Publications (18)24.83 Total impact
-
Article: Lower expression of Th1-related cytokines and inducible nitric oxide synthase in mice with streptozotocin-induced diabetes mellitus infected with Mycobacterium tuberculosis.
[show abstract] [hide abstract]
ABSTRACT: Diabetes mellitus is an important predisposing factor for tuberculosis. The aim of this study was to investigate the mechanism underlying this association using a murine model. Mice with streptozotocin-induced diabetes mellitus were prone to Mycobacterium tuberculosis infection, as indicated by increased numbers of live bacteria in lung, liver and spleen. In diabetic mice, the levels of IL-12 and IFN-gamma in the lung, liver and spleen were lower than those in control animals on day 14 postinfection, while the opposite was true for IL-4 levels in the lung and liver. The expression pattern of inducible nitric oxide synthase (iNOS), in the two mice types was as for IL-12 and IFN-gamma. In addition, peritoneal exudate cells obtained from diabetic mice produced lower amounts of IL-12 and NO than those from control mice, when stimulated in vitro with M. bovis BCG. Spleen cells from diabetic mice infected with M. tuberculosis produced a significantly lower amount of IFN-gamma upon restimulation with purified protein derivatives (PPD) than those from infected nondiabetic mice. Interestingly, addition of high glucose levels (33 mM) to the cultures of PPD-restimulated spleen cells reduced the synthesis of IFN-gamma only in diabetic mice, and not in nondiabetic mice. Finally, control of blood glucose levels by insulin therapy resulted in improvement of the impaired host protection and Th1-related cytokine synthesis. Our results suggest that the reduced production of Th1-related cytokines and NO account for the hampered host defense against M. tuberculosis infection under diabetic conditions.Clinical & Experimental Immunology 02/2005; 139(1):57-64. · 3.36 Impact Factor -
Article: A calcified caecal mass.
Gut 09/2004; 53(8):1063, 1081. · 10.11 Impact Factor -
Article: [Spinal cord protection during thoracoabdominal aortic aneurysm repair; efficacy of distal aortic perfusion and segmental aortic clamping].
[show abstract] [hide abstract]
ABSTRACT: Despite improvement in adjuncts for thoracoabdominal aortic aneurysms (TAAA) repairs, many devastating complications remains after the surgery. Our experience with these aneurysms has been reviewed in order to identify those methods at risk of major morbidity, as well as which further improvements required. During last 16 years, 53 consecutive patients were operated on TAAA. The mean age was 58 years. Twenty patients had dissecting aneurysms and 13 patients had had prior aortic surgery. A femoro-femoral bypass was used to maintain distal aortic perfusion in most patients. Reimplantation of intercostal or lumbar arteries under the multi-segmental aortic clamping is consistent in our technique. Motor evoked potentials (MEP) were measured to monitor spinal cord protection since 2000. The hospital mortality was 9.4% (5/53), 22.2% (2/9) for emergency operation and 15.4% (2/13) for patients with prior aortic surgery. The mortality for the first and elective operations was 3.2% (1/31). No any neurologic dysfunction was observed in all patients including the hospital deaths. In view of clinical results, our adjuncts and techniques are useful for prevention of spinal cord ischemia during the TAAA surgery.Kyobu geka. The Japanese journal of thoracic surgery 05/2004; 57(4):268-73. -
Article: Blood distribution to the anterior spinal artery from each segment of intercostal and lumbar arteries.
[show abstract] [hide abstract]
ABSTRACT: Prevention of paraplegia, a serious complication of surgery for thoracoabdominal aortic aneurysm, has been well documented. However no assured prophylaxis against this complication has yet been found. Spinal ischemia is believed to be the major cause of paraplegia. We conducted an experimental study to define the development of paraplegia with regard to the blood supply to the spinal cord. A porcine model was used to evaluate blood distribution to the anterior spinal artery. Colored silastic agent was selectively injected into the intercostal and lumbar arteries, and distribution to the anterior spinal artery was evaluated on 50 animals. The intercostal and lumbar arteries were ligated in the segments where the blood supply to the anterior spinal artery would be interrupted. Whether or not paraplegia developed was checked 2 days later. Colored silastic agent arrived at the anterior spinal artery from all segments of the 8th intercostal to 4th lumbar arteries. Two of 9 pigs (22.2%) that underwent ligation of the segments from the 9th intercostal to 2(nd) lumbar artery suffered paraplegia. In 3 non-paraplegic pigs, colored silastic agent injected into the preserved arteries was found to have covered a wider range. All the intercostal and lumbar arteries supplied blood to the anterior spinal artery. When large segments of intercostal and lumbar arteries were ligated, the blood flow from the preserved segments acquired increased dominance. The possibility exists that any intercostal and lumbar artery can supply blood to the spinal cord and become collateral circulation to the anterior spinal artery.The Journal of cardiovascular surgery 11/2003; 44(5):637-45. · 1.56 Impact Factor -
Article: Role of tetrahydrobiopterin on ischemia-reperfusion injury in isolated perfused rat hearts.
