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Symptomatic intracerebral hemorrhages (ICHs) are a rare complication after atrial fibrillation (AF) catheter ablation, while the incidence of asymptomatic ICHs detected by magnetic resonance (MR) imaging remains unclear. This study aimed to investigate the incidence, characteristics, and predictors of new-onset ICHs on MR imaging after AF ablation. We retrospectively studied 1257 consecutive AF ablation procedures in 1201 patients who underwent MR imaging on the day after the procedure. Repeat MR imaging within 3 months post-ablation was available in 352 procedures. Old ICHs on the initial MR imaging were observed in 28 procedures (2.2%). Post-ablation new ICHs were observed in 14 procedures (4.0%), including one symptomatic (0.3%) and 13 (3.7%) asymptomatic ICHs. One patient had a new ICH on the initial MR imaging, while the remaining 13 had such on the repeat MR imaging. A univariate analysis revealed that a previous ischemic stroke or transient ischemic attack (TIA) and the CHA2DS2-VASc score were positive predictors of new ICHs (odds ratios, 5.502 and 1.435; P = 0.004 and 0.044). The lesion diameter did not significantly differ between the old and new ICHs (median, 6.1 mm vs. 8.0 mm, P = 0.281), while the predominant location differed (lobar areas, 22.6% vs. 53.3%; cerebellum, 22.6% vs. 20.0%; others, 54.8% vs. 26.7%; P = 0.026). A few asymptomatic ICHs may occur after AF ablation. Most of the post-ablation new ICHs occurred a few days or later after the procedure. A previous ischemic stroke/TIA and the CHA2DS2-VASc score may be risk factors for post-ablation ICHs.

INTRODUCTION Local impedance (LI) drops during radiofrequency ablation can predict lesion formation. Some conduction gaps during pulmonary vein isolation (PVI) can be associated with nonendocardial connections. This study aimed to investigate the incidence, characteristics, and predictors of endocardial and nonendocardial conduction gaps during an LI-guided PVI. METHODS AND RESULTS We prospectively enrolled 157 consecutive patients undergoing an initial LI-guided extensive PVI of atrial fibrillation (AF). After the first-pass encirclement, the residual conduction gaps and reconnected gaps were mapped using Rhythmia (Boston Scientific) and a mini-basket catheter. Right and left PV (RPV/LPV) gaps were observed in 22.3% and 18.5% of the patients, respectively: 27 endocardial and 49 nonendocardial gaps. The carina regions were common sites for the gaps (51 carina-related vs. 25 noncarina-related). The carina-related gaps consisted of more nonendocardial gaps than endocardial gaps (RPVs: 90.0% vs. 10.0%, p = .001; LPVs: 76.2% vs. 23.8%, p

An ablation catheter capable of contact force (CF) and local impedance (LI) monitoring (IntellaNav StablePoint, Boston Scientific) has been recently launched. We evaluated the relationship between the CF and LI values during radiofrequency catheter ablation (RFCA) along the cavotricuspid isthmus (CTI).Fifty consecutive subjects who underwent a CTI-RFCA using IntellaNav StablePoint catheters were retrospectively studied. The initial CF and LI at the start of the RF applications and mean CF and minimum LI during the RF applications were measured. The absolute and percentage LI drops were calculated as the difference between the initial and minimum LIs and 100 × absolute LI drop/initial LI, respectively.We analyzed 602 first-pass RF applications. A weak correlation was observed between the initial CF and LI (The effective sites during the CF-guided CTI-RFCA had greater initial LI and LI drops than the ineffective sites. Absolute and percentage LI drops of 21 Ω and 10.8% may be appropriate targets for an effective ablation.

