Search

Introduction: The standard treatment for severe open limb fractures comprises fracture fixation and flap surgery. In complicated injuries, secondary surgeries are required for flap-covered fracture sites. Given the risk of flap necrosis, secondary surgery using a flap-dividing approach is generally avoided. Nonetheless, a more efficient secondary surgery can be undertaken in combination with strategies to prevent flap necrosis. We describe a "trans-flap approach" for secondary surgery and the subsequent treatment course and clinical outcomes of patients who were treated with this novel approach., Methods: We retrospectively identified and enrolled patients who underwent flap surgery for severe open limb fractures and subsequently received secondary surgery using the trans-flap approach between 2020 and 2023. Patient demographics and injuries, type of flap used for acute soft tissue reconstruction, indications for secondary surgery, duration from soft tissue reconstruction to secondary surgery, soft tissue healing, and postoperative complications were investigated., Results: Among the 15 study participants, the injuries involved the hand in 3 cases, lower leg in 9 cases, and foot in 3 cases. The flaps used for acute soft tissue reconstruction included a pedicled flap in 2 cases and a free flap in 13 cases. In all cases, the wounds healed without necrosis and complications, except for a deep infection in 1 patient., Conclusion: Regardless of the type of flap, wound healing was achieved without necrosis in all 15 cases. Trans-flap approach can be an effective option in secondary surgery for severe open limb fractures., Competing Interests: Declarations. Conflict of interest: The authors declare that they have no conflicts of interest. The authors have no relevant financial or non-financial interests to disclose. Ethical approval: This study received ethical approval from the TOKUSHUKAI GROUP COMMMITE under the protocol number TGE02323-012. Consent to participate: All the patients provided written informed consent upon the study enrollment. Consent for publication: All the patients provided written informed consent for the publication of any associated data and accompanying images., (© 2025. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background: Calcification score by cardiac computed tomography (CT) is required for diagnosis of paradoxical low-flow/low-gradient (PLFLG) aortic stenosis (AS). According to the guideline, velocity ratio (VR) < 0.25 by echocardiography is defined as severe AS, but utility of VR in patients with PLFLG AS remains unknown. This retrospective study was therefore conducted to investigate the utility of VR for a diagnosis of severe AS based on CT in patients with PLFLG AS., Methods: We studied 58 patients with PLFLG AS. Severity of AS was defined as calcium score derived from cardiac CT., Results: Of the 58 patients, 28 (48.3%) were diagnosed with severe AS based on CT, while 23 of them (82.1%) had VR < 0.25. It was noteworthy that receiver operating characteristic curve analysis showed that the optimal VR cutoff value for a diagnosis of severe AS was 0.25, with an area under the curve of 0.870 (P < 0.001). Sensitivity, specificity, positive predictive value, and negative predictive value of VR < 0.25 for a diagnosis of severe AS were 82.1%, 86.7%, 85.2% and 83.9%, respectively. Furthermore, patients who match the value of VR and severity of AS based on CT had higher prevalence of atrial fibrillation, higher serum brain natriuretic peptide concentration, larger left ventricular end-diastolic volume, and left ventricular stroke volume index., Conclusion: The measurement of VR is simple, and VR < 0.25 can be used for diagnosis of patients with PLFLG AS as severe. Our findings may thus have clinical implications for routine clinical practice., (© 2024. Japanese Society of Echocardiography.)

