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Interactions of the heart and the liver remain to be fully understood in the pathophysiology of heart failure (HF). Hepatokines are proteins synthesized and secreted from the liver and regulate systemic metabolisms of peripheral tissues. This study sought to clarify the clinical relevance of hepatokine Fetuin-A in patients with HF.We enrolled 217 participants including 187 hospitalized patients with HF and 30 control subjects who were sought with a comparable age- and sex profile and who had never had HF or structural cardiac abnormalities. First, we examined the levels of Fetuin-A and found that its levels were significantly lower in patients with HF than in the controls. Next, HF patients were categorized into four groups based on hepatic hemodynamics assessed by abdominal ultrasonography which determines liver hypoperfusion by peak systolic velocity (PSV) of the celiac artery and liver stiffness by shear wave elastography (SWE). Fetuin-A levels were significantly decreased in HF patients with liver hypoperfusion compared to those without, but were not different between HF patients with and without elevated liver stiffness. Correlation analysis revealed that circulating Fetuin-A was positively correlated with PSV of the celiac artery but not with SWE of the liver. Kaplan-Meier analysis demonstrated that HF patients with lower Fetuin-A levels were significantly associated with increased adverse outcomes including cardiac deaths and decompensated HF.Liver-derived hepatokine Fetuin-A may be a novel target involved in the cardio-hepatic interactions, as well as a useful biomarker for predicting the prognosis in patients with HF.

It has been reported that the pattern of hepatic vein (HV) waveforms determined by abdominal ultrasonography is useful for the diagnosis of hepatic fibrosis in patients with chronic liver disease. We aim to clarify the clinical implications of HV waveform patterns in patients with heart failure (HF).We measured HV waveforms in 350 HF patients, who were then classified into 3 categories based on their waveforms: those with a continuous pattern (C group); those whose V wave ran under the baseline (U group), and those with a reversed V wave (R group). We performed right-heart catheterization, and examined the rate of postdischarge cardiac events, such as cardiac death and rehospitalization due to worsening HF.The number of patients in each of the 3 HV waveform groups was as follows: C group, n = 158; U group, n = 152, and R group, n = 40. The levels of B-type natriuretic peptide (R vs C and U; 245.8 vs 111.7 and 216.6 pg/mL;Among HF patients, those with reversed V waves had higher right atrial pressure and were at higher risk of adverse prognosis.Nous avons appris que le tracé ondulatoire de la veine hépatique (VH) à l’échographie abdominale est utile au diagnostic de la fibrose hépatique chez les patients atteints d’une maladie chronique du foie. Nous avons pour objectif de clarifier les implications cliniques des tracés ondulatoires de la VH chez les patients atteints d’insuffisance cardiaque (IC).Nous avons mesuré les ondulations de la VH de 350 patients atteints d’IC et les avons ensuite classifiés en trois catégories selon leurs ondulations : ceux qui avaient un tracé continu (groupe C); ceux dont l’onde V se présentait selon les valeurs de référence (groupe U); ceux qui avaient une onde V inversée (groupe R). Nous avons réalisé un cathétérisme cardiaque droit et examiné le taux d’événements cardiaques après la sortie de l’hôpital tels que la mort d’origine cardiaque et la réhospitalisation en raison de l’aggravation de l’IC.Le nombre de patients dans chacun des trois groupes d’ondulations de la VH était réparti comme suit : groupe C, n = 158; groupe U, n = 152 et groupe R, n = 40. Les concentrations en peptides natriurétiques de type B (RChez les patients atteints d’IC, ceux qui avaient des ondes V inversées avaient une pression plus élevée de l’oreillette droite et étaient exposés à un risque plus élevé de pronostic défavorable.