[show abstract] [hide abstract]
ABSTRACT: It has recently been shown that nitric oxide synthase in the presence of suboptimal levels of tetrahydrobiopterin (BH(4)), an essential cofactor of nitric oxide synthase, may favor increased production of oxygen free radicals. This study was designed to define the role of BH(4) in myocardial ischemia-reperfusion injury. Isolated perfused rat hearts were subjected to 37 degrees C ischemia and reperfusion. Hearts were received with BH(4) or vehicle for 5 min just before ischemia and during the first 5 min of the reperfusion period. The effects of BH(4) on left ventricular function, myocardial contents of lipid peroxidation and high energy phosphates, and levels of lactate dehydrogenase and nitrite plus nitrate in perfusate before ischemia and after reperfusion were estimated. Moreover, the effect of BH(4) given with 2,4-diamino-6-hydroxypyrimidine (DAHP), a selective inhibitor of BH(4) production, intraperitoneally 24 h before the experiments were estimated. BH(4) improved contractile and metabolic abnormalities in reperfused hearts. Furthermore, BH(4) significantly alleviated ischemic contracture during ischemia, and restored diminished perfusate levels of nitrite plus nitrate after reperfusion. On the other hand, DAHP-treatment aggravated ischemia-reperfusion induced functional and metabolic abnormalities. Administration of BH(4) improved DAHP-induced functional and metabolic abnormalities. Results demonstrated that BH(4) lessens ischemia-reperfusion injury in isolated perfused rat hearts. Conversely, deficiency of BH(4) seems to accelerate endothelial dysfunction and myocardial ischemia-reperfusion injury. Present data may be compatible with the hypothesis that nitric oxide synthase in the presence of insufficiency of BH(4) serve as the cause of oxidative injury.The Journal of cardiovascular surgery 03/2003; 44(1):37-49. · 1.56 Impact Factor -
Article: [Impact of multi-segmental aortic clamping and distal aortic perfusion on the prevention of postoperative paraplegia during thoracoabdominal aortic graft replacement].
[show abstract] [hide abstract]
ABSTRACT: We present the impact of multisegmental aortic clamping under distal aortic perfusion and segmental artery reimplantation on the prevention of postoperative paraplegia during thoracoabdominal aortic graft replacement. During the last 14 years in 47 patients (age range: 22 to 82 years; average: 57,9 +/- 13,2 years; 16 females and 31 males) with thoracoabdominal aortic aneurysm a graft replacement was performed with adjuncts of normothermic partial bypass and multisegmental aortic clamping. As many patent segmental arteries as possible were reimplanted. Five patients died during hospitalization, for an in-hospital mortality rate of 10,6 %. In the elective patients (n = 40), the hospital mortality rate was 7,5 %. The average number of segmental aortic clampings per patient was 2,83 +/- 1,19 times. In 39 patients (82,9 %), 117 segmental arteries were reimplanted or preserved by beveled anastomosis. Eighty-three out of 117 segmental arteries (70,9 %) were located between TH9 and L2. Postoperative paraplegia/paraparesis did not occur in any patient. In view of our results reimplantation of as many segmental arteries as possible under multisegmental aortic clamping with adequate distal aortic perfusion can be recommended for effective prevention of spinal cord ischemia in TAAA surgery.Zentralblatt für Chirurgie 10/2002; 127(9):733-6. · 1.02 Impact Factor -
Article: Management of the heart rate during coronary artery bypass grafting on the beating heart: newly devised methods of decreasing heart rate--a preliminary report-.
