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Background: Most Japanese medical schools likely continue to rely on peer physical examination (PPE) as a tool to for teaching physical examination skills to students. However, the attitudes of medical students in Japan toward PPEs have not be identified. Therefore, we evaluated students' attitudes toward PPE in a Japanese medical school as a preparation for developing a PPE policy tailored to the context of Japanese culture. Methods: We conducted a mixed-methods study with an explanatory sequential approach, in which qualitative data were used to interpret the quantitative findings. Surveys and interviews were conducted with medical students and junior residents at a Japanese university. A total of 63 medical students and 50 junior residents responded to the questionnaire. We interviewed 16 participants to reach theoretical saturation and investigated the attitudes of medical students toward PPE and the themes emerging from the interview data, providing detailed descriptions of the quantitative findings. Results: Female participants were significantly more likely than male participants to report varying degrees of resistance to being a model patient during PPE (male: 59.7%, female: 87%, p < 0.001). Most of the participants who took on the role of patients that involved undressing were males. The participants expected improvements in issues related to the guarantee of freedom to refuse to be a model patient and measures to protect confidentiality. Approximately 22% of the participants reported that they witnessed incidental findings (including variations within the normal range) in front of other students during PPE. Conclusions: The findings imply that medical students expect high levels of autonomy and confidentiality when volunteering as model patients during PPE. Thus, developing a PPE policy suitable for Japanese culture may be effective in establishing a student-centered PPE environment. [ABSTRACT FROM AUTHOR]

In Japan, a limited number of laboratories perform comprehensive genetic testing for rare diseases; this study investigated the attitudes of these laboratories toward the disclosure of secondary finding (SF). Following a preliminary survey, we identified laboratories conducting comprehensive genetic testing for participation. Subsequently, an online survey involving 20 selected facilities was conducted. The response rate was 80% (16/20). Of the 14 facilities, 71.4% had SFs. While 42.9% of them had a policy to disclose SFs with clinical utility, only 14.3% actively searched for actionable variants that could be included in the American College of Medical Genetics and Genomics list. Japan was less enthusiastic than the USA regarding SF disclosure. With regard to the reasons for not disclosing SFs, the factors "the thought that participants may have a low desire for SFs" and "uncertainty regarding their wish" were considered more important than in the USA. A content analysis of what was sought as a solution to this difficulty revealed a need to improve databases on pathogenicity and actionability and collect public thoughts on the issue. The factor "to promote entry in research" was not considered a critical reason for disclosing SFs, indicating that the thirst for information was not possibly due to anxiety but rather due to scientific interest. Japanese medical professionals may not be confident that society requires the disclosure of SFs. To improve the environment, it is necessary to survey the public regarding their thoughts on SF disclosure and discuss this issue in society., (© 2024 Japanese Teratology Society.)

The issue of incidental findings encountered in medical researches and in clinical practices becomes controversial in recent years. In what situations should researchers and clinicians disclose incidental findings to study participants or patients? According to previous studies, the concept of "actionability" is one of most important notions in determining the management of incidental findings, however, the understanding of this concept is also inconsistent among people and the inconsistency can affect the management of incidental findings. That is why we surveyed the difference in conceptual understanding of "actionability" for incidental findings with genomic researches in Japan. Methods: We conducted focus groups with individuals conducting genomics research or genetic testing at the National Centers in Japan, all of which are expected to contribute significantly to genomics research and subsequent clinical practice in Japan. Results: As far as our survey and analysis, there exists crucial discrepancy; one might consider that an "actionable" finding should be one that would be useful in treatment or prevention; another might consider if the finding could lead to a definitive diagnosis, it should be considered "actionable," regardless of the treatment potential of the disease; moreover another might considered that a finding that would lead to the opportunity to participate in a clinical trial was "actionable". Conclusion: Based on the present study which we conducted, we have examined thus far the concept of "actionability", which may influence the management of incidental findings. The present study revealed discrepancies in the understanding of this concept among the National Centers in Japan, which all bear similar expectations from society. And this difference in "actionability" would lead to variations in management of incidental findings. [ABSTRACT FROM AUTHOR]

Background: Patient safety is associated with patient outcomes. However, there is insufficient evidence of patient safety in the dental field. This study aimed to compare incidents reported by dentists and physicians, compare the type of errors made by them, and identify how dentists prevent dental errors., Methods: A mixed-methods study was conducted using open data from the Japan Council for Quality Health Care database. A total of 6071 incident reports submitted for the period 2016-2020 were analyzed; the number of dentists' incident reports was 144, and the number of physicians' incident reports was 5927., Results: The percentage of dental intern reporters was higher than that of medical intern reporters (dentists: n = 12, 8.3%; physicians: n = 180, 3.0%; p = 0.002). The percentage of reports by dentists was greater than that by physicians: wrong part of body treated (dentists: n = 26, 18.1%; physicians: n = 120, 2.0%; p < 0.001), leaving foreign matter in the body (dentists: n = 15, 10.4%; physicians: n = 182, 3.1%; p < 0.001), and accidental ingestion (dentists: n = 8, 5.6%; physicians: n = 8, 0.1%; p < 0.001), and aspiration of foreign body (dentists: n = 5, 3.4%; physicians: n = 33, 0.6%; p = 0.002). The percentage of each type of prevention method utilized was as follows: software 27.8% (n = 292), hardware (e.g., developing a new system) 2.1% (n = 22), environment (e.g., coordinating the activities of staff) 4.2% (n = 44), liveware (e.g., reviewing procedure, double checking, evaluating judgement calls made) 51.6% (n = 542), and liveware-liveware (e.g., developing adequate treatment plans, conducting appropriate postoperative evaluations, selecting appropriate equipment and adequately trained medical staff) 14.3% (n = 150)., Conclusion: Hardware and software and environment components accounted for a small percentage of the errors made, while the components of liveware and liveware-liveware errors were larger. Human error cannot be prevented by individual efforts alone; thus, a systematic and holistic approach needs to be developed by the medical community., (© 2023. The Author(s).)

