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Aim Familial hypercholesterolemia (FH) is an underdiagnosed autosomal dominant genetic disorder characterized by high levels of plasma low-density lipoprotein cholesterol (LDL-C) from birth. This study aimed to assess the genetic identification of FH in children with high LDL-C levels who are identified in a universal pediatric FH screening in Kagawa, Japan. Method In 2018 and 2019, 15,665 children aged 9 or 10 years underwent the universal lipid screening as part of the annual health checkups for the prevention of lifestyle-related diseases in the Kagawa prefecture. After excluding secondary hyper-LDL cholesterolemia at the local medical institutions, 67 children with LDL-C levels of ≥ 140 mg/dL underwent genetic testing to detect FH causative mutations at four designated hospitals. Results The LDL-C levels of 140 and 180 mg/dL in 15,665 children corresponded to the 96.3 and 99.7 percentile values, respectively. Among 67 children who underwent genetic testing, 41 had FH causative mutations (36 in the LDL-receptor, 4 in proprotein convertase subtilisin/kexin type 9, and 1 in apolipoprotein B). The area under the curve of receiver operating characteristic curve predicting the presence of FH causative mutation by LDL-C level was 0.705, and FH causative mutations were found in all children with LDL-C levels of ≥ 250 mg/dL. Conclusion FH causative mutations were confirmed in almost 60% of the referred children, who were identified through the combination of the lipid universal screening as a part of the health checkup system and the exclusion of secondary hyper-LDL cholesterolemia at the local medical institutions.

Clinical Introduction A 69-year-old woman with hypertension and dyslipidemia developed sudden onset of substernal chest pain at night and was admitted to our hospital the following day. A 12-lead and 18-lead ECG (Nihon Kohden, Japan) was done (figure 1A,B). Question Which is the most likely diagnosis? Reperfused anterior acute myocardial infarction Takotsubo (stressed) cardiomyopathy Pericarditis Apical hypertrophic cardiomyopathy For answer see page 2.

Background Atrial fibrillation (AF), which contributes to an increased risk of stroke, frequently remains undetected, suggesting an unmet need for easier and more reliable AF screening. The reports on screening AF using an Omron blood pressure (BP) monitor with an irregular heartbeat (IHB) detector show inconsistent results, so the aim of this study was to develop a novel algorithm to accurately diagnose AF with 3 BP measurements using an Omron automated BP monitor with IHB detector.Methods and Results:In total, 303 general cardiac patients were included. Real-time single-lead ECG revealed AF in 44 patients. BP measurement was performed 3 times per patient using the Omron BP monitor HEM-907, and the number of IHBs detected was recorded. Based on these data, we developed the following algorithm: ≥1 IHB is detected during at least 2 of 3 BP measurements and the maximum number of IHBs detected is ≥2. Using this algorithm, we achieved a sensitivity of 95.5% and specificity of 96.5%, for diagnosing AF. Conclusions The novel algorithm with 3 BP measurements using the Omron automated BP monitor with IHB detector showed high sensitivity and specificity for diagnosing AF in general cardiac patients.

Twelve-lead electrocardiography provides us the clue about the differential diagnosis between atrioventricular nodal reentrant tachycardia and atrioventricular reentrant tachycardia.

We often observe patients with antiphospholipid syndrome (APS) presenting with both venous and arterial thrombi. Anticoagulant therapy is effective for venous and peripheral arterial embolisms in these patients; however, it has opposite effects when applied for thoracic aortic mural thrombosis because of the risk of new arterial embolisms. Recently, thoracic endovascular aortic repair (TEVAR) has been used to prevent arterial embolisms due to aortic thrombosis. However, we generally hesitate to implant artificial materials in patients in a hypercoagulable state because this can cause new thrombi to develop. Here, we present a case of successful treatment by anticoagulant therapy and TEVAR in an APS patient presenting with pulmonary embolisms (PEs) and multiple arterial embolisms due to thoracic aortic mural thrombosis. A 46-year-old man was referred to our hospital due to dyspnea and leg pain. Since contrast-enhanced computed tomography revealed PEs, thoracic aortic mural thrombosis, and lower limb arterial embolisms, we administered anticoagulation therapy. Three days later, contrast-enhanced computed tomography revealed new arterial embolisms in the right kidney. To prevent further arterial embolisms due to thoracic aortic mural thrombosis, we performed emergent TEVAR in addition to anticoagulant therapy. Thereafter, no venous or arterial embolisms recurred during the 13-month follow-up period.

Compressed sensing-based reconstruction (CSR) is a new magnetic resonance (MR) image reconstruction method based on the compressed sensing (CS) technique. CSR suppresses ringing artifacts from truncated k-space sampling by estimating the high spatial frequency information required to support the acquired k-space data. CSR is intended to replace the existing zero-fill interpolation (ZIP) reconstruction. We investigated the usefulness of the CSR technique by obtaining sagittal T2-weighted images of the cervical spine and phantom images using CSR or ZIP. Our results indicated that the CSR technique reduces truncation artifacts compared to ZIP without prolonging the scan time or impairing image sharpness.