[show abstract] [hide abstract]
ABSTRACT: To develop new methods for achieving bradycardia, we studied the feasibility of producing transient, reversible bradycardia with atrial stimulation and cooling of the sinoatrial node. In an animal study, the atrium was stimulated electrically during the refractory period of the atrioventricular node. Alternatively, an area of the sinoatrial node was cooled regionally. The two methods were also performed in combination. In a clinical study, atrial stimulation was applied in seven consecutive patients who underwent coronary artery bypass grafting (CABG). In the animal study, atrial stimulation was effective only when 2 mg/kg of diltiazem was administered. Such atrial stimulation decreased heart rate (beats/minute) from 95.8+/-16.9 to 64.2+/-20.0 (the average reduction from the control value 66.1+/-10.3%). Cooling the sinoatrial node decreased heart rate, and was effective with or without administration of diltiazem. Heart rate was decreased from 156.6 31.7 to 110.7+/-21.7 (average reduction from control value 71.3+/-9.2%) before using diltiazem and from 102.0+/-11.9 to 63.5+/-13.9 (average reduction from control value 62.0+/-10.4%) after administration of diltiazem. By combining the two methods, heart rate was decreased from 102.0+/-12.3 to 44.6+/-9.1 (average reduction from control value 43.5+/-6.3%). In our clinical study, the atrial stimulation method was effective. Atrial stimulation or regional cooling of the sinoatrial node slowed the heart rate. By combining the two methods, the heart rate was slowed to 40. Clinically, atrial stimulation was effective in CABG patients.Annals of thoracic and cardiovascular surgery: official journal of the Association of Thoracic and Cardiovascular Surgeons of Asia 01/2002; 7(6):358-67. · 0.69 Impact Factor -
Article: [Pericaval fat collection that mimics space-occupying lesion of the inferior vena cava complicated with liver cirrhosis].
Nippon Shokakibyo Gakkai zasshi The Japanese journal of gastro-enterology 01/2002; 98(12):1384-7. -
Article: Effect of 1-week treatment with erythropoietin on the vascular endothelial function in anaesthetized rabbits.
[show abstract] [hide abstract]
ABSTRACT: Chronic administration of erythropoietin (EPO) is often associated with hypertension in animals and humans. The aim of this study was to estimate whether 1-week treatment with EPO can affect the vascular endothelial function. Rabbits were given with EPO (400 iu kg(-1) s.c.) or saline each other day for 1 week. Hypotensive responses to intravenously given acetylcholine (ACh), endothelium-independent nitric oxide donors (NOC7, nitroprusside and nitroglycerin) and prostaglandin I2 were tested before and after administration of N(G)-nitro-L-arginine methyl ester (L-NAME), a specific nitric oxide synthase inhibitor, under pentobarbitone anaesthesia. Blood haemoglobin concentration in EPO group was significantly higher than that in control group, whereas baseline values of aortic pressure, heart rate and femoral vascular resistance were similar. The dose of ACh (172 ng kg(-1)) requiring for a 15 mmHg hypotension from the baseline in EPO group was apparently higher than that (55 ng kg(-1)) in control group. On the contrary, hypotensive responses to NOC7, nitroprusside, nitroglycerin and prostaglandin I2 were comparable between two groups. The extent of ACh-induced hypotension did not correlate with haemoglobin concentration. L-NAME significantly inhibited the ACh-induced vasodilating response in control group but did not in EPO group. In another set of rabbits, the same treatment with EPO also decreased vasodilating responses to carbachol, bradykinin and substance P besides ACh as compared with control group. These results indicate that 1-week treatment with EPO selectively attenuates depressor responses to endothelium-dependent vasodilators in anaesthetized rabbits, most likely due to inhibition of endothelial nitric oxide synthase.British Journal of Pharmacology 07/2001; 133(3):395-405. · 4.41 Impact Factor -
Article: One-stage thoracic aortic aneurysm treatment and coronary artery bypass grafting.