The use of human embryonic stem cells (hESCs) in clinical studies has been expanding in recent years. The application of hESCs in clinical studies raises ethical issues from a different standpoint compared with the use of other types of stem cells. In Japan, the Guidelines on the Derivation of Human Embryonic Stem Cells, and Guidelines on the Distribution and Utilization of Human Embryonic Stem Cells had been revised for clinical studies in 2014. In the revised guidelines, the method for protection of personal information was changed to offer the choice between unlinkable anonymization and linkable anonymization, to enable the use of information on diseases suffered by donors and the assurance of traceability for safety. Procedures for re-consent are generally prohibited out of consideration for donors' feelings. However, obtaining re-consent is permitted when consent for re-consent has been received in advance and approval has been given by an ethical review board, in which case the donors may be contacted. Incidental findings obtained from hESCs are not disclosed individually to donors, while the research results should be actively published for the common good. These guidelines have enabled the derivation, distribution, and use of hESCs for clinical studies. [ABSTRACT FROM AUTHOR]

Tumour genomic profiling (TGP), conducted in search of therapeutics, sometimes reveals potentially pathogenic germline variants as secondary findings (SFs). Physicians involved in TGP are often specialised in oncology and not in clinical genetics. To better utilise SFs, we explored issues physicians have during disclosure and the potential for collaborations with clinical genetics professionals. Semi-structured interviews were conducted with 14 physicians who had experience in handling outpatient TGP at designated core hospitals for cancer genomic medicine in Japan. The data were analysed thematically. The difficulties physicians experienced during informed consent (IC) included educating patients about SFs, providing detailed information on SFs, and explaining the impact of SFs on patients' family members. When SFs were detected, physicians had reservations regarding the relevance of the disclosure criteria. Confirmatory germline tests were performed using peripheral blood when tumour-only tests detected suspected SFs. Some physicians had reservations about the necessity of confirmatory tests when they did not affect the patients' treatment options. To encourage patients to receive confirmatory tests, improvements are necessary in the healthcare system, such as insurance reimbursements, education for physicians so that they can provide a better explanation to their patients, and genetic literacy of physicians and patients. The physicians offered insights into the challenges they experienced related to IC, disclosure of SFs, and expectations for active collaborations with clinical genetics professionals. Wider healthcare insurance coverage and better genetic literacy of the population may lead to more patients taking confirmatory tests when SFs are suspected., (© 2021. The Author(s), under exclusive licence to European Society of Human Genetics.)

Extra-cardiovascular incidental findings (IFs) on preoperative computed tomography (CT) are frequently observed in transcatheter aortic valve implantation (TAVI) candidates. However, the backgrounds of TAVI candidates and comorbidities differ based on the race and/or country, and data on IFs in a specific population are not always applicable to another. The aim of this study was to assess the prevalence, type, and clinical impact of IFs in Japanese TAVI candidates. This was a retrospective, single-center, observational study. CT reports of 257 TAVI candidates were reviewed, and IFs were classified as (a) insignificant: findings that did not require further investigation, treatment, or follow-up; (b) intermediate: findings that needed to be followed up or were considered for further investigation but did not affect the planning of TAVI; and (c) significant: findings that required further investigation immediately or affected the planning of TAVI. At least one IF was found in 254 patients (98.8%). Insignificant, intermediate, and significant IFs were found in 253 (98.4%), 153 (59.5%), and 34 (13.2%) patients, respectively. Newly indicated significant IFs were found in 19 patients (7.4%). In 2 patients (0.8%), TAVI was canceled because of significant IFs. In patients who consequently underwent TAVI, the presence of significant IFs was not associated with the duration from CT performance to TAVI [28 (19-40) days vs. 27 (19-43) days, p = 0.74] and all-cause mortality during the median follow-up period of 413 (223-805) days (p = 0.44). Almost all Japanese TAVI candidates had at least one IF, and the prevalence of significant IFs was not negligible. Although the presence of significant IFs was not associated with mid-term mortality, appropriate management of IFs was considered important., (© 2021. Springer Japan KK, part of Springer Nature.)

Objective: Some cardiac abnormalities could be a substrate for potential embolic source in cryptogenic stroke (CS). We evaluated whether cardiac and echocardiographic markers were associated with CS in patients with incidental patent foramen ovale (PFO) as defined using the Risk of Paradoxical Embolism (RoPE) score., Materials and Methods: Among 677 patients enrolled in a multicenter observational CS registry, 300 patients (44%) had PFOs detected by transesophageal echocardiography. They were classified into probable PFO-related stroke (RoPE score>6, n = 32) and stroke with incidental PFO (RoPE score≤6, n = 268) groups, and clinical characteristics, laboratory findings, cardiac and echocardiographic markers (i.e. brain natriuretic peptide, left atrial [LA] diameter, ejection fraction, early transmitral flow velocity/early diastolic tissue Doppler imaging velocity [E/e'], LA appendage flow velocity, spontaneous echo contrast, atrial septal aneurysm, substantial PFO, and aortic arch plaques), stroke recurrence, and excellent outcome (modified Rankin scale score <2) at discharge were compared. Risk factors for low RoPE scores were determined using multiple logistic regression analysis., Results: Higher brain natriuretic peptide levels (p = 0.032), LA enlargement (p < 0.001), higher E/e' (p = 0.001), lower LA appendage flow velocity (p < 0.001), non-substantial PFO (p = 0.021), and aortic arch plaques (p = 0.002) were associated with the low RoPE score group. Patients with high RoPE scores had excellent outcomes (58% versus 78%, p = 0.035). LA enlargement (age- and sex-adjusted odds ratio, 1.15; 95 % confidence interval, 1.00-1.32; p = 0.039) was an independent predictor of low RoPE scores., Conclusions: Abnormal cardiac substrate could be associated with CS occurrence in a subset of patients with PFO. Patients with CS who had incidental PFO may be at risk of cardioembolism., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background We assessed cases of incidental unruptured intracranial aneurysm (UIA) discovered on screening magnetic resonance angiography to identify hemodynamic and atherosclerotic risk factors. Methods and Results The data of 1376 healthy older subjects (age range, 31-91 years) without cerebro- or cardiovascular diseases who underwent brain magnetic resonance angiography as part of a medical checkup program at a health screening center were examined retrospectively. We looked for an increase in classical risk factors for UIAs (age, sex, hypertension, and smoking) and laboratory data related to lifestyle diseases among subjects with UIAs. Brachial-ankle pulse wave velocity, central systolic blood pressure, radial augmentation index, and carotid flow pulsatility index were also compared between those with and without UIAs. We found UIAs in 79 (5.7%) of the subjects. Mean age was 67.1±9.0 years, and 55 (70%) were women. Of the 79 aneurysms, 75 (95%) were in the anterior circulation, with a mean diameter of 3.1 mm (range, 2.0-8.0 mm). Subjects with UIAs were significantly older and had more severe hypertension. The carotid flow pulsatility index was significantly lower in subjects with UIAs and negatively and independently correlated with UIAs. Tertile analysis stratified by carotid flow pulsatility index revealed that subjects with lower indices had higher levels of low-density lipoprotein cholesterol. Conclusions The presence of UIAs correlated with lower carotid flow pulsatility index and elevated low-density lipoprotein cholesterol in the data from a population of healthy older volunteers. A reduced carotid flow pulsatility index may affect low-density lipoprotein cholesterol elevation by some molecular pathways and influence the development of cerebral aneurysms. This may guide aneurysm screening indications for institutions where magnetic resonance angiography is not routine.