Objective This historical control study was performed to evaluate i) the rebleeding rate of bleeding colon diverticula treated with endoscopic band ligation (EBL) versus endoscopic clipping (EC) and ii) risk factors for rebleeding of diverticula initially treated by endoscopic hemostasis. Methods From January 2010 to December 2012, 68 patients were treated with EC, and from January 2013 to August 2016, 67 patients were treated with EBL. All patients in each group were followed up for one year to check for rebleeding. Results The rebleeding rate was lower in the EBL group (7 of 67, 10%) than in the EC group (21 of 68, 31%; p

Introduction: Familial hypercholesterolemia (FH) is an autosomal hereditary disease found in patients who have elevated low-density lipoprotein cholesterol (LDL-C) levels from birth. Early detection and treatment of FH during childhood potentially reduces the risk of premature cardiovascular events. In Kagawa prefecture, a unique community health system, involving three steps, has been conducted to prevent lifestyle-related diseases for 10-year-old children. This system includes universal lipid screening, selection by pediatricians, and next-generation sequencing (NGS) of FH-related genes in the hospitals. The aim of this study is to investigate whether this system can be effective in detection of FH. Methods: In Kagawa prefecture, the universal lipid screening of children at 10 years of age is performed annually at school, covering over 90% of the target group. After excluding secondary hypercholesterolemia, pediatric clinics introduced children with LDL-C levels >140 mg/dL to four hospitals to perform NGS to detect FH. Results: In 2017, 279 children (3.7%) showed elevated LDL-C >140mg/dL among 7,647 ones who received the screening. We performed NGS for 46 children after excluding secondary hypercholesterolemia by pediatricians (LDL-C 186.0±50.3 mg/dL; M/F 27/19) and 26 children (57%) had FH genetic mutations (23 LDL-R, 3 PCSK9). The children with LDL-C >180mg/dL are recommended to receive statin therapy according to the guideline from the Japanese Atherosclerosis Society (JAS). Children with LDL-C levels ≥180 mg/dL have 74% of positive genetic mutations, and even those with 140-180 mg/dl LDL-C levels have as much as 44%, respectively (Table). Conclusions: The unique community health system in Kagawa can efficiently detect FH of children. Further investigation will be required for the effective prevention of future atherosclerotic cardiovascular diseases.

Introduction: Familial hypercholesterolemia (FH) is an autosomal hereditary disease found in patients who have elevated low-density lipoprotein cholesterol (LDL-C) from birth. Early detection and treatment of FH during childhood potentially reduces the risk of premature cardiovascular events. In Kagawa prefecture, a unique community health system, involving three steps, has been conducted to prevent lifestyle-related diseases for 10-year-old children. This system includes universal lipid screening, selection by pediatricians, and next-generation sequencing (NGS) of FH-related genes in hospitals. The aim of this study is to compare 3 international guidelines to detect pediatric FH with this unique community health system in Kagawa. Methods: In Kagawa prefecture, the universal lipid screening of approximately 8,000 children at 10 years of age is performed annually, covering over 90% of the target group. After excluding secondary hypercholesterolemia, pediatric clinics introduced children with LDL-C >140mg/dL to 4 designated hospitals to perform NGS. We applied the guidelines of the Dutch Lipid Clinic Network (DLCN), Simon Broome (SB), and the Japanese Atherosclerosis Society (JAS) to children who received NGS in the unique community health system in Kagawa. Results: We performed NGS for 46 children from January 2018 to February 2020 (LDL-C 186.0±50.3 mg/dL; Male/F 27/19) and 26 (57%) had FH genetic mutations (23 LDL-R and 3 PCSK9 mutations). Seventeen children met FH criteria for DLCN (35%), 10 for Simon Broome (22%), and 11 for JAS (24%), respectively. The combination of NGS and either of the 3 guidelines increased the number of children diagnosed as FH up to 31 (67%). Conclusion: International guidelines detected only half of pediatric FH who were diagnosed by the unique community health system in Kagawa. Further investigation will be required to build an effective universal screening system for pediatric FH.

BACKGROUND The screening and treatment of Helicobacter pylori infection for all junior high students in Saga Prefecture, Japan, were started in 2016. The present study aims to evaluate the influence of adverse reactions on the success of the eradication therapy. METHODS From 2017 to 2019, 25,006 third-grade junior high school students were tested for urinary anti-H. pylori antibodies. Positive cases were confirmed by H. pylori stool antigen tests. Of the 531 students who were found to be H. pylori-positive, 390 (358 in first-line and 32 in second-line therapy) underwent eradication therapy, and 274 (242 in first-line and 32 in second-line) students actually completed a self-reported form to rate stool consistency (based on the Bristol Stool Scale), the maximum number of bowel movements, and abdominal symptoms during the 7 days of treatment. RESULTS Among the 274 students, the total of primary and secondary eradication success rates was 87% (95% confidential interval: 82.9-90.1) in intention-to-treat analysis. On days 4, 5, and 6, stool consistency was looser in the primary eradication failure group than in the success group (p

This study aimed to evaluate the influence of Helicobacter pylori infection and its eradication on the upper gastrointestinal symptoms of relatively healthy Japanese subjects. A total of 3,005 subjects (male/female: 1,549/1,456) undergoing medical health checkups were enrolled in the present study, at five hospitals in Saga, Japan, from January to December 2013. They had no significant findings following upper gastrointestinal endoscopy. All subjects completed a questionnaire that addressed a frequency scale for symptoms of gastroesophageal reflux disease. The questionnaire comprised seven questions regarding reflux symptoms and seven regarding acid-related dyspepsia, which were answered with a score based on the frequency of symptoms. Helicobacter pylori infection was identified by a rapid urease test and/or H. pylori antibody titer, and an eradication history was confirmed by the subjects’ medical records. Helicobacter pylori infection was positive in 894 subjects out of 3,005 (29.8%). Eradication of Helicobacter pylori was successfully achieved in 440 subjects of 458 treated. Helicobacter pylori infection had no influence on the acid-related dyspepsia evaluated by the questionnaire, whereas the mean reflux score was relatively high in the Helicobacter pylori native negative subjects compared to Helicobacter pylori native positive. Eradication of Helicobacter pylori and time span after the eradication had no effect on the upper gastrointestinal symptoms evaluated by the questionnaire. Helicobacter pylori infection and history of eradication did not affect acid-related dyspepsia symptoms in Japanese healthy subjects.