Background: Traumatic diaphragmatic injury (TDI) is well-known worldwide as rare and life-threatening. However, because no nationwide cohort study of penetrating and blunt TDI has been conducted in Japan and other countries where penetrating trauma is relatively uncommon, the clinical characteristics of all TDI are unknown. We aimed to describe the characteristics of TDI patients, compare penetrating TDI with blunt TDI, and identify mortality risk factors in Japan., Methods: We retrospectively identified TDI patients between 2004 and 2019 using data from the Japan Trauma Data Bank. We extracted data on patient demographics, type of trauma, cause of trauma, physiological parameters, region of concomitant injury, associated injury, and management. We compared penetrating and blunt TDI for each variable. The primary outcome was mortality. Multivariable logistic regression was performed to identify mortality risk factors., Results: Of the 338,744 patients, 1,147 (0.3%) had TDI, of which 771 were eligible for analysis (excluding 308 in cardiac arrest on arrival). Penetrating TDI represented 29.8% and blunt TDI 70.2%, and comparing penetrating and blunt TDI, the most common cause was self-inflicted (48.7%) vs. accident (85.6%), males were 68.7% vs. 66.0% of the patients (P = 0.50), and the mortality rate was 8.3% vs. 26.4% (P < 0.001). Multivariable analysis found that age (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01-1.04), Injury Severity Score (OR 1.03, 95%CI 1.006-1.06), Revised Trauma Score (OR 0.55, 95%CI 0.45-0.67), severe concomitant abdominal injury (OR 2.45, 95%CI 1.32-4.56), severe concomitant upper extremity injury (OR 3.38, 95%CI 1.24-9.17) were independent predictors of mortality, and computed tomography (CT) (OR 0.32, 95%CI 0.15-0.69) and diaphragm repair (OR 0.44, 95%CI 0.25-0.78) were protective factors., Conclusions: In Japan, we found that penetrating TDI was mainly caused by self-injury and the male-female ratio was the same as for blunt TDI, although blunt TDI was much more frequent. TDI was considered highly lethal, with over 25% of patients in cardiac arrest on arrival. Our unique independent predictors were CT, severe concomitant abdominal injury, and severe concomitant upper extremity injury. These findings may help in the management of TDI in countries with less common penetrating trauma., Competing Interests: Declarations. Ethics approval and consent to participate: This study was approved by the institutional review board of Jichi Medical University. The need to obtain informed consent was waived because all analyses used anonymized data (approval no. RINDAI 21–079). Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Purpose: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is beneficial for uncontrollable torso bleeding; however, prolonged REBOA causes ischemia-reperfusion injury. The purpose of this study is to examine the hypothesis that continuous renal replacement therapy (CRRT) with a cytokine-adsorbing hemofilter would improve mortality due to hemorrhagic shock with REBOA-reperfusion injury by controlling metabolic acidosis, hyperkalemia, and hypercytokinemia., Methods: Hemorrhagic shock with 40% blood loss was induced by phlebotomy in eight female swine. CRRT was performed on four swine after 90 min of REBOA, and the remaining four swine (control group) underwent the same procedures except for CRRT. We evaluated the survival time and trends of pH, HCO 3- , potassium, lactate, circulatory inflammatory cytokines, and histopathology of the intestine for 180 min after REBOA deflation., Results: Two swine in the CRRT group and one in the control group survived; no significant difference were observed in survival rates between the groups (p = 0.45). Furthermore, no significant differences in the transition of biomarkers and histopathological grades were observed between the groups. The CRRT group showed a tendency of increasing pH and HCO 3- , decreasing lactate, lower elevation of potassium and cytokine levels (interleukin 6, CRRT: 1008.5 [770.4-1246.6], control; 1636.7 [1636.7-1636.7] pg/mL at t = 270), and lower intestine histopathological grade (jejunum, CRRT; 1.5 [1.3-1.8], control; 4.0 [4.0-4.0], ileum, CRRT; 1.5 [1.3-1.8], control; 4.0 [4.0-4.0] at t = 270) than the control group., Conclusions: CRRT may mitigate acute-REBOA-related ischemia-reperfusion injury by controlling biomarkers. Further research is required to evaluate the impact on long-term mortality., Competing Interests: Declarations. Ethics approval and consent to participate: All methods were performed in accordance with the relevant guidelines and regulations and were approved by the Institutional Animal Experiment Committee (authorization number: 21006-01). Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Introduction: Blunt brachial artery injuries (BAI) require reconstruction with an extensive vein graft due to the wide area of arterial damage. In the upper arm, safe options for pedicle flaps are limited, and selecting recipient vessels for free-flap surgery is challenging, complicating the treatment of soft tissue injuries associated with blunt BAI. This study aimed to analyze the characteristics and soft tissue reconstruction of blunt BAI and propose treatment strategies for treating associated soft tissue injuries., Methods: Patients with blunt BAI who treated between August 2013 and April 2024 were included. Blunt BAI cases were classified into three groups (Type1A, Type1B, and Type2) based on soft tissue injury localization and elbow flexion reconstruction necessity. Patient demographics, treatment details, and treatment outcomes were investigated., Results: Seven patients were included to this study. There were two cases of Type1A, three Type1B, and two Type2. Three cases of Type1B underwent soft tissue reconstruction using pedicled latissimus dorsi flap and concurrent reconstruction of the elbow flexion. One case of Type2 was treated with free latissimus dorsi flap using AV loop, and the remaining case of Type2 was performed forearm amputation., Conclusion: This study examined the treatment details of seven patients with blunt BAI. If a soft tissue injury is localized to the upper arm, it can be treated with a pedicle flap. However, if the damage extends beyond the forearm, a free flap is essential and some ingenuity is required to select the recipient blood vessel., Competing Interests: Declarations. Conflict of interest: The authors declare that they have no conflicts of interest. The authors have no relevant financial or non-financial interests to disclose. Ethical approval: This study received ethical approval from Institutional Review Boards of the authors’ affiliated institutions. Consent to participate: All the patients provided written informed consent upon the study enrollment. Consent for publication: All the patients provided written informed consent for the publication of any associated data and accompanying images., (© 2025. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Competing Interests: This work was made possible by support from National Institutes of Health (grant P01 HL164311 to Dr Shivkumar) and from the UCLA Amara-Yad Project. Dr Shivkumar has received support from National Institutes of Health grant P01 HL164311. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Objectives: Falls are among the most prevalent workplace accidents, necessitating thorough screening for susceptibility to falls and customization of individualized fall prevention programs. The aim of this study was to develop and validate a high fall risk prediction model using machine learning (ML) and video-based first 3 steps in middle-aged workers., Methods: Participants to provide training data (n = 190, mean [SD] age = 54.5 [7.7] years, 48.9% male) and validation data (n = 28, age = 52.3 [6.0] years, 53.6% male) were enrolled in this study. Pose estimation was performed using a marker-free deep pose estimation method called MediaPipe Pose. The first 3 steps, including the movements of the arms, legs, trunk, and pelvis, were recorded using an RGB camera, and the gait features were identified. Using these gait features and fall histories, a stratified k-fold cross-validation method was used to ensure balanced training and test data, and the area under the curve (AUC) and 95% CI were calculated., Results: Of 77 gait features in the first 3 steps, we found 3 gait features in men with an AUC of 0.909 (95% CI, 0.879-0.939) for fall risk, indicating an "excellent" (0.9-1.0) classification, whereas we determined 5 gait features in women with an AUC of 0.670 (95% CI, 0.621-0.719), indicating a "sufficient" (0.6-0.7) classification., Conclusions: These findings suggest that fall risk prediction can be developed based on ML and the first 3 steps in men; however, the accuracy was only "sufficient" in women. Further development of the formula for women is required to improve its accuracy in the middle-aged working population., (© The Author(s) [2025]. Published by Oxford University Press on behalf of the Japan Society for Occupational Health.)