[show abstract] [hide abstract]
ABSTRACT: The treatment of thoracic aortic aneurysm accompanied by ischemic heart disease presents a surgical challenge and has up to now shown a high hospital mortality rate. This report discusses the factors contributing to improved results in these cases. We conducted a retrospective analysis of the records of 24 consecutive patients who had undergone replacement of thoracic aorta with combined coronary artery bypass grafting (CABG) between May 1991 and October 1998. Fifteen patients received total arch replacement (Arch-with-CABG Group), and the other 9 patients received the Bentall operation (Bentall-with-CABG Group). These results were compared with those patients who had undergone replacement of the thoracic aorta without CABG (Without-CABG Group). In the combined CABG groups, the overall operative mortality rate was 16.7%. In comparison with the Arch-without-CABG Group, there was a significantly longer cardiopulmonary bypass time and longer selective cerebral perfusion time in the Arch-with-CABG Group. However, no significant difference was observed in postoperative complications between the two groups. In addition, there was no significant difference in either actuarial survival or the cardiac-event-free rate at 5 years between the replacement of thoracic aorta with- and without-CABG Groups (83.1% vs. 90.4%, and 78.5% vs. 77.7%, respectively). No reoperation and no late death were observed during the follow-up period (mean 21.3 months). We concluded that replacement of the thoracic aorta combined with CABG can be carried out safely, and that revascularization for coronary artery disease is useful for preventing any occurrence of cardiac event.The Japanese Journal of Thoracic and Cardiovascular Surgery 05/2001; 49(4):236-43. -
Article: Comparison of contractile responses relative to protein between isolated diabetic and non-diabetic rat aortae to KCl and alpha-adrenoceptor agonists in different extracellular calcium concentrations.
[show abstract] [hide abstract]
ABSTRACT: The influence of extracellular Ca2+ concentration on contractile responses of aortae isolated from diabetic rats to KCl and alpha-adrenoceptor agonists was compared with that of non-diabetic rat aortae. Diabetic rats 6 weeks after administration of streptozotocin showed significantly lower body weight and higher plasma glucose concentration, but the protein content per each aortic ring preparation was not significantly different from that of non-diabetic preparation. Both diabetic and non-diabetic aortae showed concentration-dependent contractile responses to norepinephrine, which were concentration-dependently inhibited by prazosin. On the other hand, clonidine induced small contractions in both aortae, which tended to be more inhibited by prazosin than yohimbine. In non-diabetic aortae, the contractile responses to KCl, norepinephrine, methoxamine and clonidine were significantly greater with 2.5 mmol/l of extracellular Ca2+ than 1.25 mmol/l. In diabetic aortae, however, the contractile responses were not significantly influenced by changes in extracellular Ca2+ concentration. Additionally, the contractile responses to each agonist were markedly greater in non-diabetic aortae than diabetic ones. The present results indicate that the contractions of diabetic vasculature do not respond to changes in extracellular Ca2+ concentration, suggesting that there may be some impairment of Ca2+ related mechanisms.Arzneimittel-Forschung 01/2001; 50(12):1078-83. · 0.72 Impact Factor -
Article: Long-term angiographic evaluation of free internal thoracic artery grafting for myocardial revascularization.
[show abstract] [hide abstract]
ABSTRACT: Between 1990 and 1998, 41 patients underwent free internal thoracic artery grafting for coronary artery bypass. To investigate usefulness of free internal thoracic artery grafting, we compared the postoperative graft patency of free internal thoracic artery grafts with that of in situ internal thoracic artery grafts, and compared the long-term results such as actual survival and cardiac-event free rate in patients receiving free internal thoracic artery grafts with those results in patients receiving in situ internal thoracic artery grafts. Postoperative changes in luminal diameter of free internal thoracic artery grafts were calculated as the difference between the first and secondary angiographic evaluation in 17 patients who were followed-up for more than 5 years. The early postoperative graft patency rate of free internal thoracic artery was 95.2%. All these early patent grafts remained patent at the time of the late study. At 9 years post-surgery, patients who received free internal thoracic artery grafts had a survival rate of 100% and a cardiac event-free rate of 77.5%; the luminal diameter enlargement was 0.57 mm, and the mean matching rate increased 27.8%. We conclude that the free internal thoracic artery provides long-term results comparable with those of in situ internal thoracic artery.Annals of thoracic and cardiovascular surgery: official journal of the Association of Thoracic and Cardiovascular Surgeons of Asia 01/2001; 6(6):378-82. · 0.69 Impact Factor -
Article: Long-term results of root reconstruction using the Carrel patch.