Aim To examine whether superparamagnetic iron oxide (SPIO)-enhanced magnetic resonance imaging (MRI) can be used to assess the malignant potential of hepatic hypovascular nodules showing hypointensity during the hepatobiliary phase (HBP) on gadoxetic acid (Gd–EOB–DTPA)-enhanced MRI. Methods The study included 42 patients with chronic liver disease who had small hypovascular nodules (5–15 mm) showing hypointensity during the HBP on Gd–EOB–DTPA-enhanced MRI. The SPIO-enhanced T2-weighted MRI analyzed whether the signal intensity of each nodule was high. Nodules were prospectively followed up until hypervascularization by periodic Gd–EOB–DTPA-enhanced MRI. Initial MRI findings and clinical variables were used to analyze predictive factors for hypervascularization. Results We analyzed 77 nodules, of which 19 (25%) showed hypervascularization during the observation period. The cumulative rates for hypervascularization were 11% and 22% at 1 and 2 years, respectively. Hyperintensity was observed in 12 nodules (16%) on SPIO-enhanced T2-weighted MRI; among these, 7 (58%) showed hypervascularization, whereas 12 (18%) of the remaining 65 nodules without hyperintensity showed hypervascularization (P = 0.007). A Cox model revealed that independent predictors of hypervascularization included hyperintense nodules on SPIO-enhanced MRI (P

Purpose Image non-uniformity may cause substantial problems in magnetic resonance (MR) imaging especially when a 3-T scanner is used. We evaluated the effect of image non-uniformity correction in gadolinium ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced MR imaging using a 3-T scanner. Methods Two commercially available methods for image non-uniformity correction, surface coil intensity correction (SCIC), and phased-array uniformity enhancement (PURE), were applied to Gd-EOB-DTPA-enhanced images acquired at 3-T in 20 patients. The calibration images were used for PURE and not for SCIC. Uniformity in the liver signal was evaluated visually and using histogram analysis. The liver-to-muscle signal ratio (LMR) and liver-to-spleen signal ratio (LSR) were estimated, and the contrast enhancement ratio (CER) was calculated from the liver signal, LMR, and LSR. Results Without non-uniformity correction, hyperintensity was consistently observed near the liver surface. Both SCIC and PURE improved uniformity in the liver signal; however, the superficial hyperintensity remained after the application of SCIC, especially in the hepatobiliary-phase images, and focal hyperintensity was shown in the lateral segment of the left hepatic lobe after the application of PURE. PURE increased LMR dramatically and LSR mildly, with no changes in CERs. SCIC depressed temporal changes in LMR and LSR and obscured contrast effects, regardless of the method used for calculation of CER. Conclusion SCIC improves uniformity in the liver signal; however, it is not suitable for a quantitative assessment of contrast effects. PURE is indicated to be a useful method for non-uniformity correction in Gd-EOB-DTPA-enhanced MR imaging using a 3-T scanner.

Adult aortic coarctation is often asymptomatic and this condition can be detected because of a murmur or unexplained hypertension. Here, we report an adult case of aortic coarctaion with heart failure and a characteristic finding of pulsation below the bilateral clavicle. A 58-year-old man with refractory heart failure due to unknown reasons was referred to our hospital. Auscultation presented no murmur and high blood pressure had been treated with medicine. Interestingly, precise physical examination revealed the bilateral pulsation at the midclavicular line from the 2nd to the 5th intercostal areas. Echographic examination revealed the dilated vessel and arterial blood flow 1–2 cm in depth from the body surface at the midclavicular 2nd intercostal areas. Contrast-enhanced computed tomography showed thoracic aortic coarctation and a well-developed collateral circulation via the bilateral internal thoracic arteries and epigastric arteries. The cause of heart failure was diagnosed as aortic coarctation. Palliative revascularization was performed and his blood pressure was lowered. When we see the patients with refractory heart failure due to unknown reasons, pulsation below the bilateral clavicle may give us a clue to diagnose the “hidden” aortic coarctation.

Introduction. Display contrast can be changed nonlinearly by manipulating the gamma value of the grayscale. We investigated the contrast of the hepatobiliary-phase images acquired with different flip angles (FAs) and displayed with different gamma values in Gd-EOB-DTPA-enhanced magnetic resonance imaging. Material and Methods. Twenty patients with liver tumors were studied. Hepatobiliary-phase images were acquired at low (12°) and high (30°) FAs. Low-FA images were converted to simulate images displayed with different gamma values, using ImageJ software. To assess image contrast, the liver-to-muscle signal ratio (LMR), liver-to-spleen signal ratio (LSR), contrast ratio (CR), liver signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR) were calculated. Results. The LMR, LSR, and CR were higher in the high-FA images than in the low-FA original images. Although the SNR was lower in the high-FA images, indicating an increase in noise, the CNR was higher. Raising the gamma value increased the LMR, LSR, and CR, notably decreased the SNR, and slightly decreased the CNR. Conclusion. Increasing the FA enhanced image contrast, supporting its usefulness for improving the delineation of focal liver lesions. Although the associated increase in noise may be problematic, raising the grayscale gamma value enhances the display contrast of low-FA images.

Septal penetration causes collimator-dependent differences in the heart-to-mediastinum (H/M) ratio in 123I-metaiodobenzylguanidine (MIBG) cardiac imaging. We investigated generally applicable methods to correct such differences. Four hours after 123I-MIBG injection, 40 patients underwent anterior chest imaging successively with medium-energy (ME) and various non-ME collimators. The H/M ratios obtained with the non-ME collimators before and after 123I-dual-window penetration correction were compared with the ME-derived standard values to determine patient-based conversion equations for empiric and combined corrections, respectively. A 123I point source was imaged with various collimators, and the central ratio, the ratio of count in a small central region of interest to count in a large one, was calculated. The method of predicting the conversion equations from the central ratios was determined. Correction using the patient-based conversion equations removed systematic underestimation of the H/M ratios obtained with the non-ME collimators, and combined correction depressed residual random errors to some degree. Point-source-based equations yielded results comparable to the patient-based equations. Empiric and combined corrections effectively reduce collimator-dependent differences in the H/M ratio. The conversion equations can be predicted from simple point-source imaging, which would allow to apply these corrections to data obtained with various collimators.