Background: Migraine is associated with cervical artery dissection (CeAD). Calcitonin gene-related peptide (CGRP) is a multifunctional neuropeptide with vasodilatory effects. The use of anti-CGRP monoclonal antibodies (CGRP mAb) may affect cerebrovascular disease risk; however, no reports have associated CGRP mAb with CeAD., Case Presentation and Faers Database Analysis: We report a case of vertebral artery dissection in a 39-year-old woman with migraine treated with galcanezumab. We searched the number of cases where cerebral and cervical artery dissection were reported as adverse effects of CGRP mAb using the FDA Adverse Event Reporting System (FAERS) database. Six and ten such cases were reported regarding galcanezumab and CGRP mAbs use, respectively. The reporting odds ratios for galcanezumab and CGRP mAbs were elevated., Conclusion: Although migraine is reported to be associated with CeAD, the use of CGRP mAb might be related to CeAD and warrant further investigation., Competing Interests: Declarations. Ethics approval and consent to participate: Not applicable. Consent for publication: The patient gave written informed consent for their personal or clinical details along with any identifying images to be published in this study. Competing interests: Tsubasa Takizawa is a consultant/advisor and/or serves on an advisory board for Eli Lilly, Otsuka, Amgen, Pfizer, and Teijin and has received speaker honoraria from Eli Lilly, Daiichi Sankyo, Otsuka, Amgen, Kowa, Kyowa Kirin, Eisai, UCB Japan, Takeda, Sawai, and Santen Pharmaceutical and grants from Eli Lilly, Pfizer and Tsumura outside the submitted work; Jin Nakahara has received honoraria and research scholarships from Amgen and Daiichi Sankyo. Tsubasa Takizawa is a member of the Editorial Board of BMC Neurology and was not involved in the journal’s peer reviewprocess or decisions related to this manuscript., (© 2025. The Author(s).)