Background: Intrahepatic cholangiocarcinoma had been considered a contraindication for liver transplantation because of poorer outcomes. However, incidental intrahepatic cholangiocarcinoma in the explanted liver has been reported because of the difficulty of obtaining an accurate diagnosis in cirrhotic livers on preoperative imaging., Methods: We conducted a nationwide survey to analyze the incidence of incidental intrahepatic cholangiocarcinoma and outcomes after liver transplantation, in Japan., Results: Forty-five of 64 institutions (70%) responded to our initial investigation. Between January 2001 and December 2015, 6627 liver transplantations were performed in these 45 institutions, with 19 cases (0.3%) of incidental intrahepatic cholangiocarcinoma reported from 12 transplant centers. Six cases were diagnosed as hepatocellular carcinoma preoperatively. The 1-, 3-, and 5-year recurrence-free survival rates were 79%, 45%, and 45%, respectively. Tumor recurrence after liver transplantation was found in 10 patients (53%). The 1-, 3-, and 5-year overall survival rates were 79%, 63%, and 46%, respectively., Conclusions: Intrahepatic cholangiocarcinoma at liver transplantation is associated with a high risk of recurrence and poor prognosis, even these tumors are detected incidentally in the explanted liver., (© 2021 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

This study aimed to characterize diabetic patients incidentally found to be positive for glutamic acid decarboxylase autoantibodies (GADA) in general practice. Using bridging-type enzyme-linked immunosorbent assay, we screened 1,040 patients with phenotypic type 2 diabetes for GADA, finding 25 (2.4%) to be positive. However, on retesting, with a median interval of 19 days, 44% of GADA-positive patients turned negative (Disappearing Group). The mean age at diabetes onset was significantly higher (P < 0.05) and GADA titers at first determination were significantly lower (P < 0.001) in the Disappearing Group compared with the Persistent Positive Group. On initial screening, all patients in the Disappearing Group had GADA titers of <6.5 U/mL. The current study showed that a portion of phenotypic type 2 diabetic patients incidentally identified as GADA-positive were falsely positive, and that to avoid the misclassification, remeasurement of GADA is essential in cases showing very low titers., (© 2020 The Authors. Journal of Diabetes Investigation published by Asian Association for the Study of Diabetes (AASD) and John Wiley & Sons Australia, Ltd.)

Background: Unexpected gallbladder cancer (UGBC) is sometimes found in the resected gallbladder of patients during or after surgery. Some reports have indicated UGBC identification rates for all gallbladder surgeries, but scarce data are available for the UGBC identification rates for specific gallbladder diseases. The present study was performed to clarify UGBC rates and the factors suspicious for UGBC categorized according to preoperative diagnoses, in patients undergoing laparoscopic cholecystectomy (LSC)., Methods: We recorded data for all LSC surgeries performed in the Department of Surgery, Sada Hospital, Japan since 1991, and analyzed the 28-year data. We used the chi-square test and Kaplan-Meier analysis for this retrospective case-control study., Results: The UGBC identification rate was 0.69% (63/9186 patients). The UGBC identification rates categorized according to the preoperative diagnoses were 1.3% (13/969) for acute cholecystitis, 2.4% (16/655) for benign tumor, 2.0% (28/1383) for chronic cholecystitis or cholecystitis, and 0.054% (3/5585) for cholecystolithiasis. The percentage of older patients (≥ 60 years) was significantly higher in UGBCs compared with cases finally diagnosed as benign in each group categorized according to the preoperative diagnoses (p≤0.0014), except for cholecystolithiasis. In cases pre-diagnosed as benign tumor, UGBCs were associated with higher rates of thickened gallbladder wall compared with benign tumor (69.2% vs. 27.9%, respectively; p = 0.0011). UGBCs pre-diagnosed as acute cholecystitis had higher T2-T4 rates (100% vs. 64.3%, respectively; p<0.05) and lower survival rates (p = 0.0149) than UGBCs pre-diagnosed with chronic cholecystitis., Conclusions: UGBC identification rates depend on the preoperative diagnosis and range from 0.054% to 2.4%. Older age (≥ 60 years) could be related to UGBC, and a pre-diagnosis of acute cholecystitis might indicate more advanced cancer compared with a pre-diagnosis of chronic cholecystitis., Competing Interests: The authors have declared that no competing interests exist.

Purpose: The incidence of prostate cancer is increasing in Asian countries. Studies using prostatectomy specimens have reported a racial difference in tumor location within the prostate, with a greater incidence of transition zone cancer in Asian men compared with Caucasian men. However, there may be potential biases in studies based on surgical specimens. We describe the pathological features of subclinical prostate cancer, such as latent cancer and incidental cancer, to elucidate tumor location of contemporary Japanese patients. We also compare the prevalence of latent and incidental prostate cancer to determine whether the incidence of prostate cancer is higher in patients with bladder cancer., Materials and Methods: Overall 182 men autopsied and 148 who underwent cystoprostatectomy for bladder cancer were included in the study. Each prostate gland was fixed and sliced in step sections. Histological evaluation was performed by a single genitourinary pathologist. The index tumor location was categorized into transition zone or peripheral zone., Results: Prostate cancer was found in 39.0% of the autopsy specimens and 31.6% of the cystoprostatectomy specimens. The prevalence and pathological characteristics were not significantly different between latent and incidental cancer. The prevalence of transition zone cancer was 39.0% (46 of 118). In elderly men peripheral zone cancer was more frequently diagnosed than transition zone cancer (p=0.049). The pathological characteristics of transition and peripheral zone cancers were similar except for the pT stage., Conclusions: Transition zone cancer was prevalent in contemporary Japanese men. The incidence of prostate cancer in men with bladder cancer might not be higher than that in healthy men.