We aimed to clarify clinical implications of intrarenal hemodynamics assessed by intrarenal Doppler ultrasonography (IRD) and their prognostic impacts in heart failure (HF). We performed a prospective observational study, and examined IRD and measured interlobar renal artery velocity time integral (VTI) and intrarenal venous flow (IRVF) patterns (monophasic or non-monophasic pattern) to assess intrarenal hypoperfusion and congestion in HF patients (n = 341). Seven patients were excluded in VTI analysis due to unclear imaging. The patients were divided into groups based on (A) VTI: high VTI (VTI ≥ 14.0 cm, n = 231) or low VTI (VTI

In hospital microbial laboratories, morphological and biochemical analyses are performed to identify pathogenic microbes;however, these procedures lack rapidity and accuracy. Recently, Matrix-Assisted Laser Desorption/Ionization Time-of-Flight Mass Spectrometry (MALDI-TOF MS) has been clinically utilized, and is expected to enable rapid and accurate microbial identification. We aimed to validate two MALDI-TOF MS devices available in Japan: the VITEK-MS (BioMérieux) and the Microflex LT (Bruker Daltonics). Clinically isolated bacteria, 100 samples in all, detected in blood cultures but incompletely identified by conventional procedures, were reanalyzed using the two devices. The VITEK-MS and Microflex LT, respectively, identified 49% (49/100) and 80% (80/100) of the tested bacteria at the species level, as well as 96% (96/100) and 95% (95/100) at the genus level. Among those reidentified strains, 26% (26/100) at the species level and 88% (88/100) at the genus level were concordant with each other, though three strains were unmatched. Moreover, four bacterial strains were unable to be identified using the VITEK-MS, versus five using the Microflex LT. MALDI-TOF MS devices can provide more rapid and accurate bacterial identification than ever before;however, the characteristics of each system were slightly different;therefore, it is necessary to understand the difference in performance of MALDI-TOF MS models.

BackgroundIt has been recently reported that the renal venous stasis index (RVSI) assessed by renal Doppler ultrasonography provides information to stratify pulmonary hypertension that can lead to right-sided heart failure (HF). However, the clinical significance of RVSI in HF patients has not been sufficiently examined. We aimed to examine the associations of RVSI with parameters of cardiac function and right heart catheterization (RHC), as well as with prognosis, in patients with HF.MethodsWe performed renal Doppler ultrasonography, echocardiography and RHC in hospitalized patients with HF (n = 388). RVSI was calculated as follows: RVSI = (cardiac cycle time-venous flow time)/cardiac cycle time. The patients were classified to three groups based on RVSI: control group (RVSI = 0, n = 260, 67%), low RVSI group (0 < RVSI ≤ 0.21, n = 63, 16%) and high RVSI group (RVSI > 0.21, n = 65, 17%). We examined associations of RVSI with parameters of cardiac function and RHC, and followed up for cardiac events defined as cardiac death or worsening HF.ResultsThere were significant correlations of RVSI with mean right atrial pressure (mRAP; R = 0.253, P < 0.001), right atrial area (R = 0.327, P < 0.001) and inferior vena cava diameter (R = 0.327, P < 0.001), but not with cardiac index (R = −0.019, P = 0.769). During the follow-up period (median 412 days), cardiac events occurred in 60 patients. In the Kaplan–Meier analysis, the cumulative cardiac event rate increased with increasing RVSI (log-rank, P = 0.001). In the multivariate Cox proportional hazard analysis, the cardiac event rate was independently associated with RVSI (high RVSI group vs. control group: hazard ratio, 1.908; 95% confidence interval, 1.046–3.479, P = 0.035).ConclusionRVSI assessed by renal Doppler ultrasonography reflects right-sided overload and is associated with adverse prognosis in HF patients.

Clinical significance of reduced vagal activity following pulmonary vein isolation (PVI) for atrial fibrillation (AF) remains unclear. Periesophageal vagal nerve injury following PVI may be a powerful contributing factor of decreased vagal tone. Drug‐refractory 51 AF patients (31 males, 64 ± 11 years), who underwent successful PVI, were enrolled. We performed esophagogastroduodenoscopy 2 days after PVI and assessed delayed gastric emptying (DGE). Additionally, the coefficient of variance of R-R interval (CVRR) as a surrogate for vagal tone was measured before PVI, as well as at 1 day and 3 months after PVI. The patients were divided into two groups, patients with DGE and patients without DGE, and changes in CVRR were compared. After PVI, 12 out of 51 patients (23.5%) had DGE. The baseline CVRR did not differ between the patients with (n = 12) and those without (n = 39) DGE (median 3.13%, interquartile range 1.69–5.13 vs. median 3.76%, interquartile range 2.96–5.90, P = 0.297). However, CVRR at 1 day after PVI was significantly lower in the patients with DGE than in those without (median 1.49%, interquartile range 0.90–2.19 vs. median 2.59%, interquartile range 1.58–3.86, P = 0.035), and then CVRR at 3 months became similar between the two groups, suggesting that the two groups had different changes in vagal tone after PVI. The recurrence of AF was similar at 3–6 months after PVI between the two groups. A significantly decreased CVRR immediately after PVI is a sign of DGE incidence, implying collateral damage to the esophagus.