Hemorrhagic shock is a significant cause of trauma-related mortality. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a less-invasive aortic occlusion maneuver for severe hemorrhagic shock but potentially inducing oxidative stress injuries. In an animal model, this study investigated hydrogen gas inhalation therapy's potential to mitigate post-REBOA ischemia-reperfusion injuries (IRIs). Ten healthy female swine underwent REBOA placement after induced 40% hemorrhagic shock. They were observed during the IRI phase after a 60-minute Zone 1 occlusion for 180 minutes until euthanasia. 2% hydrogen gas inhalation was started simultaneously with REBOA inflation in the hydrogen group. We evaluated survival time, lactate, and 8-hydroxy-2'-deoxyguanosine (8-OHdG) biomarkers, gross findings, and pathological grades. One swine in the control group died at 90 min, and the remaining animals survived throughout the experiment. Survival analysis showed no significant differences between the two groups (control vs. hydrogen, 4/5 vs. 5/5; Log-rank, P = 0.317). Lactate levels during and after REBOA suggested a tendency towards lower levels in the hydrogen group (10.5 ± 4.2 vs. 7.6 ± 2.3 mmol/L, peak, T = 90). Serum 8-OHdG concentrations showed a lower trend in the hydrogen group (Range: 0.12-0.32 vs. 0.11-0.19 ng/mL). The villi of the ileum were destroyed during REBOA inflation and after reperfusion. Changes in the pathological grade of the ileum demonstrated no significant differences in both groups (2.8 ± 1.0 vs. 2.0 ± 1.0, proximal ileum, T = 240). Hydrogen gas inhalation therapy exhibited no significant difference compared to the control group in survival, lactate level, 8-OHdG, and intestinal mucosal injury following REBOA in a hemorrhagic shock model. Although it may slightly reduce mortality, biomarkers, and intestinal pathology, hydrogen gas inhalation therapy was not shown to have sufficient evidence to mitigate REBOA-IRI., Competing Interests: Declarations. Competing interests: The authors declare no competing interests. Grant-in-Aid for Scientific Research (B), Japan Society for the Promotion of Science (JSPS), Grant Number 21H03029. Ethical approval: This study was conducted in an accredited animal research laboratory (Center for Development of Advanced Medical Technology, Jichi Medical University, Tochigi, Japan). Approval was obtained before conducting the research from the Animal Experiment Committee of the Center for Experimental Medicine, Jichi Medical University (authorization no. 17045-05; October 29, 2020). This study is reported following ARRIVE guidelines ( https://arriveguidelines.org )., (© 2024. The Author(s).)

This paper revisits and shows comprehensive femoral access site anatomy with a combination of images obtained from detailed cadaveric dissection, fluoroscopy, computed tomography, ultrasound, and 3-dimensional printings. Part 2 focuses on the fluoroscopic anatomy, pelvic cavity, and complications. In addition, a file for 3-dimensional printing is provided. Profound understanding of this region is fundamental to facilitate safe procedures and to avoid unnecessary complications., Competing Interests: This work was supported by NIH grant P01 HL164311 to KS and the UCLA Amara-Yad Project. The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2024 The Authors.)

We revisit and show comprehensive femoral access site anatomy with a combination of images obtained from detailed cadaveric dissection, fluoroscopy, computed tomography, ultrasound, and 3-dimensional printings. Part 1 focuses on the femoral triangle, femoral bifurcation, fluoroscopic and/or ultrasonographic anatomy, and branches of the femoral artery. Profound understanding of this region is fundamental to facilitate safe procedures and to avoid unnecessary complications., Competing Interests: This work was made possible by support from National Institutes of Health grant P01 HL164311 to Dr Shivkumar and the UCLA Amara-Yad Project (https://www.uclahealth.org/medical-services/heart/arrhythmia/about-us/amara-yad-project). The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2024 The Authors.)

Background: Popliteal artery injury (PAI) is sometimes accompanied by proximal tibial fracture or knee dislocation. We hypothesized that revascularisation approach should be selected depending on the associated injury. The purpose of this study is to propose revascularisation approach that does not interfere with definitive surgery., Methods: Patients with PAI who were treated between 2013 and 2023 were included. Associated injuries, revascularisation approach, and skin incision for the definitive surgery were investigated. We investigated whether varus-valgus instability remained as an outcome., Results: 21 limbs with PAI were included. There were 6 cases with proximal tibial fracture. Medial incision was used in 2 cases and crank shaped incision in 4 cases. In 4 cases of crank shaped incision, osteosynthesis was performed through a crank shaped incision. There were 8 cases with knee dislocation. Medial incision was used in 1 case, S shaped incision in 4 cases, and crank shaped incision in 3 cases. In cases of S shaped incision, extra-articular ligament was repaired through independent incisions. In three cases of crank shaped incision, it was not possible to repair extra-articular ligament because of interfere with the initial incision. As a result, knee joint instability remained. There were 7 cases without proximal tibial fracture or knee dislocation. Medial incision was used in 1 case, S shaped incision in 3 cases, and crank shaped incision in 3 cases. There was no interference between the incisions for revascularisation and for definitive surgery., Conclusion: For PAI, revascularisation approaches should be selected depending on the associated injury., Competing Interests: Declaration of competing interest The authors report no conflict of interest., (Copyright © 2024 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Objective: This study aimed to examine the spatiotemporal coherence of capillary lumen fluctuations in relation to spatial variations in the pericyte lining in the cortex of anesthetized mice., Methods: Two-photon microscopic angiography data (previously published) were reanalyzed, and spatial variations in capillary diameter fluctuations at rest and in capillary lining with vascular mural cells were measured along capillary centerlines., Results: Relatively large diameters of the capillaries (5.5 μm) coincided with a dense pericyte lining, while small capillaries (4.3 μm) had a sparse pericyte lining. Temporal variations had a frequency of about 0.1 Hz with an amplitude of 0.5 μm, which were negatively correlated with pericyte lining density. Spatial frequency analysis further revealed a common pattern of spatial variations in capillary diameter and pericyte lining, but temporal variations differed. The temporal variations in capillary lumens were locally distinct from those in neighboring locations, suggesting intrinsic fluctuations independent of the pericyte lining., Conclusions: Capillary lumens in the brain exhibit slow microfluctuations that are independent of pericyte lining. These microfluctuations could affect the distribution of flowing blood cells and may be important for homogenizing their distribution in capillary networks., (© 2024 The Author(s). Microcirculation published by John Wiley & Sons Ltd.)