Objective: Incidental aneurysms pose a challenge for physicians, who need to weigh the rupture risk against the risks associated with treatment and its complications. A statistical model could potentially support such treatment decisions. A recently developed aneurysm rupture probability model performed well in the US data used for model training and in data from two European cohorts for external validation. Because Japanese and Finnish patients are known to have a higher aneurysm rupture risk, the authors' goals in the present study were to evaluate this model using data from Japanese and Finnish patients and to compare it with new models trained with Finnish and Japanese data., Methods: Patient and image data on 2129 aneurysms in 1472 patients were used. Of these aneurysm cases, 1631 had been collected mainly from US hospitals, 249 from European (other than Finnish) hospitals, 147 from Japanese hospitals, and 102 from Finnish hospitals. Computational fluid dynamics simulations and shape analyses were conducted to quantitatively characterize each aneurysm's shape and hemodynamics. Next, the previously developed model's discrimination was evaluated using the Finnish and Japanese data in terms of the area under the receiver operating characteristic curve (AUC). Models with and without interaction terms between patient population and aneurysm characteristics were trained and evaluated including data from all four cohorts obtained by repeatedly randomly splitting the data into training and test data., Results: The US model's AUC was reduced to 0.70 and 0.72, respectively, in the Finnish and Japanese data compared to 0.82 and 0.86 in the European and US data. When training the model with Japanese and Finnish data, the average AUC increased only slightly for the Finnish sample (to 0.76 ± 0.16) and Finnish and Japanese cases combined (from 0.74 to 0.75 ± 0.14) and decreased for the Japanese data (to 0.66 ± 0.33). In models including interaction terms, the AUC in the Finnish and Japanese data combined increased significantly to 0.83 ± 0.10., Conclusions: Developing an aneurysm rupture prediction model that applies to Japanese and Finnish aneurysms requires including data from these two cohorts for model training, as well as interaction terms between patient population and the other variables in the model. When including this information, the performance of such a model with Japanese and Finnish data is close to its performance with US or European data. These results suggest that population-specific differences determine how hemodynamics and shape associate with rupture risk in intracranial aneurysms.

Background: TMPRSS2:ERG fusion is the most common genetic event in prostate cancer (PCa). However, its association with prognosis is controversial. Overexpression of serine protease inhibitor Kazal-type 1 (SPINK1) was almost exclusively defined in ERG-negative PCa in most studies. This study aimed to determine the association between ERG and SPINK1 expression and the biological aggressiveness of PCa by analyzing their expression in incidental and metastatic cohorts., Methods: A total of 143 cystoprostatectomy specimens of invasive bladder cancer and 98 biopsy specimens from de novo metastatic PCa were analyzed. The prostate gland of cystoprostatectomy specimens was fixed and sliced in step sections. Immunohistochemistry of ERG and SPINK1 was conducted, and the results were correlated with the clinicopathological characteristics of the patients., Results: The overall prevalence of incidental cancer was 32.2% (46/143). The frequencies of both ERG and SPINK1 expression were not significantly different between incidental and metastatic cohorts (15.2% and 14.3%; P = 1.00, and 6.5% and 12.2%; P = 0.38, respectively). In the metastatic cohort, any pre-treatment factors were not significantly associated with the frequencies of ERG and SPINK1 expression. However, SPINK1 expression was significantly associated with a shorter time to castration-resistant PCa (CRPC) (P = 0.048). Meanwhile, overall survival was not significantly associated with the expression status of ERG and SPINK1 (P = 0.71)., Conclusions: ERG and SPINK1 expression may not have significant influence on the metastatic behavior of PCa. SPINK1 expression was significantly associated with a shorter time to CRPC in metastatic PCa. The expression profile of ERG and SPINK1 may be a useful predictor for effect of androgen deprivation therapy in patients with metastatic castration-sensitive PCa., (© 2018 Wiley Periodicals, Inc.)

Objectives: Incidentally discovered lymphangioleiomyomatosis (LAM) in sampled lymph nodes are infrequent but intractable issues for gynecologists. The aims of this study were to elucidate the prevalence of incidental nodal LAM in a consecutive cohort of gynecologic surgical specimens from Japanese patients, to document clinicopathological features of nodal LAM cases, and to investigate the association between the subsequent development of pulmonary LAM and tuberous sclerosis complex (TSC)., Study Design: We retrospectively reviewed 1732 consecutive Japanese patients who underwent gynecologic surgery with lymph node sampling in the National Cancer Center Hospital between January 2004 and April 2017. The pathological diagnosis of LAM was performed by pathologists. Clinicopathological data were obtained from patients' electronic medical records., Results: We found that 0.46% (8/1732) of gynecologic surgical specimens with lymph node sampling showed incidental nodal LAM. The size of the lesions was less than 10 mm, and external iliac and obturator nodes were frequently affected. Although there has been no report of a case of incidental nodal LAM developing pulmonary LAM, we identified the first case of a 36-year-old woman who developed pulmonary LAM 7 years after the diagnosis of incidental nodal LAM. None of the 8 patients had a personal or family history of TSC., Conclusions: Our case brings attention to the risk of developing subsequent pulmonary LAM. To date, insufficient long-term follow-up data of young patients have hindered us from drawing a definite conclusion that patients with incidental nodal LAM are not at risk for subsequent pulmonary LAM. Future studies should collect and share long-term follow-up data to elucidate the true risk of developing pulmonary LAM in women with incidental nodal LAM., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Patients with primary spontaneous pneumothorax (PSP) usually complain of sudden-onset dyspnea and pleuritic chest pain. However, asymptomatic PSP has been incidentally detected on chest X-rays. In this study, we analyzed the incidence, characteristics, risk factors, and prognosis of asymptomatic PSP detected during regular medical check-ups in university students., Methods: In this study, 101,709 chest X-rays were performed during medical check-ups for students at the University of Tokyo between April 2011 and March 2016. Among them, 43 cases of asymptomatic PSP (0.042%) were detected. We calculated the lung collapse rate of pneumothorax using Kircher's method. We also analyzed risk factors associated with asymptomatic PSP using characteristics inspected in medical check-ups., Results: The incidence of asymptomatic PSP was significantly higher in men than in women (0.050% vs 0.018%). Multivariate analysis revealed an association of younger age, greater height, lower body mass index, and greater height growth per year with an increased risk of asymptomatic PSP in male students. Mild lung collapse (<10%) was present in 22 of 43 students with asymptomatic PSP; among these, eight students eventually underwent an invasive therapy., Conclusions: The prevalence of asymptomatic PSP among university students was as high as 0.042%. In addition to known risk factors for conventional PSP, greater height growth was a risk factor for asymptomatic PSP. Careful follow-up is very important because a considerable number of patients with mild lung collapse eventually require an invasive medical procedure.