Background: It has been recently reported that liver stiffness assessed by transient elastography reflects right atrial pressure (RAP) and is associated with worse outcomes in patients with heart failure (HF). However, the relationship between shear wave dispersion (SWD, a novel indicator of liver viscosity) determined by abdominal ultrasonography and RAP, and the prognostic impact of SWD on HF patients have not been fully examined. We aimed to clarify the associations of SWD with parameters of liver function test (LFT) and right heart catheterization (RHC), as well as with cardiac events such as cardiac death and worsening HF, in patients with HF. Methods: We performed abdominal ultrasonography, LFT and RHC in HF patients (n = 195), and followed up for cardiac events. We examined associations between SWD and parameters of LFT and RHC. Results: There were significant correlations between SWD and circulating levels of direct bilirubin (R = 0.222, p = 0.002), alkaline phosphatase (R = 0.219, p = 0.002), cholinesterase (R = &minus, 0.184, p = 0.011), and 7S domain of collagen type IV (R = 0.177, p = 0.014), but not with RAP (R = 0.054, p = 0.567) or cardiac index (R = &minus, 0.015, p = 0.872). In the Kaplan&ndash, Meier analysis, cardiac event rate was significantly higher in the high SWD group (SWD &ge, 10.0 (m/s)/kHz, n = 103) than in the low SWD group (SWD &lt, 10.0 (m/s)/kHz, n = 92, log-rank, p = 0.010). In the Cox proportional hazard analysis, high SWD was associated with high cardiac event rates (hazard ratio, 2.841, 95% confidence interval, 1.234&ndash, 6.541, p = 0.014). In addition, there were no interactions between SWD and all subgroups, according to the subgroup analysis. Conclusions: SWD assessed by abdominal ultrasonography reflects liver fibrosis rather than liver congestion, and is associated with adverse prognosis in HF patients.

Background It has been reported that liver stiffness assessed by transient elastography are correlated with right atrial pressure, which is associated with worse outcome in patients with heart failure (HF). We aimed to clarify clinical implications of hepatic hemodynamic evaluation (liver congestion and hypoperfusion) by abdominal ultrasonography in patients with HF. Methods and Results We performed abdominal ultrasonography, right‐heart catheterization, and echocardiography, then followed up for cardiac events such as cardiac death or worsening HF in patients with HF. Regarding liver congestion, liver stiffness assessed by shear wave elastography (SWE) of the liver was significantly correlated with right atrial pressure determined by right‐heart catheterization ( R =0.343; P R =0.291; P P =0.033). In the Cox proportional hazard analysis, high SWE and low PSV were associated with high cardiac event rate (high SWE: hazard ratio [HR], 2.039; 95% CI, 1.131–4.290; low PSV: HR, 2.211; 95% CI, 1.199–4.449), and the combination of high SWE and low PSV was a predictor of cardiac events (HR, 4.811; 95% CI, 1.562–14.818). Conclusions Intrahepatic congestion and hypoperfusion determined by abdominal ultrasonography (liver SWE and celiac PSV) are associated with adverse prognosis in patients with HF.