Competing Interests: The Section of Arrhythmia is supported by an endowment from Abbott Japan, Boston Scientific Japan, and Medtronic Japan. K. F. and K. I. belong to the Section. K. F. receives an endowment from Biotronik Japan. However, all authors report no conflict of interest for this manuscript’s content. The other authors report no conflicts of interest.

Background: Severe extremity trauma is one of the most challenging injuries to treat. Limb salvage after severe extremity trauma requires rapid revascularization, accurate and appropriate bone and soft tissue reconstruction, and appropriate management to address critical complications. The purpose of this study was to report the treatment outcomes for severe extremity trauma injuries at our independent orthopedic trauma center., Methods: This study included patients with severe extremity trauma who underwent major vascular repair or soft tissue reconstruction. Bone reconstruction method, presence or absence of revascularization, and flap type were investigated. Complications were investigated, including revascularization failure, flap failure, infection, and ultimately, whether amputation was required. Additionally, we investigated the number of surgeries performed on each patient at the time of initial hospitalization., Results: Thirty-five patients who underwent revascularization or soft tissue reconstruction were included in this study. Plate fixation was performed in 18 patients, intramedullary nail fixation in 8, screw fixation in 1, pinning in 4, and without implant fixation in 4. Revascularization was performed in six patients, and no vascular complications occurred. Pedicled and free flaps were used in 17 and 16 patients, respectively. Partial flap necrosis occurred in four patients, and arterial occlusion occurred in one. Infection occurred in 10 patients who were treated with frequent irrigation and high-concentration antibiotics local infusion therapy. None of the 35 patients required limb amputation. Mean number of surgeries was 12.5., Conclusions: The limb of all the 35 patients with severe extremity trauma treated at our independent orthopedic trauma center were salvaged., Competing Interests: Declaration of competing interest The authors report no conflict of interest., (Copyright © 2024 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Background: Patients with migraine are typically advised to avoid passive smoking because it may aggravate headaches and other health conditions. However, there is insufficient high-quality evidence on the association between passive smoking and migraine, which warrants further investigation using animal models. Therefore, using a mouse model, we examined the effect of passive smoking on susceptibility to cortical spreading depolarization (CSD), the biological basis of migraine with aura., Findings: Fifty C57BL/6 mice (25 males and 25 females) were exposed for one hour to cigarette smoke or room air. Subsequently, potassium chloride (KCl) was administered under isoflurane anesthesia to induce CSD, and the CSD threshold, frequency of induction, and propagation velocity were determined. The threshold to induce CSD (median [interquartile range (IQR)]) was significantly lower in female mice (adjusted p = 0.01) in the smoking group (0.05 [0.05, 0.088]) than in the sham group (0.125 [0.1, 0.15]); however, there was no significant difference in the male mice (adjusted p = 0.77). CSD frequency or propagation velocity did not differ significantly between the two groups for either sex., Conclusions: Female mice in the smoking group showed lower CSD threshold compared to the sham group, suggesting a potential sex-specific difference in the effect of smoking on the pathogenesis of CSD and migraine with aura. This finding may contribute to the understanding of migraine pathophysiology in association with passive smoking and sex difference., (© 2024. The Author(s).)

Some patients develop ischemic stroke despite taking direct oral anticoagulants because of the presence of other risk factors such as coagulopathies. A 65-year-old male patient with non-valvular atrial fibrillation (NVAF) taking rivaroxaban was diagnosed as having embolic stroke and antithrombin-III (AT-III) deficiency. Echocardiography revealed a thrombus in the left atrial appendage (LAA). He was prescribed warfarin, and after resolution of the thrombus, we successfully performed percutaneous LAA closure (LAAC), with no subsequent recurrence or device-related thrombosis. Warfarin and LAAC may be feasible for NVAF patients with AT-III deficiency.