Introduction: Lymphangiomas are rare, benign tumors. An intra-abdominal location of these lesions is rarer still and there are only a few reports describing laparoscopic resection for retroperitoneal lymphangiomas, especially in tumors that mimic pancreatic tumors., Case Presentation: We present the case of an asymptomatic 30-year-old Japanese woman in whom a cystic tumor was found incidentally in close approximation to the pancreas. Because the tumor was located in the retroperitoneal space and the body of the pancreas was compressed, we were unable to distinguish a cystic lymphangioma from cystic pancreatic tumors. We started the procedure laparoscopically with five ports. The tumor was in fact separated from the pancreas and was dissected free from the body of the pancreas using scissors and laparoscopic coagulating shears. The left gastric vessels, which were compressed by the tumor, were preserved. As we realized that the tumor was connected to the retroperitoneal lymphatic tissue, we completed the procedure by performing a cystectomy without rupture. The specimen was extracted using a plastic bag. Our patient was discharged on postoperative day 7 without any complications. There is no evidence of recurrence during a >2-year observation period., Conclusions: In addition to the therapeutic significance in differentiating between a cystic lymphangioma in close approximation to the body of the pancreas and a pancreatic cystic neoplasm, the laparoscopic approach is feasible and effective.

Cardiac sarcoidosis is one of the most serious and unpredictable aspects of this disease state. Heart involvement frequently presents with arrhythmias or conduction disease, although myocardial infiltration resulting in congestive heart failure may also occur. The prognosis in cardiac sarcoidosis is highly variable, which relates to the heterogeneous nature of heart involvement and marked differences between racial groups. Electrocardiography and echocardiography often provide the first clue to the diagnosis, but advanced imaging studies using positron emission tomography and MRI, in combination with nuclear isotope perfusion scanning are now essential to the diagnosis and management of this condition. The identification of clinically occult cardiac sarcoidosis and the management of isolated and/or asymptomatic heart involvement remain both challenging and contentious. Corticosteroids remain the first treatment choice with the later substitution of immunosuppressive and steroid-sparing therapies. Heart transplantation is an unusual outcome, but when performed, the results are comparable or better than heart transplantation for other disease states. We review the epidemiology, developments in diagnostic techniques and the management of cardiac sarcoidosis., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objectives: Although some interstitial pneumonia (IP) cases are not detected on computed tomography (CT) before surgery, they are confirmed by pathological diagnosis after pulmonary resection. In the present study, we aimed to investigate patients who underwent pulmonary resection for non-small-cell lung cancer (NSCLC) and subsequently showed pathological findings of IP but no apparent interstitial changes on CT., Methods: We retrospectively analysed 1688 patients with NSCLC who underwent pulmonary resection and presented with a radiological or pathological diagnosis of IP in 64 institutions between January 2000 and December 2009. We compared 135 patients without radiological findings but with pathological findings of IP (Group A) with 1553 patients with radiological findings of IP (Group B)., Results: The percent vital capacity and predicted diffusing capacity for carbon monoxide were higher in Group A than in Group B. Although there was no significant difference in the occurrence of acute exacerbation (AE) between both groups, the mortality after AE in Group A was significantly lower than that in Group B. The overall survival rates of patients in Groups A and B at 5 years were 59.1 and 40.9%, respectively (P = 0.0031)., Conclusions: The mortality after AE in patients with only pathological findings of IP was significantly lower than in those with radiological findings of IP. Moreover, the patients with only pathological findings of IP had a better prognosis than those with radiological findings of IP. Thus, our findings suggest that patients with pathological findings of IP and without radiological abnormality had early-stage IP., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: To establish appropriate measures that deal with incidental findings (IFs), the neuroscience community needs to address various ethical issues. The current state of research facilities regarding IFs and investigator attitudes as well as potentially eligible research participants must be assessed prior to future discussions and before the development of policies and guidelines. To this end, we conducted two questionnaire surveys to clarify i) how IFs are addressed at neuroimaging research facilities in Japan and ii) the views of investigators and potential research participants regarding the handling of IFs., Methods: Thirty-one principal investigators (PIs) involved in the Strategic Research Program for Brain Sciences (SRPBS), a government-funded project, were asked to fill out a questionnaire regarding ways IFs were handled at the facility. A total of 110 investigators engaged in SRPBS tasks, including 31 PIs who participated in the research facility survey and researchers conducting studies under the management of the PIs, and 500 individuals from the general public (i.e., general population) were asked to select the most appropriate way to deal with IFs in two scenarios, namely the medical school and humanities and social sciences department scenarios., Results: More than 40% of PIs responded that they did not know or were unsure of what type of approach was employed to handle IFs at their research facilities. Nevertheless, they were willing to improve the current status if sufficient resources were provided. With regard to specialist involvement, 37.7% of investigators responded that it was appropriate to have a specialist check all images in the medical school scenario, whereas 13.3% responded that such involvement was appropriate in the humanities and social sciences department scenario. In contrast, 76.1% and 61.0% of the general population indicated that specialist involvement was appropriate in the medical school and humanities and social sciences department scenarios, respectively. These results show that expectations of the general population exceed those of investigators regarding measures to address IFs. Both investigators and the general population demanded more responsibility from PIs at medical institutions, compared to PIs at non-medical institutions., Conclusions: Based on our preliminary results, we recommended that a licensed physician perform a screening test to appropriately examine clear abnormalities. These recommendations were implemented by the SRPBS as guidelines for handling IFs in national research projects in Japan.