Objectives We investigated the clinical usefulness of respiratory navigator-gating technique for the assessment of liver tumors in Gd-EOB-DTPA-enhanced magnetic resonance (MR) imaging. Methods Eighty patients who underwent Gd-EOB-DTPA-enhanced MR imaging to evaluate known or suspected liver tumors were enrolled. Three-dimensional spoiled gradient-recalled echo images of the liver were acquired in the hepatobiliary phase by the following three methods: breath-hold imaging, navigator-gated low-resolution imaging, and navigator-gated high-resolution imaging. Navigator-gated imaging was performed during free breathing. Spatial resolution was identical between breath-hold imaging and gated low-resolution imaging. Signal intensities in the liver, muscle, and spleen were measured in 20 patients. Image quality was visually evaluated in all 80 patients. The detection rate and lesion conspicuity were assessed for 71 malignant liver lesions identified in 29 patients. Results The liver-to-muscle and liver-to-spleen signal ratios were significantly lower for gated images compared to breath-hold images. Images of acceptable quality were obtained in most patients by all three methods, and the overall image quality of axial images did not differ significantly among the imaging methods, although superior reformatted coronal images were obtained by gated high-resolution imaging. The detection rates of malignant liver lesions were similar among the three imaging methods, although lesion conspicuity was significantly better for breath-hold imaging compared to gated imaging. Conclusions Navigator-gated imaging provided image qualities and detection rates of malignant liver lesions comparable to breath-hold imaging in Gd-EOB-DTPA-enhanced MR imaging; however, no additional benefits of high-resolution imaging were proven for lesion evaluation.

Background/Aims: This study aimed at (i) clarifying the factors associated with high scores on the modified frequency scale for the symptoms of gastroesophageal reflux disease (FSSG) among 3,505 relatively healthy subjects undergoing routine medical health checkups with gastrointestinal endoscopy and (ii) comparing risk factors for high FSSG scores between subjects with and without reflux esophagitis. Methods: In total, 3,505 subjects (male/female: 1,922/1,583) who underwent upper gastrointestinal endoscopy during health medical checkups at 5 hospitals in Saga, Japan from January 2013 to December 2013 were enrolled. All subjects completed a modified FSSG questionnaire, which comprised 7 questions regarding reflux symptoms and 7 questions regarding acid-related dyspepsia. Each question was assigned a score based on the frequency of symptoms. Results: Younger age, female gender, hiatal herniation, and endoscopic reflux esophagitis were risk factors for a FSSG score with a high total. Subjects with high scores but without esophagitis were women, and hiatal herniation and Barrett's esophagus were frequently seen in patients with reflux esophagitis. Conclusion: Younger age, female gender, hiatal hernia, and endoscopic esophagitis were risk factors for a high FSSG score, and women tended to complain of upper gastrointestinal symptoms more frequently than did men among subjects without endoscopic esophagitis.

Aim Portopulmonary venous anastomoses (PPVA) are shunts between esophageal varices and pulmonary veins. Because PPVA can cause serious complications at the time of sclerotherapy for esophageal varices, it is essential to confirm the existence of any PPVA before treatment. Methods The study group comprised 101 patients in whom hemodynamics were evaluated on three-dimensional computed tomography (3D-CT) before either elective or prophylactic treatment of esophageal varices at Kitasato University East Hospital from October 2007 through August 2013. The presence or absence of PPVA, laboratory test results and 3D-CT findings were retrospectively examined in these patients. Results Nine patients had PPVA, and 92 patients did not. The underlying diseases in the PPVA group were: hepatitis C liver cirrhosis in three; non-B, non-C liver cirrhosis in three; non-alcoholic steatohepatitis in one; primary biliary cirrhosis in one; and autoimmune hepatitis in one. The distribution of underlying diseases did not differ between the PPVA group and the non-PPVA group. When the study variables were statistically compared between the groups, the incidence of large, coil-shaped esophageal varices (grade F3) differed significantly between the groups (P = 0.001). Multivariate analyses of factors related to PPVA revealed that only the grade F3 type of esophageal varices differed significantly between the groups (P = 0.005; hazard ratio, 5.21; 95% confidence interval, 3.1–16.4). Conclusion In patients with grade F3 esophageal varices, the treatment method should be selected on the basis of an accurate hemodynamic analysis using 3D-CT before therapy.

Background The impact of nicorandil as adjunctive therapy for percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI) is controversial. We performed 15O-labeled water positron emission tomography (PET) to quantify regional myocardial perfusion in patients with STEMI who received nicorandil or no adjunctive therapy during PCI. Methods PCI was performed within 8 h after STEMI onset in 33 patients. 14 patients received intracoronary nicorandil 2 mg immediately after recanalization of the culprit lesion (Nico group). After 3–4 weeks, PET was performed in which myocardial blood flow (MBF) was measured at baseline and during adenosine triphosphate (ATP)-induced hyperemia. Myocardial vascular resistance (MVR) was calculated for all segments. Data were obtained from the reperfused (Rep) and normal segments (Cont) in each patient. Results In patients not given nicorandil (No-Nico group), the MBF was significantly lower in Rep than that in Cont at baseline and during hyperemia (Cont vs. Rep: 0.82 ± 0.14 vs. 0.68 ± 0.11, P = 0.001, ATP-Cont vs. ATP-Rep: 2.00 ± 0.72 vs. 1.52 ± 0.61, P = 0.017), which was restored in the Nico group (Cont vs. Rep: 0.79 ± 0.17 vs. 0.78 ± 0.20; ATP-Cont vs. ATP-Rep: 2.02 ± 0.84 vs. 1.84 ± 0.62). MVR was elevated in Rep at baseline and during hyperemia in the No-Nico group. MVR elevation in Rep was prevented in the Nico group. Conclusions 15O-labeled water PET was feasible for segmental analysis of MBF during the subacute phase of STEMI. It revealed that intracoronary administration of nicorandil to STEMI patients who underwent PCI prevented MVR elevation and thus restored MBF in the reperfused segments to a level similar to that in the normal segments., Highlights • 15O-labeled water positron emission tomography (PET) is a tool to compare directly reperfused segments with normal segments simultaneously in each patient's hearts. • 15O-labeled water PET permits noninvasive quantitative measurement of myocardial blood flow during the subacute phase of myocardial infarction. • 15O-labeled water PET detects restoration of myocardial blood flow after intracoronary administration of nicorandil in STEMI patients.