Background: Hemothorax caused by a right intercostal artery (ICA) injury behind the left atrium (LA) is a potentially fatal complication during pulmonary vein isolation. However, their anatomic relationship has not been fully elucidated., Objective: This study aimed to investigate the clinical anatomy of the right ICA in relation to the LA., Methods: This retrospective study included 100 patients (70.2 ± 10.6 years; 39.0% female) who underwent cardiac computed tomography. The patients were divided into sinus rhythm and atrial fibrillation groups. We focused on the distance between the LA and right ICAs and its predictive factors., Results: On average, 3.7 ± 0.7 right ICAs were found behind the LA. Of these, the eighth ICA was the closest in 54% of the cases, followed by the seventh ICA in 29% and the ninth ICA in 14%. The average closest distance between them was 3.8 ± 3.8 mm, which was significantly shorter in the atrial fibrillation group than in the sinus rhythm group (3.0 ± 3.2 mm vs 4.7 ± 4.2 mm; P = .006). Multivariate analysis revealed that a thinner chest cavity (β = -0.512; P = .002) and LA dilation (β = -0.432; P = .001) were predictors of shorter distance. The closest points distributed along the vertebral column, generally near the inferior pulmonary vein orifices., Conclusion: Right ICA-LA proximity was systematically clarified. Particularly in cases with an enlarged LA or thin chest cavity, operators should be aware of the potential risk of injuring the right ICA during pulmonary vein isolation., Competing Interests: Disclosures The authors have no conflicts of interest to disclose., (Copyright © 2024 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

The 88 th Annual Scientific Meeting of the Japanese Circulation Society (JCS2024) was held from Friday, March 8 th to Sunday, March 10 th in Kobe, Japan. The main theme of this 3-day meeting was "The Future of Cardiology: Challenges in Overcoming Cardiovascular Disease". As COVID-19 has been finally conquered, with revision of its categorization under the Infectious Disease Control Law and relaxation of infection prevention measures, it was once again possible to have face-to-face presentations and lively discussion. JCS2024 was a major success, with 19,209 participants and attendees, thanks to the greatly appreciated cooperation and support from all affiliates.

The Tsuruoka Metabolomics Cohort Study (TMCS) is an ongoing population-based cohort study being conducted in the rural area of Yamagata Prefecture, Japan. This study aimed to enhance the precision prevention of multi-factorial, complex diseases, including non-communicable and aging-associated diseases, by improving risk stratification and prediction measures. At baseline, 11,002 participants aged 35-74 years were recruited in Tsuruoka City, Yamagata Prefecture, Japan, between 2012 and 2015, with an ongoing follow-up survey. Participants underwent various measurements, examinations, tests, and questionnaires on their health, lifestyle, and social factors. This study uses an integrative approach with deep molecular profiling to identify potential biomarkers linked to phenotypes that underpin disease pathophysiology and provide better mechanistic insights into social health determinants. The TMCS incorporates multi-omics data, including genetic and metabolomic analyses of 10,933 participants, and comprehensive data collection ranging from physical, psychological, behavioral, and social to biological data. The metabolome is used as a phenotypic probe because it is sensitive to changes in physiological and external conditions. The TMCS focuses on collecting outcomes for cardiovascular disease, cancer incidence and mortality, disability and functional decline due to aging and disease sequelae, and the variation in health status within the body represented by omics analysis that lies between exposure and disease. It contains several sub-studies on aging, heated tobacco products, and women's health. This study is notable for its robust design, high participation rate (89%), and long-term repeated surveys. Moreover, it contributes to precision prevention in Japan and East Asia as a well-established multi-omics platform.

Objective: We attempted to record the regional cerebral blood flow (CBF) simultaneously at various regions of the cerebral cortex and the striatum during middle cerebral artery (MCA) occlusion and to evaluate neurological deficits and infarct formation., Methods: In male C57BL/6J mice, CBF was recorded in three regions including the ipsilateral cerebral cortex and the striatum with laser Doppler flowmeters, and the origin of MCA was occluded with a monofilament suture for 15-90 min. After 48 h, neurological deficits were evaluated, and infarct was examined by triphenyltetrazolium chloride (TTC) staining., Results: CBF decrease in the striatum was approximately two-thirds of the MCA-dominant region of the cortex during MCA occlusion. The characteristic CBF fluctuation because of spontaneously occurred spreading depolarization observed throughout the cortex was not found in the striatum. Ischemic foci with slight lower staining to TTC were found in the ipsilateral striatum in MCA-occluded mice for longer than 30 min (n = 54). Twenty-nine among 64 MCA-occluded mice exhibited neurological deficits even in the absence of apparent infarct with minimum staining to TTC in the cortex, and the severity of neurological deficits was not correlated with the size of the cortical infarct., Conclusion: Neurological deficits might be associated with the ischemic striatum rather than with cortical infarction., (© 2024 The Authors. Microcirculation published by John Wiley & Sons Ltd.)