Spinal meningeal cysts in the sacrum (SMC) are known to be occasionally symptomatic with low back pain as well as leg pain, but no distinct prevalence of this pathological entity including asymptomatic lesions has been described. This prospective study investigated the prevalence of SMCs based on magnetic resonance (MR) myelography in 102 consecutive Japanese women with gynecological problems, who underwent pelvic conventional MR imaging. Ten of 102 patients were suspected of being positive for SMC (9.8%), but pseudo-positive findings were possible. A high probability of positive SMC was found in 7/102 (6.9%). MR myelography was better to detect SMCs than conventional MR imaging. Multiplicity and female preponderance may be other features of SMC. The speculated prevalence of SMCs in Japanese females ranged from 6.9% to 9.8%.

Background: Major artery aneurysms may be found incidentally while evaluating moyamoya disease (MMD). The purpose of this study was to delineate the prevalence and characteristics of these uncommon aneurysms with a brief mention of their management and outcomes., Methods: We conducted a retrospective review of 249 adult patients who were diagnosed with non-hemorrhagic MMD. Cerebral angiograms obtained at the time of initial diagnosis were carefully reviewed to identify incidental aneurysms located on a major intracranial artery or near its tributaries. Aneurysms originating from distal peripheral arteries or moyamoya vessels were ineligible for this study., Results: Nine patients (3.6%) were found to have 13 major artery aneurysms, 7 (54%) of which were located in the posterior circulation, especially in older patients with bilateral MMD. The sizes of all aneurysms were less than 10 mm. Surgical clipping was performed on two aneurysms, and endovascular coiling on six (five posterior circulation aneurysms). Ischemic complications occurred in two patients after clipping of an anterior communicating artery aneurysm and in one patient after the second coiling of a recanalized basilar tip aneurysm., Conclusions: Incidental major artery aneurysms can be found in 3.6% of adult patients with non-hemorrhagic MMD, an observed frequency that increases with age. About half of these aneurysms are located in the posterior circulation, particularly in older patients with bilateral MMD. Considering the risks of treatment-related complications, more information about the natural course of these aneurysms is needed to design proper management strategies both for the aneurysms and MMD.

Background and Purpose: The natural history and optimal management of incidentally found small unruptured aneurysms <5 mm in size remain unclear. A prospective study was conducted to determine the optimal management for incidentally found small unruptured aneurysms., Methods: From September 2000 to January, 2004, 540 aneurysms (446 patients) were registered. Four hundred forty-eight unruptured aneurysms <5 mm in size (374 patients) have been followed up for a mean of 41.0 months (1306.5 person-years) to date. We calculated the average annual rupture rate of small unruptured aneurysms and also investigated risk factors that contribute to rupture and enlargement of these aneurysms., Results: The average annual risks of rupture associated with small unruptured aneurysms were 0.54% overall, 0.34% for single aneurysms, and 0.95% for multiple aneurysms. Patient <50 years of age (P=0.046; hazard ratio, 5.23; 95% CI, 1.03 to 26.52), aneurysm diameter of >or=4.0 mm (P=0.023; hazard ratio, 5.86; 95% CI, 1.27 to 26.95), hypertension (P=0.023; hazard ratio, 7.93; 95% CI, 1.33 to 47.42), and aneurysm multiplicity (P=0.0048; hazard ratio, 4.87; 95% CI, 1.62 to 14.65) were found to be significant predictive factors for rupture of small aneurysms., Conclusions: The annual rupture rate associated with small unruptured aneurysms is quite low. Careful attention should be paid to the treatment indications for single-type unruptured aneurysms <5 mm. If the patient is <50 years of age, has hypertension, and multiple aneurysms with diameters of >or=4 mm, treatment should be considered to prevent future aneurysmal rupture.

Objectives: The objective of this study was to investigate and characterize the clinicopathological features of incidentally detected prostate cancer in radical cystoprostatectomy specimens from Japanese men with bladder cancer., Materials and Methods: We reviewed the pathological reports of 251 male patients who underwent radical cystoprostatectomy for bladder cancer at our institution and identified men with incidentally detected prostate cancer in these specimens. Clinicopathological data of patients with incidental prostate cancer in cystoprostatectomy specimens (group A) were compared with those of 193 patients with clinically detected prostate cancer who underwent radical prostatectomy (group B). Immunohistochemical staining was also performed to measure the expression levels of Ki-67, p53 and androgen receptor (AR) proteins in specimens from both groups A and B., Results: In this series, a total of 31 patients (12.3%; group A) were incidentally diagnosed as having prostate cancer in radical cystoprostatectomy specimens. Clinically significant cancer, defined as any tumor greater than 0.5 cc according to the report by Stamy et al. (Cancer 71:933-938, 1993) was detected in 9 (29.0%) in group A and 170 (88.1%) in group B. Mean age in group A was significantly older than that in group B, while despite the lack of significant difference in the incidence of seminal vesicle invasion between these two groups, other parameters in group A were significantly more favorable than those in group B, including serum prostate-specific antigen, pathological stage, Gleason score, perineural invasion and capsular penetration. None of the patients in group A had biochemical recurrence (median observation period, 82 months); however, biochemical recurrence occurred in 41 (21.2%) in group B (median observation period, 46 months). Furthermore, immunohistochemical study demonstrated the significantly greater expression of Ki-67, p53 and AR proteins in group B than in group A., Conclusions: Clinicopathological features of incidentally detected prostate cancer are markedly more favorable than those of clinically detected prostate cancer, which may reflect less aggressive biological phenotypes of incidental prostate cancer arising in Japanese men.