Doppler ultrasound measurements were done for the thickness of synovial effusion and synovial proliferation (pannus), and diameter of the fl ow signals using digital cali- pers as well as fl ow signal grades and vascular resistance in the knee joint synovitis of patients with rheumatoid arthritis (RA) treated with infl iximab. Forty knee joints of 20 RA patients were assessed before and after three injections of infl iximab. The fl ow signals in the pannus were classifi ed into the superfi cial and the deep signals and the joints were classifi ed into the superfi cial signal pattern and the deep signal pattern. After treatment, the number of joints with superfi cial signal pattern reduced from 23 to 11, whereas the number of joints with deep signal pattern increased from 17 to 29 (P = 0.0066), with a signifi cant reduction of the superfi cial signal grades (P = 0.0003). The mean cortical (posterior) pannus thickness increased signifi cantly in the joints with superfi cial signal pattern (P = 0.022) and in the total joints (superfi cial plus deep signal pattern) (P = 0.031) but not in the joints with deep signal pattern. After 6 weeks of treatment with infl iximab, the hyperemia in the superfi - cial layer of the pannus developed into proliferation of the cortical pannus in the knee joints.

Power Doppler and spectral Doppler ultrasonography were used to scan 127 knee joints of 72 patients with rheumatoid arthritis (RA). Synovial effusion thickness and synovial proliferation (pannus) thickness, as well as the flow signal diameter, were measured on ultrasonogram prints of the power Doppler using digital calipers. In addition, color-flow signal grades on power Doppler and the resistance index (RI) values on spectral Doppler were evaluated. The values of these five variables were compared among 58 joints with superficial pattern flow signals and 69 joints with deep pattern flow signals. Compared with the joints with deep pattern signals, the joints with superficial pattern signals had significantly higher mean values of effusion thickness (P < 0.0001) and flow signal grades (P < 0.0001), and significantly lower mean RI (P < 0.0001). On the other hand, the joints with deep pattern signals had a significantly higher value of signal diameter (P = 0.0125) and had a trend to higher value of pannus thickness (P = 0.079) as well. Significant correlations were observed between effusion thickness and signal grades (P < 0.0001); effusion thickness and RI (P < 0.0001); signal diameter and pannus thickness (P = 0.0102); signal diameter and RI (P < 0.0001); and signal grades and RI (P < 0.0001). The ultrasonographic measurements of synovitis in RA patients provide valuable information on synovial inflammation.

Children are often frightened, cry, refuse to sit still, and may not cooperate during a physiological examination. Technologists must take considerable care to reduce the child's anxiety. Specifically, we should use creative solutions, start by interacting with the patient, using dolls or toys, and explain the procedure to him/her in a friendly way, communicating more effectively with the patient's family. When performing the actual examinations, technologists need to work skillfully with a complete understanding of the purpose of the examinations, having the ability to identify the changes that occur in various developmental stages and interpret the pathophysiological mechanisms specific to children. Furthermore, we must always have an awareness of safety, taking measures to prevent falls from the bed and/or to keep the room warm if examinations require the child to be naked, so that he/she will not catch a cold. I explain various points of caution and possible solutions regarding electrocardiograms, electroencephalograms, and ultrasonography, from the viewpoint of a medical technologist.

We used Doppler sonography to evaluate the therapeutic effects of infliximab on the knee and metacarpophalangeal (MCP) joints of 10 patients with rheumatoid arthritis (RA), based on the color flow signals (CFS) and resistance index (RI) of synovial vascularity. After three injections of infliximab, we observed significant improvement in numbers of tender joints (P < 0.01), values of C-reactive protein (CRP) (P < 0.01), erythrocyte sedimentation rate (ESR) (P < 0.001), disease activity scores including tender joints, swollen joints, and ESR (DAS28-E3) (P < 0.0001), and CFS of knee (P < 0.001) and MCP (P < 0.05) joints. There was no significant improvement in RI values of knee or MCP joints after the therapy. We observed significant correlation between CFS of knee joints (knee-CFS) and values of CRP (P < 0.01), ESR (P < 0.01), and DAS28-E3 (P < 0.05), but not between CFS of MCP joints (MCP-CFS) and values of CRP, ESR, and DAS28-E3. However, no significant correlation was observed between 10 difference values (before values-after values) of CFS grades of knee or MCP joints and 10 difference values each of CRP, ESR, or DAS28-E3. The knee joints are more suitable than MCP joints for obtaining CFS in Doppler sonography, and are more useful than MCP joints for evaluation.