Aim Transcatheter arterial chemoembolization (TACE) has been recognized as a treatment option for patients with intermediate hepatocellular carcinoma (HCC). This randomized, controlled study compared the local control efficacy of TACE with miriplatin (platinum monohydrate) or with epirubicin. Methods The study group consisted of 200 Japanese patients with unresectable HCC treated at the Kitasato University East Hospital (Sagamihara, Japan) between July 2010 and June 2013. The primary end-point of the study was time to tumor progression (TTP). Results We analyzed 198 patients (99 in the miriplatin group and 99 in the epirubicin group) treated with TACE. The median TTP in the epirubicin group was 5.9 months (95% confidence interval [CI], 4.8–7.0) and 7.6 months (95% CI, 5.8–9.4) in the miriplatin group. There was a significant difference between the two groups (P = 0.021; risk ratio, 1.488; 95% CI: 1.061–2.086). In the epirubicin group, 53 patients (53%) had complete response, 24 patients (24%) had partial response, 12 patients (12%) had stable disease, and 10 patients (10%) had progressive disease. In the miriplatin group, 38 patients (38%) had complete response, 41 patients (41%) had partial response, 2 patients (2%) had stable disease, and 18 patients (18%) had progressive disease. There was no significant difference in the response rate (P = 0.862). Overall incidences of adverse events and adverse drug reactions did not differ significantly between the two groups. Conclusion Miriplatin proved more effective than epirubicin in TACE for unresectable HCC. The trial described in this work has been registered under the trial number: UMIN000004790.

Septal penetration causes underestimation of the heart-to-mediastinum (H/M) ratio in cardiac (123)I-metaiodobenzylguanidine (MIBG) imaging with a low-energy high-resolution (LEHR) collimator. We aimed to improve the method of estimating the H/M ratios using the LEHR collimator.4 hours after (123)I-MIBG injection, 40 patients were imaged successively with the medium-energy (ME) and LEHR collimators using gamma cameras having 3/8-inch crystals. Severe underestimation of the H/M ratios was observed with the LEHR collimator when compared to the ME collimator. Narrowing the energy window width did not reduce the underestimation. Application of (123)I-dual-window (IDW) correction using a narrow or wide subwindow reduced the underestimation substantially but not entirely. The H/M ratios estimated from the LEHR images with or without IDW correction were corrected based on their correlations with the ratios estimated from the ME images. This empiric correction removed systematic underestimation, and residual errors were reduced when the H/M ratios after IDW correction were converted using the empiric equation. The conversion equation was successfully applied to the correction of the H/M ratios determined in another 40 patients using a 5/8-inch crystal.In estimating the H/M ratios using an LEHR collimator, empiric correction combined with IDW correction improves concordance with ME-based values in comparison with empiric correction alone.

Objective We evaluated intra- and interoperator reproducibilities in calculating the conventional indices HH15 and LHL15 from 99mTc-diethylenetriamine pentaacetic acid galactosyl human serum albumin (99mTc-GSA) scintigraphy, and proposed new, simple methods for the calculation of quantitative indices.

Septal penetration of high-energy photons affects quantitative results in imaging of 123I-labeled tracers. We investigated acquisition protocols (collimator choice and energy window setting) and correction methods for estimating the heart-to-mediastinum (H/M) ratio in cardiac 123I-metaiodobenzylguanidine (MIBG) imaging. Methods: Four hours after 123I-MIBG injection, 40 patients successively underwent planar anterior chest imaging with the medium-energy (ME) (ME method) and low-energy high-resolution (LEHR) (LEHR method) collimators. A 20% energy window was used for both collimators. Another 40 patients were imaged successively with the ME collimator and a 20% window (ME method), the low-medium-energy (LME) collimator and a 20% window (LME20 method), and the LME collimator and a 15% window (LME15 method). The H/M ratios obtained by the LEHR, LME20, and LME15 methods were corrected using their correlations with the H/M ratio obtained by the ME method (empiric correction). The 123I-dual-window (IDW) correction was also applied to remove the influence of high-energy photons. Results: Without correction, severe underestimation of the H/M ratio was shown for the LEHR method using the ME method as a standard, and this underestimation increased with increasing H/M ratios. Underestimation substantially decreased using the LME20 method and further using the LME15 method. Empiric correction reduced the error in the H/M ratio by the LEHR method, but the error was still evident. After empiric correction, the H/M ratios with the LME collimator were comparable to those with the ME collimator. The IDW correction only partially reduced underestimation by the LEHR method and caused a small overestimation for the LME15 method. Conclusion: The use of an LME collimator appears to be acceptable for cardiac 123I-MIBG imaging as an alternative to an ME collimator, and the application of a 15% energy window is recommended when an LME collimator is used. Empiric correction is also expected to improve exchangeability between H/M ratios calculated with ME and LME collimators. Neither the use of an LEHR collimator nor the use of IDW correction is recommended.