Background: The increasing use of magnetic resonance imaging (MRI) in brain researches has led to growing concern over incidental findings (IFs). To establish a practical management protocol for IFs, it is useful to know the actual prevalence and problems of IF management. In the present study, we report the prevalence proportion and some handling problems of IFs in healthy Japanese children, and suggest a management protocol from ethical and practical standpoints., Methods: Between 2006 and 2008, 120 healthy children aged 5-8 years participated in a structural MRI study conducted in a pediatric cohort in Japan. All MRI images were reviewed by a pediatric neurologist, and detected IFs were classified into 4 categories., Results: IFs of all categories were detected in 40 of the 110 participants (36.4%) for whom T2-weighted or 3D-T1-weighted images were available. Findings of sinusitis and/or otitis media were most frequent (26.4%). Excluding these findings, the prevalence of IFs was still 10.9% (12 findings): 9 findings were categorized as "no referral" (8.2%), 2 as "routine referral" (1.8%), 1 as "urgent referral" (0.9%), and 0 as "immediate referral" (0.0%). In "routine referral" category, only one participant was referred for further examinations., Conclusions: Although the prevalence of IFs was high, the proportion of those requiring further examination was low. This result revealed a fairly high false-positive rate and suggested that evaluating equivocal findings was the most difficult part of IF management. A management protocol needs to include a process to properly assess the clinical importance of findings.

Background: Clinicoradiological variability of vertebrobasilar dolichoectasia (VBD) is known. Little is known about cardiovascular disease (CVD) risk and neuroradiological profiles of asymptomatic VBD., Methods: A total of 7,345 adults (5,534 men and 1,811 women) underwent physical checkup (PC) and brain magnetic resonance (MR) studies between 2004 and 2007. Asymptomatic VBD was diagnosed by neurological examination and MR angiography. Neuroradiological features were analyzed in VBD subjects. CVD risk factors were compared between VBD subjects and 5,000 controls matched by sex and age., Results: Ninety-six subjects (85 men and 11 women) had asymptomatic VBD. The detection rate was 1.3% and the male/female ratio 2.5. The mean age +/- SD was 60.4 +/- 10.6 years (60.0 +/- 10.2 in men and 64.0 +/- 13.1 in women). As compared to controls, the frequency of hypertension, obesity, smoking, dyslipidemia, diabetes mellitus and a family history of stroke or CVD was increased significantly in VBD subjects. The mean diameter +/- SD of the basilar artery (BA) was 4.7 +/- 0.2 mm. Only 4 subjects (4%) had a severe degree of elongation and lateral displacement of the BA. Contact of the vertebral artery with the rostral ventrolateral medulla (AMC) was found in 81 subjects: right AMC in 22 subjects and left AMC in 59 subjects. Frequency of hypertension was significantly higher in the left-AMC subjects (57%) than in subjects with right AMC (9%) and no AMC (5%). Other neuroradiological findings revealed small infarcts in 42 subjects, brainstem compression in 4, hydrocephalus in 4 and brain saccular aneurysm in 3., Conclusions: Asymptomatic VBD was detected in 1.3% of the Japanese PC group. Our data indicated male predominance, multiple CVD risk factors, neurovascular hypertension and small infarcts in asymptomatic VBD., (Copyright 2010 S. Karger AG, Basel.)

The current study aimed to identify risk factors for atrial fibrillation (AF) detected during routine medical checkups of male workers in Japan. A nested case-control study was conducted using retrospective data from January 1998 to December 2006 collected at a hospital in Ishikawa Prefecture. Cases were those first diagnosed with AF with no record of AF events during the preceding 3 years. For each case, 2 controls were matched for age and time of medical checkup, randomly selected from among those who had not been diagnosed with AF during the same 3 years. Logistic regression was used to identify risk factors in the 3 years prior for new-onset AF. Sixty-nine cases and 138 controls were recruited; their average ages were 57.6 (SD 6.7) and 57.4 years (SD 6.7), respectively. In the logistic models, new-onset AF was associated with systolic blood pressure and drinking habits in the 3 years prior.

Introduction: We have occasionally seen ring-shaped lateral ventricular nodules <1 cm in diameter during routine brain magnetic resonance imaging (MRI). We investigated retrospectively clinical and MRI findings of the nodules., Materials and Methods: Review of radiological records was performed for 39,607 patients who underwent brain MRI between January 2001 and April 2008. Nodules were assessed for number, location, shape, and signal intensity, which was determined based on the range of signal intensity from gray to white matter on T1- and T2-weighted imaging. Fluid-attenuated inversion recovery (FLAIR) and diffusion-weighted imaging (DWI), contrast enhancement characteristics, and serial MRI changes of nodules were assessed when available., Results: Nine of 39,607 patients (0.023%) showed the nodules. No symptoms associated with the nodules. Among the nine patients, 11 nodules were identified (one nodule in seven patients (77.8%) and two nodules in two patients (22.2%)). Location was limited to the roof of the body for six nodules (54.5%) and the frontal horn for five patients (45.5%). All nodules (100%) were round and isointense on T1- and T2-weighted imaging. On FLAIR imaging of eight nodules, six (75%) were hyperintense, and two (25%) were isointense. On DWI of seven nodules, all nodules (100%) were isointense. None of seven nodules (0%) examined using postcontrast MRI showed enhancement. None of eight nodules (0%) examined using serial MRI (range, 4-60 months) showed changes in morphology over time., Conclusion: These nodules were incidentally encountered and shared similar MRI features. Although pathological confirmation was lacking in our cases, these nodules may be of nonaggressive nature.

Background and Purpose: Pathogenesis of leukoaraiosis is incompletely understood and accumulation of small infarctions may be one of the possible sources of such white matter lesions. Thus, the purpose of this study was to identify the rate of incident infarction as depicted on diffusion-weighted images (DWIs) obtained from a general patient population., Materials and Methods: During the 4-year study period, a total of 60 patients (36 men and 24 women) had an incidental DWI-defined infarction without overt clinical symptoms suggestive of a stroke or a transient ischemic attack. All of the MR images were obtained by using a similar protocol on 2 identical 1.5T whole-body scanners. The patient's vascular risk factors, as well as the presence of white matter lesions (WMLs) on MR imaging and atheromatous changes on MR angiography, were assessed retrospectively. The incidental DWI-defined infarcts were also characterized in terms of their lateralization, lobe, and specific location., Results: A total of 16,206 consecutive brain MR images were done during the study period; the overall incidence of incidental infarcts was 0.37%. Most of these patients with an incidental infarct had vascular risk factors and WMLs on MR images. Most of these patients (80%) had a single lesion on DWI. A total of 88 lesions were identified; most were located in the white matter of the supratentorial brain, primarily in the frontoparietal lobes. There were also lesions involving the brain stem (n = 2). The lesions involving cerebrum were more commonly located in the right side (right to left = 52:34)., Conclusion: Small, DWI-defined acute brain infarctions can be found incidentally in an asymptomatic population; this finding may account, at least in part, for the pathogenesis of WMLs identified on MR imaging.