BACKGROUND Inferior vena cava (IVC) injury is a potentially fatal injury with a high mortality rate of 34-70%. In cases in which the patient's condition is stable, diagnosis by computed tomography (CT) is the criterion standard. Findings on CT include retroperitoneal hematoma around the IVC, extravasation of contrast medium, and abnormal morphology of the IVC. We report a case of an IVC injury that could not be diagnosed by preoperative CT examination and could not be immediately detected during laparotomy. CASE REPORT A 73-year-old woman had stabbed herself in the neck and abdomen at home using a knife. When she arrived at our hospital, we found a stab wound several centimeters long on her abdomen and a cut approximately 15 cm long on her neck. We activated the massive transfusion protocol because she was in a condition of hemorrhagic shock. After blood transfusion and blood pressure stabilization, contrast-enhanced computed tomography (CT) revealed a small amount of fluid in the abdominal cavity. An otorhinolaryngologist performed successful drainage and hemostasis, and a laparotomy was performed. Gastric injury and mesentery injury of the transverse colon were identified and repaired with sutures. Subsequent search of the retroperitoneum revealed massive bleeding from an injury to the inferior vena cava (IVC). The IVC was repaired. Postoperative progress was good, and she was discharged from the hospital 65 days after her injuries. CONCLUSIONS We experienced a case of penetrating IVC injury, which is a rare trauma. Occult IVC injury may escape detection by preoperative CT examination or during laparotomy.

Aim: Non-occlusive mesenteric ischemia (NOMI) is associated with high mortality rates, but definitive treatments have not yet been established. Although experimental animal models are worthwhile, reproducible models that reflect the pathophysiology of NOMI have not been developed., Methods: We combined risk factors for NOMI, comprising hemorrhagic shock, systemic vasopressor infusion, and local vasopressor infusion from the superior mesenteric artery (SMA) in swine under maintained anesthesia. Experiment 1 involved full-intensity (40%) phlebotomy and systemic vasopressor (norepinephrine and epinephrine). Experiment 2 involved full-intensity (40%) phlebotomy, systemic norepinephrine, and local vasopressor infusion into the SMA. Experiment 3 involved moderate (27%) phlebotomy, systemic norepinephrine infusion, and local epinephrine infusion. We evaluated serum lactate levels, intestinal serosa color, computed tomography (CT) angiography, and pathological findings., Results: After inducing hemorrhage, systemic vasopressor alone and in combination with local vasopressin or norepinephrine infusion did not induce ischemic color changes in the intestine. The combination of systemic norepinephrine and local epinephrine (0.5 μg/kg/min) after moderate (27% blood loss) hemorrhage induced gross color change, pathological destruction, and elevation of serum lactate. Patent flow in the SMA was confirmed on CT angiography., Conclusion: We established a swine NOMI model with systemic norepinephrine infusion and local epinephrine with moderate hemorrhagic shock., Competing Interests: The authors declare no conflicts of interest., (© 2024 The Author(s). Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.)