Gastric uptake of (67)Ga may be observed in patients with no obvious gastric lesions, as well as those with gastric malignancy. The aim of this study was to investigate whether the use of an effervescent agent aids in evaluating gastric (67)Ga uptake.Twenty patients having or suspected of having gastric uptake on whole-body (67)Ga scintigrams were studied. Anterior abdominal images were obtained at baseline and after the oral intake of the effervescent agent (gas contrast image). The presence or absence of malignant gastric uptake was judged visually using the baseline image or gas contrast image. The judgment was compared with the clinical diagnosis, and the clinical usefulness of the gas contrast technique was assessed.In all patients, successful distension of the stomach was indicated in the gas contrast image. Clinical assessment showed gastric lesions in six patients (gastric involvement of lymphoma in 3, primary gastric lymphoma in 2, and adenocarcinoma in 1). The gas contrast image yielded accurate judgments of malignant gastric uptake in all patients except one with adenocarcinoma. Imaging after gastric distension induced by the oral effervescent agent contributed to excluding malignant gastric uptake in eight patients and demonstrating malignant gastric uptake in four patients.Benign gastric uptake may complicate the assessment of gastric lesions in (67)Ga scintigraphy. Additional spot imaging after oral intake of an effervescent agent can aid in evaluating malignant gastric lesions through gastric distension.

Introduction Hepatic encephalopathy is an important underlying cause of consciousness disorders. Possible causes of hepatic encephalopathy include hepatic failure and shunt encephalopathy resulting from a portosystemic venous shunt. Balloon-occluded retrograde transvenous obliteration is generally an effective treatment for hepatic encephalopathy. Case presentation A 73-year-old Japanese woman was referred to our department because of disturbance of consciousness. Hepatic venous angiography disclosed a shunt between her left hepatic vein and her portal vein. The shunt was closed with the use of coils and N-butyl 2-cyanoacrylate. One hour after the procedure, she lost consciousness. The bleeding was ascribed to catheter-induced vascular injury. Emergency angiography was performed, and hemostasis was achieved with coils. Conclusion Although bleeding is relatively rare after balloon-occluded retrograde transvenous obliteration, postoperative intraperitoneal bleeding is a serious complication.

Purpose: The purpose of this study was to investigate the utility of diffusion-weighted imaging (DWI) and the apparent diffusion coefficient (ADC) value in differentiating benign and malignant breast lesions and evaluating the detection accuracy of the cancer extension. Materials and Methods: We used DWI to obtain images of 191 benign and malignant lesions (24 benign, 167 malignant) before surgical excision. The ADC values of the benign and malignant lesions were compared, as were the values of noninvasive ductal carcinoma (NIDC) and invasive ductal carcinoma (IDC). We also evaluated the ADC map, which represents the distribution of ADC values, and compared it with the cancer extension. Results: The mean ADC value of each type of lesion was as follows: malignant lesions, 1.22±0.31×10-3 mm2/s; benign lesions, 1.67±0.54×10-3 mm2/s; normal tissues, 2.09±0.27×10-3 mm2/s. The mean ADC value of the malignant lesions was statistically lower than that of the benign lesions and normal breast tissues. The ADC value of IDC was statistically lower than that of NIDC. The sensitivity of the ADC value for malignant lesions with a threshold of less than 1.6×10-3 mm2/s was 95% and the specificity was 46%. A full 75% of all malignant cases exhibited a near precise distribution of low ADC values on ADC maps to describe malignant lesions. The main causes of false negative and underestimation of cancer spread were susceptibility artifact because of bleeding and tumor structure. Major histologic types of false-positive lesions were intraductal papilloma and fibrocystic diseases. Fibrocystic diseases also resulted in overestimation of cancer extension. Conclusions: DWI has the potential in clinical appreciation to detect malignant breast tumors and support the evaluation of tumor extension. However, the benign proliferative change remains to be studied as it mimics the malignant phenomenon on the ADC map.

This study aimed to determine whether prophylactic endoscopic injection sclerotherapy prolonged survival in patients with esophageal varices complicated by liver cirrhosis in the absence of hepatocellular carcinoma, compared with emergency sclerotherapy. Methods: The subjects included 160 patients suffering from esophageal varices complicated by liver cirrhosis without hepatocellular carcinoma. Sixty-eight patients underwent emergency therapy for bleeding varices and the remaining 92 patients underwent prophylactic sclerotherapy. All subjects continued to receive therapy until the varices disappeared. Results: Five-year survival was significantly better in the prophylactic group compared with the emergency group. During the 5-year observation period, 20 of the 68 patients in the emergency group experienced rebleeding and 5 patients died as a result of rebleeding. These rates were significantly higher than those in the prophylactic group (1 of 9 patients with bleeding died among the 92 prophylactic sclerotherapy patients). Multivariate analysis showed that prophylactic therapy and Child's C hepatic function were significant factors for 5-year survival. Conclusions: Prophylactic sclerotherapy for esophageal varices might be more effective in prolonging longterm survival of patients complicated by liver cirrhosis in the absence of hepatocellular carcinoma, compared with emergency sclerotherapy.