Objectives: To assess the general health-related quality of life (GHQOL) of patients with superficial bladder cancer who underwent transurethral resection (TUR)., Methods: We assessed the GHQOL a total of 178 times for 133 patients with superficial bladder cancer before multiple TURs. The GHQOL was assessed using the Medical Outcome Study Short-Form 36-item survey (SF-36). Ninety-three patients answered the questionnaire at the first TUR, 34 at the second TUR, 17 at the third TUR, and 34 at the fourth or later TUR., Results: Compared with age-matched and sex-matched Japanese norms, the general health perception was severely impaired in patients with superficial bladder cancer. Their mental health was also severely impaired at the first TUR, but gradually returned to normal as TUR was repeated. The scores of physical functioning, social functioning, and role-emotional demonstrated a nadir at the second or third TUR, and increased thereafter if TUR was repeated four or more times. Intravesical treatment for prevention of recurrence increased the score of bodily pain., Conclusions: Although superficial bladder cancer is not frequently lethal, patients with this disease believed their general health was much impaired. Only two domains of bodily pain and vitality had no negative impact from this disease. As urologists, we should notice the considerable affect of superficial bladder cancer on the GHQOL of patients.

In patients suffering from subarachnoid haemorrhage (SAH) and presenting with multiple intracranial aneurysms (MIA) two questions have to be decided on: 1st when is the ideal moment to eliminate the ruptured aneurysm and 2nd when to treat the coexisting aneurysms. In our series we retrospectively analysed 124 SAH-patients presenting with a total of 323 aneurysms. In 57 patients the ruptured aneurysm and all coexisting aneurysms were clipped during the first operation, whereas in 9 patients only some of the coexisting aneurysms (group-A; age in median 55 years) were clipped besides the ruptured one. In 55 patients (group-B; age in median 55 years) the first operation was restricted to clipping the ruptured aneurysm, dealing with the coexisting aneurysm subsequently. Immediately after admission 3 patients passed away. One of the 64 patients waiting (average 60 days, median 14 days) for the subsequent clipping of the not yet secured aneurysms suffered a SAH. Six to 12 months after the initial SAH, 78% of the cases in both groups reached a Glasgow Outcome Score of 4 or 5. Even if in patients with coexisting unruptured intracranial aneurysms the elimination of each and every aneurysm is recommended, the advantages of an unstaged procedure versus the additional strain caused by the prolongation of the procedure, e.g. approach over the midline, 2 or more craniotomies, and the risk of additional ischemic damage to the brain, caused by increased manipulation of cerebral arteries and brain tissue, have to be carefully considered. This is of special importance in dealing with patients in higher Hunt and Hess grades.

The treatment and natural course of unruptured cerebral aneurysms were analyzed in 615 patients with 712 unruptured cerebral aneurysms registered from seven Japanese national hospitals and Zurich University hospital. For 209 aneurysms in 181 cases, the natural course of the aneurysms was observed without surgical treatment. During the follow-up period of 3,862 months (321.8 years), 11 of these aneurysms ruptured giving a rupture rate of 3.42%/year. Five of these 11 aneurysms were less than 10 mm in diameter. Seventeen aneurysms of these 209 untreated aneurysms had blebs. Seven of these 17 aneurysms ruptured yielding the high rupture rate of 28.3%/year. The likelihood of unruptured cerebral aneurysms to rupture was not exceedingly low even when the aneurysms were smaller than 10 mm. Since the risk of rupture and morbidity in relation to surgical treatment cannot be predicted by size alone, the morphology, especially the presence of blebs, should be considered when treating unruptured cerebral aneurysms. In 434 patients, 503 cerebral aneurysms were treated surgically either by craniotomy in 472 aneurysms or endovascular coil embolization in 31 aneurysms. Surgical outcome was influenced by the presence of concurrent diseases, patient age, size and location of the aneurysms. Complications after surgical treatment of 128 incidentally found aneurysms were reported in four cases; three cases of hemiparesis and one case showing disturbance of higher brain function, with a morbidity rate of 3.1%. These results suggest that surgical treatment may be acceptable in cases of incidentally found cerebral aneurysms, especially when blebs are present.

The development of computed tomography(CT) and magnetic resonance imaging (MRI) has resulted in the discovery of unsuspected endocrinologically silent pituitary masses(pituitary incidentalomas). The management of these pituitary incidentalomas is controversial. Some lesions may increase in size, compress optic chiasm while others will remain unchanged in size. Five hundred and six patients with pituitary incidentalomas were obtained by questionnaire from March 1999 to May 2000 under the auspices of the Ministry of Health, Labor and Welfare in Japan. In thirty-three patients with pituitary incidentalomas (13.3%) developed tumor enlargement during the mean follow-up period of 45.5 months. Of 115 estimated non-functioning adenomas, 23(20.0%) tumor increased during mean follow up period of 50.7 months (range 10 to 173 months), while 5(5.4%) of 94 estimated Rathke's cysts increased in size during follow up. Pituitary apoplexy was occurred in one patient of 248 patients (0.4%). Pituitary incidentalomas usually follow a benign course. Transsphenoidal adenectomy is indicated for a solid mass attached to optic chiasma. For other patients, MRI every 6 months for the first 2 years, and then yearly may be recommended.

Adrenal incidentaloma is defined as clinically inapparent adrenal mass identified at abdominal imagine undertaken for health screening or examination of unrelated diseases. Recent national Survey by Research Committee of Japanese Ministry of Health and Labor revealed 2,016 cases of adrenal incidentaloma in year 1999. Analysis of 2,626 cases including additional new cases indicate 51% was non-functional adrenocortical adenoma, cortisol producing adenoma 8.9%, pheochromocytoma 8.5%, aldosteronoma 4.2%, adrenal cancer 1.4%. Cut of point for cancer was estimated at 5 cm. 1 mg dexamethasone test and circadian rhythm of cortisol secretion evaluation may be necessary for exclusion of clinically inapparent cortisol producing adrenal adenoma known as preclinical Cushing's syndrome. Clinical aspect and management of adrenal incidentaloma was briefly reviewed based on this national report.