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Apical ballooning syndrome, the so-called takotsubo cardiomyopathy (TTC), is characterized by wall-motion abnormality. The wall-motion abnormality includes hypokinesis in the mid and apical segments of the left ventricle (LV) with hyperkinesis in the mid LV segment. The LV dysfunction is reversible. TTC has been reportedly been found in 1 to 2 % of patients suspected of having acute coronary syndrome (ACS). Although the wall-motion abnormality of TTC is a significant feature, clinical presentation involving chest pain or ECG abnormalities is similar to that for ACS. Therefore, the diagnosis of TTC is still a challenge in emergency settings. Cardiovascular imaging may assist in the diagnosis and understanding of the pathophysiology of TTC.

Bilirubin is taken up from blood into hepatocytes by sinosuidal membrane transporters and then excreted into bile through the bile canalicular membrane mainly as bilirubin glucuronides. (1) Mechanism of bilirubin uptake into hepatocytes: many organic anions are incorporated into hepatocytes by organic anion transporting polypeptides (rat, oatp 1, oatp2, oatp3; human, OATP), liver-specific transporter (rlst/HLST), and/or by organic anion transporters (OAT2, OAT3). Oatp1 and HLST transport bilirubin monoglucuronide. However, a transporter of unconjugated bilirubin in the sinusoidal membrane has not as yet been identified. Unconjugated bilirubin may also go across the hepatocyte sinusoidal membrane by a diffusion process. (2) Intrahepatic transport and conjugation of bilirubin: ligandin carries bilirubin to the endoplasmic reticulum (ER) of hepatocytes. In the ER, bilirubin is conjugated by bilirubin uridine diphosphate (UDP)-glycosyltransferase (bilirubin UGT; UGT1A1) to form mono- and diglucuronides of bilirubin. (3) Transport mechanism of bilirubin glucuronides across the hepatocyte canalicular membrane: at the canalicular membrane, bilirubin glucuronides are excreted into bile by multidrug resistance-associated protein 2 (MRP2), a member of the ATP-binding cassette transporter family. (4) Regurgitation of bilirubin glucuronides into blood: MRP3, which is located in the lateral membrane, transports bilirubin glucuronides into blood under conditions of impaired biliary bilirubin excretion.

Background: Frequent and long-term commuting is a requirement for dialysis patients. Accessibility thus affects their quality of lives. In this paper, a new model for accessibility measurement is proposed in which both geographic distance and facility capacity are taken into account. Simulation of closure of rural facilities and that of capacity transfer between urban and rural facilities are conducted to evaluate the impacts of these phenomena on equity of accessibility among dialysis patients. Methods: Post code information as of August 2011 of all the 7,374 patients certified by municipalities of Hiroshima prefecture as having first or third grade renal disability were collected. Information on post code and the maximum number of outpatients (capacity) of all the 98 dialysis facilities were also collected. Using geographic information systems, patient commuting times were calculated in two models: one that takes into account road distance (distance model), and the other that takes into account both the road distance and facility capacity (capacity-distance model). Simulations of closures of rural and urban facilities were then conducted. Results: The median commuting time among rural patients was more than twice as long as that among urban patients (15 versus 7 minutes, p, The software used in this study was supplied by the Higher Education Grant Program of ESRI Japan Corp (Tokyo, Japan). Ministry of Education, Culture, Sports, Science and Technology (Tokyo, Japan) sponsored this research.