[show abstract] [hide abstract]
ABSTRACT: The treatment of annuloaortic ectasia in patients, including those with Marfan syndrome, ascending aortic dissection, and other disorders of the ascending aorta and aortic valve presents a surgical challenge that has, unfortunately, shown high hospital mortality up to now. Improvements in graft materials and advanced surgical techniques have, however, begun to reduce hospital mortality. We retrospectively analyzed the records of 47 consecutive patients who undergoing aortic root reconstruction using the Carrel patch between January 1991 and March 1999. Postoperative complications included myonephrotic metabolic syndrome caused by femoral artery cannulation in 2 patients. Reexploration was done to halt bleeding in 2 patients. In 1 of 4 acute dissection patients, retrograde filling of the false lumen was demonstrated postoperatively. Overall surgical mortality in this series was 2.1% (1 of 47). The cardiac-event free rate was 98% at 5 years and 88% at 8 years. Actual survival is 97.8% at 8 years. No anastomosis complications were seen during follow-up (average: 32.7 months) (about 2.73 years). Surgery is considered feasible in any anatomic variation of aortic root disease, even in coronary ostial minimal dislocation, and the Carrel patch holds hope in preventing of anastomotic pseudaneurysm and ensuring long-term survival. Our experience suggests that modified Bentall operation, or aortic root remodeling using the Carrel patch, has few late-term complications, even in Marfan patients.The Japanese Journal of Thoracic and Cardiovascular Surgery 06/2000; 48(5):267-73. -
Article: Cardiac operations in patients with severe pulmonary impairment.
[show abstract] [hide abstract]
ABSTRACT: Many reviews concerning pulmonary complications after cardiac surgical procedures in patients with serious pulmonary disease have been published. However, no strict pulmonary function guidelines were proposed to help the clinician identify the patients at greater risk. We considered whether a low pulmonary function became a risk factor of cardiac operations. We conducted a retrospective analysis of records of 32 patients with severely impaired preoperative pulmonary function who had undergone cardiac operations between July 1988 and March 1999. There was 1 hospital death. The over-all mortality rate was 3.1% (1 of 32). However, this death could not be directly attributed to postoperative pulmonary complications. Postoperative pulmonary complications were seen in 2 patients (6.3%) who required tracheostomy due to atelectasis and pneumonia. No late deaths due to pulmonary complications were observed during the follow-up period. The actual survival rate is 68% at 7 years. A low pulmonary function did not, by itself, become a risk factor of cardiac operations, although a pulmonary function test can be used to alert the clinician to possible postoperative complications, including the requirement of tracheostomy. Especially strict control of postoperative respiration is necessary in patients with forced expiratory volume (FEV) of 1.0 <= 800 ml and/or FEV1.0/BSA <= 600 ml/m2.Annals of thoracic and cardiovascular surgery: official journal of the Association of Thoracic and Cardiovascular Surgeons of Asia 05/2000; 6(2):100-5. · 0.69 Impact Factor -
Article: [Evaluation of the results of the combined maze procedure for chronic atrial fibrillation with organic heart disease].
[show abstract] [hide abstract]
ABSTRACT: To examine the surgical indications and the results of the maze procedure, we reviewed 30 cases who underwent the maze procedure concomitantly with other open heart surgery from October 1995 to October 1997.: the average age was 60.9 years (37 to 75 years) and mean follow up period was 12.3 months (1 to 25 months). The modified maze procedure described by Kosakai and associates was applied in all patients. Twenty one patients (72.4%) regained atrial rhythm and eight patients (27.6%) sustained atrial fibrillation in the follow up periods. The left atrial diameter measured by echocardiography and cardiothoracic ratio were significantly larger in the latter group of patients, compared with those who recovered normal sinus rhythm (63.8 +/- 19.5 versus 51.2 +/- 7.8 mm and 67.7 +/- 8.1 versus 59.2 +/- 5.4%). In order to perform the combined maze procedure, cardiac arrest time and cardiopulmonary bypass time were extended for 56.9 minutes and 65.9 minutes, respectively, compared with the cases without a maze procedure. Four patients (brady atrial fibrillation 2, brady junctional rhythm 1, and complete AV block 1) required permanent pacemaker implantation. There was no operative death, but one patient who underwent the maze procedure and AVR + MAP + TAP died after 4 months due to pulmonary infection, sepsis and multiple organ dysfunction. This patient had shown low output syndrome for 3 days postoperatively. Having considered the data that the preoperative ejection fraction was 51%, cardiopulmonary bypass and cardiac arrest time were 200 min and 165 min respectively, occurrence of low cardiac output had been influenced by prolonged aortic cross-clamp. No late deaths have been observed in follow up period. In conclusion, maze procedure should not be performed in patients who have enlarged left atrium or complex cases requiring relatively longer operative time.Kyobu geka. The Japanese journal of thoracic surgery 06/1999; 52(5):379-83. -
Article: [A case of traumatic aneurysm of the brachiocephalic artery].