Temporary intravascular shunting (TIVS) is an effective method to shorten the duration of ischemia and contribute to limb salvage in the treatment of popliteal artery injury (PAI). Traditionally used shunt tubes require ligation or clamping to the blood vessel, which has the disadvantage of causing secondary damage to the vessel. We present two cases in which TIVS was performed using the Pruitt-F3 Carotid Shunt (LeMaitre Vascular Inc., Burlington, Mass.) for traumatic PAI and report the effectiveness of the method. Two patients diagnosed with PAI had pallor of the feet and complete motor and sensory paralysis. The patients were immediately transferred to the operating room. PAI was confirmed in one patient by the medial approach and in the other by the posterior approach. In both patients, the vascular injury extended to the vicinity of the bifurcation into the anterior tibial artery. TIVS was performed using a 9Fr Pruitt-F3 Carotid Shunt. In both patients, the color tone of the feet improved. No vascular damage occurred secondary to TIVS. The popliteal artery was reconstructed using a great saphenous vein graft on the contralateral lower extremity, and the limb was salvaged. If the artery is injured near its bifurcation, it may be possible to preserve the branch vessel by using the Pruitt-F3 Carotid Shunt for TIVS., Competing Interests: The authors have no financial interest to declare in relation to the content of this article., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Competing Interests: Funding Support and Author Disclosures The Section of Arrhythmia is supported by an endowment from Abbott Japan, Boston Scientific Japan, and Medtronic Japan. Dr Hirata chairs the section, and Drs Fukuzawa and Imamura belong to the section. Dr Fukuzawa has received a scholarship donation from Biotronik Japan. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Clostridium perfringens is notorious for causing skin and soft tissue infections and food poisoning. Rarely, C. perfringens infections are associated with severe haemolysis, with a mortality rate of >80%. A previously healthy man in his 70s who presented with fever as his chief symptom was promptly admitted to a regional core hospital. Over the next 3 hours, shock and multiple organ failure ensued, leading to referral to our hospital for intensive care. We suspected a liver abscess caused by C. perfringens infection with haemolysis, findings of severe haemolysis and a liver mass with gas production that appeared within a few hours. Though surgical drainage was contemplated, low blood pressure resulted in death within 3 hours of arrival at our hospital. The next day, a blood culture confirmed C. perfringens , proving the diagnosis. Improving patient outcomes requires increased awareness of the disease and early detection., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Traumatic tension gastrothorax is a type of obstructive shock similar to tension pneumothorax. However, tension gastrothorax is not well known among emergency physicians, and no consensus has yet been reached on management during initial trauma care. We present a case of traumatic tension gastrothorax in which tube thoracostomy was performed based solely on clinical findings very similar to tension pneumothorax, followed by emergency laparotomy., Presentation of Case: A 24-year-old male motorcyclist was brought to our emergency medical center after being struck by a motor vehicle. He was in respiratory failure and hypotensive shock with findings suggestive of pneumothorax. Although the physical findings were not fully in line with tension pneumothorax, we immediately performed finger thoracostomy. Subsequent radiography revealed left diaphragmatic rupture with hernia. After unsuccessful attempts to decompress the stomach with a nasogastric tube, immediate emergency laparotomy was performed. During the operation, the stomach, which had prolapsed through the ruptured diaphragm into the thoracic cavity, was manually returned to the abdominal cavity. The ruptured diaphragm was repaired with sutures., Discussion: Although distinguishing between tension pneumothorax and tension gastrothorax based on physical examination alone is difficult, tension gastrothorax requires careful attention to avoid intrapleural contamination from gastric injury. In addition, relying solely on stomach decompression with a nasogastric tube or delaying laparotomy could lead to cardiac arrest., Conclusion: When tension pneumothorax is suspected during initial trauma care, tension gastrothorax should also be considered as a differential diagnosis and treated with immediate diaphragmatic repair once identified., Competing Interests: Declaration of competing interest All the authors declare no conflict of interests for this article., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Cerebral venous thrombosis (CVT) is challenging to diagnose, as it presents with variable symptoms. We encountered a complicated case of CVT that mimicked limbic encephalitis due to sensory aphasia. Based on the characteristic magnetic resonance imaging findings, this 72-year-old Japanese man was later confirmed to have CVT, the cause of which was periodontitis due to Eikenella corrodens, a Gram-negative facultative anaerobic that is part of the mouth's normal flora. The symptoms improved without sequelae following anticoagulation treatment and antibiotics. Clinicians should consider CVT as a differential diagnosis when unexplainable neurological symptoms suggesting limbic encephalitis are observed.

On 31 December 2019, the Municipal Health Commission of Wuhan, China, reported a cluster of atypical pneumonia cases. On 5 January 2020, the WHO publicly released a Disease Outbreak News (DON) report, providing information about the pneumonia cases, implemented response interventions, and WHO's risk assessment and advice on public health and social measures. Following 9 additional DON reports and 209 daily situation reports, on 17 August 2020, WHO published the first edition of the COVID-19 Weekly Epidemiological Update (WEU). On 1 September 2023, the 158th edition of the WEU was published on WHO's website, marking its final issue. Since then, the WEU has been replaced by comprehensive global epidemiological updates on COVID-19 released every 4 weeks. During the span of its publication, the webpage that hosts the WEU and the COVID-19 Operational Updates was accessed annually over 1.4 million times on average, with visits originating from more than 100 countries. This article provides an in-depth analysis of the WEU process, from data collection to publication, focusing on the scope, technical details, main features, underlying methods, impact and limitations. We also discuss WHO's experience in disseminating epidemiological information on the COVID-19 pandemic at the global level and provide recommendations for enhancing collaboration and information sharing to support future health emergency responses., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Pulmonary tumor thrombotic microangiopathy (PTTM) is a rare and critical malignancy-related disease characterized by acute progressive pulmonary hypertension (PH). In most cases of PTTM, the cancer can be diagnosed in advance. Identification of the primary cancer is valuable for PTTM diagnosis. Here, we present the case of a patient with PTTM due to early gastric carcinoma in whom the diagnosis of malignant cancer was not revealed until macroscopic autopsy findings. This case highlights the importance of recognizing causative occult early gastric cancer leading to PTTM in cases of acute progressive PH., Competing Interests: The authors declare no conflict of interest., (© 2024 The Authors. Pulmonary Circulation published by John Wiley & Sons Ltd on behalf of Pulmonary Vascular Research Institute.)