for secondary bone grafting in unilateral alveolar clefts. PATIENTS AND METHODS: Between 2015 and 2016, 21 patients with unilateral cleft lips and alveolar clefts were enrolled. In group I, a cancellous iliac bone graft was placed at the alveolar cleft (6 males, 5 females). In group II, a bioabsorbable HA/Col was placed at the alveolar cleft (4 males, 7 females). RESULTS: The groups did not differ in age, cleft volume, or surgical duration. There was a significant difference in intraoperative blood loss between the 2 groups (6.7 ± 1.89 mL in group II vs 38.8 ± 9.73 mL in group I [P < .01]). The use of patient-controlled intravenous analgesia was also significantly lower in group II than in group I (2.2 ± 1.9 times vs 12.2 ± 4.4 times [P < .01]). Only 1 female in group II who had maxillary sinusitis did not achieve osteosynthesis. With the exception of this patient, the 12-month bone volumes in groups I and II were 0.567 ± 0.066 and 0.596 ± 0.073 mL, respectively, without significant difference (P = .18). CONCLUSION: Compared with an autogenous bone, bioabsorbable HA/Col significantly reduces postoperative pain. In addition, the use of HA/Col alone produced the same result as an autologous bone and is effective in filling the alveolar cleft.

Cutaneous histopathology of the tick-bite region in severe fever with thrombocytopenia syndrome.

A case of severe fever with thrombocytopenia syndrome (SFTS) in which a skin biopsy from the tick-bite region was analyzed is reported. The patient was a 72-year-old woman who developed fever and thrombocytopenia after a tick bite. SFTS was diagnosed from polymerase chain reaction (PCR) analysis of a blood sample. Histopathological analysis of a skin biopsy specimen from the tick-bite region showed CD20-positive perivascular and interstitial immunoblastic cells, which were positive to anti-SFTS virus (SFTSV) nucleoprotein antibody. In addition, SFTSV RNA was detected by real-time PCR from this biopsy specimen. Moreover, hemophagocytosis was also found in the tick-bite region. To the best of our knowledge, this is the first report to analyze the details of the tick-bite region of skin in SFTS, and the first to detect virus-infected cells in the skin. The present findings may help elucidate the mechanisms of entry of SFTSV.

Impact of Mobile Cloud Electrocardiography System on Door-to-Balloon Time in Patients With Acute Coronary Syndrome in Oita Prefecture.

Background: The mobile cloud electrocardiography (C-ECG) system is useful for reducing door-to-balloon (DTB) time in patients with acute coronary syndrome (ACS), but few studies have reported the usefulness of the C-ECG system across a wide provincial prefecture, such as Oita, in Japan. Methods and Results: On 17 April 2017, the C-ECG system was integrated into the Oita remote image transmission system, in 10 ambulances of 10 respective fire departments in Oita Prefecture. During 6 months, 162 ECG indicating suspected ACS were transmitted to 18 hospitals using the C-ECG system. Of 162 patients, 17 who received emergency percutaneous coronary intervention (PCI) were assigned to the cloud group (mean age, 71±11 years). The control group consisted of 29 consecutive ACS patients who were transported to Oita University Hospital without using the C-ECG system (mean age, 66±12 years). Another 40 consecutive patients were diagnosed with ACS before transportation to Oita University Hospital, and were assigned to the diagnosed group (mean age, 70±14 years). DTB time (70±26 min vs. 96±24 min, P<0.005) and door-to-catheterization laboratory time (33±20 min vs. 53±22 min, P<0.0001) were shorter in the cloud group than in the control group, respectively. Conclusions: C-ECG system integration in Oita Prefecture was useful to appropriately transfer ACS patients to hospital and to facilitate earlier PCI than in the conventional diagnostic system.