[show abstract] [hide abstract]
ABSTRACT: Traumatic aneurysm of the brachiocephalic artery is rate. We presented a case of traumatic aneurysm of the brachiocephalic artery caused by traffic accident. A 28-year-old woman suffered a blunt chest trauma. A chest X-ray revealed a widening of the superior mediastinum and multiple rib fractures. CT scanning demonstrated left hemothorax with lung contusion and upper mediastinal hematoma. An aortography was performed which showed aneurysmal dilatation at the origin of the brachiocephalic artery. The patient underwent an operation 24 hours after chest injury. An aorto-right common carotid artery and right subclavian artery bypass with bifurcated Dacron graft was performed while monitoring temporary artery pressure. After resection of aneurysm, We found that about 3 cm longitudinal laceration of intima on the posterior wall of brachiocephalic artery. Her post operative condition was good and no neurological defect was noted.The Japanese Journal of Thoracic and Cardiovascular Surgery 10/1998; 46(9):889-92. -
Article: [An evaluation of cases carried out by both root reconstruction using Carrel patch method and concomitant procedure].
[show abstract] [hide abstract]
ABSTRACT: During the past 7 years from January 1991 to November 1997, we experienced 31 cases of aortic root reconstruction utilizing Carrel patch method. Concomitant procedure were performed in 9 cases of them due to another cardiovascular disease. Complicated cardiovascular disease included 3 cases of ischemic heart disease, 3 cases mitral regurgitation and one case of Aortic arch aneurysm. Several concomitant procedures were performed; 5 cases of CABG, 2 cases of mitral annuloplasty, one case of CABG with mitral valve replacement and one case of aortic arch replacement. The mean extra corporeal circulation time was 190.6 +/- 39.3 minutes and aortic clamp time was 147.8 +/- 34.2 minutes in these 9 cases. There were no significant differences of operative results between the simple root reconstruction group and the concomitant procedure group. We concluded that the aortic root reconstruction using the Carrel patch method has few complications. Although further long-term follow-up is required, our experiences suggest that the aortic root reconstruction with the concomitant procedure can be carry out safely with the aid of appropriate assistance method.The Japanese Journal of Thoracic and Cardiovascular Surgery 09/1998; 46(8):707-11. -
Article: [Separate operation for extensive aneurysm (mega-aorta) complicated with ischemic heart disease].
[show abstract] [hide abstract]
ABSTRACT: A seventy one year-old woman, who had an arch and thoracoabdominal aortic aneurysm (type II according to Crawford classification) with ischemic heart disease, underwent a separate operation using the elephant trunk method. At first, she underwent the ascending aorta and arch replacement the with elephant trunk technique, and, underwent CABG simulutaneously utilizing the separate extra corporeal circulation and hypothermic circulatory arrest. The Chest and abdominal CT revealed the enlargement of abdominal aortic aneurysm 5 months after operation. The second operation was performed using Stoney's spiral opening method and the revasculization of spinal arteries (Th6, 7 and Th9) underwent the segmental aortic clamping to prevent spinal cord ischemia. Furthermore, the second operation was performed using selective perfusion to visceral arteries and F-F bypass for the prevention of visceral ischemia. Each flow rate by selective perfusion in major abdominal blanches was from 50 to 100 ml/min. Therefore, hepatorenal dysfunction and paraparesis did not occur after the second operation. It was suggested that the segmental aortic clamping and the selective perfusion to visceral arteries with F-F bypass may be effective to prevent the ischemia of the spinal cord and abdominal organs.The Japanese Journal of Thoracic and Cardiovascular Surgery 09/1998; 46(8):737-42.
Top co-authors
Top Journals
Institutions
-
2000–2005
-
University of Ryukyus
- Faculty of Medicine
Okinawa, Okinawa-ken, Japan
-