Synovial vascularity of 12 patients with rheumatoid arthritis (RA) was examined by Doppler sonography for color flow signals and vascular resistance on knee joints and metacarpophalangeal (MCP) joints, and the results were compared with each other and with C-reactive protein (CRP) levels of the patients. A significant correlation was observed between knee resistance index (RI) and MCP-RI (P = 0.0140), but not between knee color flow signals and MCP color flow signals (P = 0.1029). A significant correlation was also observed between knee color flow signals and knee RI (P = 0.0107), and knee pulsatility index (PI) (P = 0.0146). On the other hand, no correlation was observed between MCP color flow signals and MCP-RI (P = 0.828), and MCP-PI (P = 0.434). There was no significant correlation between CRP levels and grades of color flow signals, RI, and PI for both knee and MCP joints. Doppler sonographic evaluation of RI, especially knee RI, could be a useful marker for estimating synovial inflammation in RA patients.

A series of 47 knee joints in 24 patients with rheumatoid arthritis were examined for intraarticular vascularization by power Doppler sonography. The intensity of vascularization was compared with the synovial effusion and proliferation evaluated by gray-scale sonography and the clinical findings in the patients. Vascularization was graded from 0 to 3 by counting the number of color-flow signals: grade 0, no signals; grade one, 1–4 signals; grade two, 5–8 signals; grade three, 9 or more signals. The grade of vascularization correlated with the grade of synovial effusion (P ≪ 0.01), the grade of synovial proliferation (P ≪ 0.05), and the serum levels of C-reactive protein (P ≪ 0.05). It correlated inversely with disease duration (P ≪ 0.01). Consistent with improvement of articular inflammation, a decrease in the number of color-flow signals was observed in two patients. Power Doppler sonography is suitable for evaluating the intensity of synovitis and for monitoring the clinical activity of rheumatoid patients.

To the Editor: In a previous issue of Modern Rheumatology, we demonstrated the usefulness of sonographic evaluation for determining the therapeutic effect of infliximab in six patients with rheumatoid arthritis (RA). Both color flow signals and resistance index (RI) (vascular resistance) in the knee joints of patients demonstrated significant improvements on Doppler sonography (P < 0.05 each) after three injections at the 6-week evaluation of infliximab treatment. The present study of 12 RA patients (including the previously reported six patients) treated using infliximab confirms the previous results. Furthermore, more significant indications of improvement were obtained in several clinico-sonographic findings compared with the previous study. All 12 RA patients satisfied the American College of Rheumatology (ACR) revised 1987 criteria for RA and received pharmacotherapy in accordance with the official Japanese guidelines for infliximab treatment of RA. Patients were injected with infliximab on days 0, 14, and 42 at a dose of 3mg/kg per injection. Clinical and sonographic evaluations were per

Synovial vascularization in the knee joints of six patients with rheumatoid arthritis who were treated with infliximab was evaluated by Doppler sonography. Power Doppler sonography demonstrated a significant reduction of color flow signals (P < 0.05), and spectral Doppler sonography demonstrated a significant increase in vascular resistance (P < 0.05) at week 6 (after three injections) evaluation of the therapy. A significant decrease in the number of tender joints (P < 0.05) and C-reactive protein value (P < 0.05) was also observed in these patients.

Synovial vascularization was analyzed by power Doppler and spectral Doppler sonography in 42 knee joints of 28 patients with rheumatoid arthritis. The synovial vessels with greater intensity of color flow signals demonstrated significantly lower indicators of vascular resistance – resistive index (P < 0.01) and pulsatility index (P < 0.01) – than those with lesser intensity. Consequently, an inverse correlation was observed between intensity of color flow signals and both resistive index (P < 0.01) and pulsatility index (P < 0.01).

Intraarticular vascularization in 54 knee joints of 27 patients with rheumatoid arthritis was examined by power Doppler sonography. Localization of the vascularity at the suprapatellar recess was classified into two patterns: intracapsular and supra-cortical. The patients with supra-cortical vascularization showed a tendency to higher grades of synovitis and higher levels of inflammatory laboratory indices than those with intracapsular vascularization.