Purpose To evaluate the feasibility of transarterial therapy (transcatheter arterial chemoembolization and transcatheter arterial infusion) for patients with hepatocellular carcinoma and chronic kidney disease (CKD). Materials and Methods The study enrolled 35 patients who received transarterial therapy. The patients were classified into a CKD group (n = 10 nondialysis chronic kidney disease [NDCKD] and n=9 end-stage renal disease [ESRD]) or a non-CKD group (n = 16). The survival rates between the two groups were compared using two different starting points: ( a ) from initial diagnosis of hepatocellular carcinoma and ( b ) from enrollment in the study. The tolerance of transarterial therapy in patients with CKD was evaluated by comparing the incidence of major adverse events. Results The 2-year and 5-year survival rates from initial diagnosis were 83.9% and 53.8% in the CKD group and 70.1% and 40.4% in the non-CKD group ( P = .478). The corresponding 3-year survival rate from enrollment in the two groups was 25.6% and 41.2%, respectively ( P = .995). The 2-year and 5-year survival rates from initial diagnosis were 70.1% and 40.4% in the non-CKD group, 90.0% and 39.4% in NDCKD patients, and 76.2% and 76.2% in ESRD patients ( P = .380). The corresponding 2-year survival rates from enrollment in these groups were 54.9%, 48.0%, and 48.6% ( P = .943). Severe contrast-induced nephropathy (n = 3) and late-onset death caused by cholesterol crystal embolism (n = 1) were observed in the NDCKD group. Conclusions Transcatheter arterial chemoembolization is feasible in patients with CKD by instituting periprocedural hemodialysis with similar 2-year and 5-year survival compared with patients without CKD.

A 28-year-old Japanese female with no past history of liver injury developed liver dysfunction and a systemic erythematous, papular rash after being administered saridon and serrapeptase. Liver histology revealed intralobular non-caseating epithelioid granuloma. No specific cause was identified and no evidence of either sarcoidosis or tuberculosis was observed. Since lymphocyte stimulation tests for isopropylantipyrine, one ingredient of saridon and serrapeptase was found to be positive, a diagnosis of drug-induced granulomatous hepatitis was thus made. The outcome was favorable after discontinuing the drugs. To our knowledge, this is the first reported case of granulomatous hepatitis associated with these drugs.

3Department of Radiology, Kitasato University School of Medicine, Sagamihara, Kanagawa 228-8555, Japan. ercutaneous radiofrequency ablation is a novel thermal ablation technique for achieving coagulative necrosis of liver tumors with fewer treatment sessions than percutaneous ethanol injection therapy requires [1, 2]. Several recent developments in radiofrequency ablation technology, such as a high-power (150–200 W) radiofrequency generator, a method for conducting radiofrequency ablation during occlusion of hepatic blood flow, and saline-enhanced radiofrequency ablation techniques, have made it possible to necrotize a larger volume of tissue—3 cm or more in diameter—during a single ablation procedure [3]. Most of the complications after radiofrequency ablation have been minor, but some severe and fatal complications have been reported [4, 5]. In a multicenter study in 2,320 patients with 3,554 lesions [4], six patients (0.3%) died after radiofrequency ablation, including two caused by multiorgan failure following intestinal perforation; one case each of septic shock, tumor rupture, liver failure after bile duct stenosis; and sudden death of unknown cause. Fifty cases (2.2%) of additional major complications were also reported, including 12 (0.5%) of peritoneal bleeding, 12 of tumor seeding, six of hepatic abscess, five of gastrointestinal wall perforation, three of hemothorax, two of rapid hepatic decompensation, and one case each of diaphragmatic paresis, common bile duct stenosis, cardiac arrest, pulmonary embolism, pneumothorax, large biloma, multisegmental hepatic infarction, acute cholestasis, and septicemia. Thermal damage has been documented as a specific complication of radiofrequency ablation. We recently encountered a patient with a diaphragmatic hernia due to thermal damage of the diaphragm. A defect of the diaphragm occurred after radiofrequency ablation for hepatocellular carcinoma (HCC) and remained quiescent for 18 months until bowel herniated through it. To our knowledge, this is the first case in the literature to report diaphragmatic hernia as a complication of radiofrequency ablation. The clinical presentation was acute abdominal pain, whereas MDCT clearly indicated a diaphragmatic defect.

Purpose To prospectively compare the navigator-echo triggering technique (navigator technique) and the conventional respiratory triggering technique using bellows (bellows technique) for free-breathing three-dimensional (3D) magnetic resonance cholangiopancreatography (MRCP) under clinical conditions. Materials and methods Forty patients referred for evaluation of biliary or pancreatic diseases underwent 3D MRCP examination using both navigator and bellows techniques. Two independent radiologists visually evaluated the image quality of 12 segments of the pancreaticobiliary tree in a blinded manner. In addition, the clarity of the lesion was compared between the two techniques in a side-by-side manner. Result MRCP images were successfully acquired using both techniques in all patients. No significant difference in acquisition time was found between the two techniques. The image quality was significantly better using the navigator technique than using the bellows technique for the following seven segments: the head, body, and tail of the pancreatic duct; right hepatic duct; anterior and posterior segments of the right hepatic duct; and cystic duct. The other segments (common hepatic and bile duct, left hepatic duct, medial and lateral segments of left hepatic duct, gallbladder) showed no significant difference. The clarity of lesion depiction was significantly better using the navigator technique than using the bellows technique. Conclusion Respiratory-triggered 3D MRCP using the navigator technique was shown to be feasible in routine clinical practice. The navigator technique improved the image quality of free-breathing 3D MRCP compared with the bellows technique. The clarity of lesion visualization was also better using the navigator technique than using the bellows technique.

Purpose: To assess the effect of motion artifact reduction on the diffusion-weighted magnetic resonance imaging (DWI-MRI) of the liver, we compared velocity-compensated DWI (VC-DWI) and VC-DWI combined with tetrahedral gradients (t-VC-DWI) to conventional DWI (c-DWI) in the assessment of apparent diffusion coefficients (ADCs) of the liver. Materials and Methods: In 12 healthy volunteers, the liver was scanned with c-DWI, VC-DWI, and t-VC-DWI sequences. The signal-to-noise ratio (SNR) and ADC of the liver parenchyma were measured and compared among sequences. Results: The image quality was visually better for t-VC-DWI than for the others. The SNR for t-VC-DWI was significantly higher than that for VC-DWI (P < 0.05) and comparable to that for c-DWI. ADCs in both hepatic lobes were significantly lower for t-VC-DWI than for c-DWI (P < 0.01). ADC in the left lobe was significantly lower for VC-DWI than for c-DWI (P < 0.01). Although ADC in the left lobe was significantly higher for c-DWI (P < 0.01), no significant differences in ADCs were found between the right and left lobes for VC-DWI and t-VC-DWI. Conclusion: The use of a t-VC-DWI sequence enables us to correct ADCs of the liver for artificial elevation due to cardiac motion, with preserved SNR. J. Magn. Reson. Imaging 2013;37:172–178. © 2012 Wiley Periodicals, Inc.

Intraperitoneal bleeding from ruptured ectopic varices is a rare and fatal complication in patients with portal hypertension. Although laparotomy with high mortality is performed, it is difficult to detect correct bleeding site and save the patient. This is probably the first case report of rupture from left gastric vein revealed by transjugular intrahepatic portosystemic shunt (TIPS). We propose the use of TIPS for diagnosing and treating intraperitoneal bleeding from ectopic varices.

The authors used breast diffusion-weighted imaging (DWI) to diagnose breast cancer and identify cancer extension. Isotropic DWI was performed with EPI. The apparent diffusion coefficient (ADC) value was calculated and displayed on an ADC map. The authors compared between the distribution of low ADC values and pathologic cancer extension. The mean ADC value of breast cancer was 1.12 +/- 0.24 x 10(-3) mm/s, which was lower than that of normal breast tissue. The ADC value for invasive ductal carcinoma was lower than that of noninvasive ductal carcinoma. The sensitivity of the ADC value for breast cancer using a threshold of less than 1.6 x 10(-3) mm/s was 95%. Seventy-five percent of all cases showed precise distribution of low ADC value as cancer extension. The causes of underestimation were susceptibility artifact from bleeding and the limit of spatial resolution. Benign proliferative change showed a low ADC value. The authors conclude that DWI has a potential for clinical appreciation in detecting breast cancer.

Goals We previously showed that endoscopic injection sclerotherapy (EIS) prolonged survival in patients with esophageal varices complicated by hepatocellular carcinoma (HCC) and liver cirrhosis. Here, we evaluated risk factors that affect EIS outcomes. Among factors, the difference between prophylactic and emergency EIS was of interest, and we analyzed precisely. Study Subjects were 134 patients with esophageal varices complicated by HCC and liver cirrhosis: 38 underwent emergent therapy for bleeding varices and 96 underwent prophylactic sclerotherapy. Results During 2-year observation, 22 of the 38 (57.9%) and 38 of the 96 (39.6%) died. Analysis by univariate Cox's proportional hazard model indicated that prognosis of patients receiving emergency EIS was inferior to those with prophylactic EIS. However, multivariate Cox's analysis showed that emergency EIS itself extended survivals of those with esophageal varices complicated by HCC and liver cirrhosis. Patients' hepatic function (Child-Pugh classes) and tumor sizes were also statistically significant factors for survival. Neither prophylactic nor emergency EIS prolonged survival of patients with Child C hepatic function or those with HCCs larger than 5 cm. Conclusions The prophylactic sclerotherapy for esophageal varices prolongs long-term survival of patients with liver cirrhosis and HCC, better than emergency therapy. However, EIS itself had no beneficial effect on patients with poor disease status.

We present two cases of acquired uterine arterial venous malformation (AVM) which was diagnosed because of massive genital bleeding successfully treated with transcatheter arterial embolization (TAE), using N-butyl-2-cyanoacrylate (NBCA) under balloon occlusion. Balloon occlusion at the uterine artery was performed in both patients for diffuse distribution of NBCA in multiple feeding branches, as well as to the pseudoaneurysm, and for the prevention of NBCA reflux. In one of our patients, balloon occlusion of the draining vein was simultaneously performed to prevent NBCA migration through accompanying high-flow arteriovenous fistula (AVF). Doppler ultrasound at 6 months of both patients documented persistent complete occlusion of AVM. Complete and safe obliteration of acquired uterine AVM was accomplished using NBCA as embolic agent, under balloon occlusion at the communicating vessels of acquired uterine AVM.

A prospective controlled study was performed between 1982 and 1991 to evaluate the efficacy of endoscopic injection sclerotherapy (EIS) in patients with esophageal varices complicated by hepatocellular carcinoma and liver cirrhosis.The study included 83 patients with esophageal varices, hepatocellular carcinoma, and liver cirrhosis. Forty-three patients (group 1) underwent prophylactic EIS or emergent EIS for bleeding varices. EIS was performed weekly 4 to 6 times until the varices disappeared. The remaining 40 patients (group 2) underwent conservative therapy and did not undergo EIS. Survival rates were compared between the 2 groups.During the 5-year observational period, all patients who did not undergo EIS died. Sixteen in group 2 (40.0%) died of gastrointestinal bleeding including ruptured esophageal varices. In contrast, patients treated with EIS survived significantly longer (p0.001). Nine patients (20.9%) treated with EIS experienced gastrointestinal bleeding as a result of which 5 (11.6%) died. EIS prolonged survival in patients classified as Child's A or B but did not affect survival in patients with Child's C hepatic function. EIS was effective in prolonging survival in patients with hepatocellular carcinomas smaller than 5 cm. However, EIS had no effect in patients with hepatocellular carcinomas that were larger than 5 cm. EIS prolonged survival only for patients with nodular hepatocellular carcinoma and had no effect in patients with massive and diffuse hepatocellular carcinoma. Further, EIS prolonged survival only for patients who did not have portal vein thrombosis.Based on this prospective study, we concluded that EIS was effective in prolonging the survival period of a select subset of patients with hepatocellular carcinoma.