Left atrial tachycardias (ATs) often occur after left atrial ablation. The incidence of symptomatic and silent cerebral embolism after radiofrequency catheter ablation of left ATs and the impact of the type of 3-dimensional electroanatomic mapping (3D-EAM) system on the incidence of cerebral embolism remain unclear.This study aimed to investigate the incidence of cerebral embolism after a 3D-EAM system-guided left AT ablation procedure and compare that between the different 3D-EAM systems.We prospectively enrolled 59 patients who underwent left AT ablation and brain magnetic resonance imaging after the procedure: 30 were guided by the Rhythmia system (Boston Scientific, Marlborough, MA) and 29 by the CARTO system (Biosense Webster, Diamond Bar, CA) (groups R and C, respectively).One transient ischemic attack occurred in group R, and no symptomatic embolism occurred in group C. Silent cerebral ischemic lesions (SCILs) were observed in 35 patients (59.3%), and group R had a significantly higher incidence of SCILs than did group C (86.2% vs 33.3%; P.001). In multivariate analysis, group R and left atrial linear ablation were independent positive predictors of SCILs (odds ratio 12.822 and 8.668; P = .001 and P = .005). The incidence of bleeding complications was comparable between groups R and C (0% vs 3.3%; P = .508).Group R exhibited a higher incidence of postablation cerebral embolism than did group C. The use of the high-resolution 3D-EAM system with a mini-basket catheter to guide radiofrequency ablation of left atrial macroreentrant tachycardias may markedly increase the risk of silent cerebral embolism. The present results require further validation in a randomized study.

BACKGROUND Air bubble intrusion through transseptal sheaths during left atrial (LA) catheter ablation can cause cerebral embolisms, especially when using complex-shape catheters. This study aimed to compare the incidence of silent cerebral events (SCEs) after atrial fibrillation (AF) catheter ablation using a mini-basket catheter (IntellaMap Orion; Boston Scientific) between the following groups: group SP, strict prevention of LA air intrusion and group CP, conventional air intrusion prevention. METHODS We enrolled 123 consecutive AF patients (group SP, n = 61 and group CP, n = 62) who underwent brain magnetic resonance imaging after a local-impedance-guided ablation using one mini-basket catheter and one circular mapping catheter. The preventive strategy in group SP included (a) the insertion of the mini-basket catheter into the transseptal sheaths in a container filled with heparinized saline and (b) no exchange of all catheters over the sheaths. RESULTS SCEs were detected in 67 patients (54.5%), and the incidence of SCEs did not significantly differ between groups SP and CP (55.7% vs 53.2%; P = .780). A multivariate analysis demonstrated that an older age, non-paroxysmal AF, and radiofrequency (RF) power output were independent positive predictors of SCEs (odds ratios: 1.079, 5.613, and 1.405; P = .005

Image data for T1 mapping are generally acquired during mid-diastole period. However, T1 mapping tends to fail for patients with high heart rate or atrial fibrillation because of short or irregular R-R interval. Focusing on the evidence that the timing of systole is more stable than that of diastole from the R wave, we compared systolic T1 mapping with conventional diastolic T1 mapping for all participants (n = 58) by visual scoring of T1 calculation error. The systolic scores were significantly better than the diastolic scores (p 0.05). This advantage of the systolic scores was confirmed selectively for patients with atrial fibrillation (p 0.05, n = 19). The successful number of nonrigid image registration alignment for extracellular volume fraction (ECV) analysis also increased significantly for systolic images compared with diastolic images (p 0.05). Thus, systolic T1 mapping improves the accuracy of T1 values and ECV analysis.

INTRODUCTION The difference in the incidence and characteristics of silent cerebral events (SCEs) after radiofrequency-based atrial fibrillation (AF) ablation between the different mapping catheters and indices used for guiding radiofrequency ablation remains unclear. This study aimed to compare the incidence and characteristics of postablation SCEs between the following two groups: Group C, Ablation Index-guided ablation using two circular mapping catheters with CARTO (Biosense Webster); Group R, local impedance-guided ablation using one mini-basket catheter and one circular mapping with Rhythmia (Boston Scientific). METHODS AND RESULTS Of 211 consecutive patients who underwent an AF ablation and brain magnetic resonance (MR) imaging after the ablation, 120 patients (each group, n = 60) were selected by propensity score matching. SCEs were detected in 37 patients (30.8%). Group R had a higher incidence of SCEs (51.7% vs. 10.0%; p

In the ancien regime, major municipalities in France constantly sent delegates, or deputies and solicitors to the court to make petitions and refer disputes to arbitration seeking favour for the ci...

Image data for T1 mapping are generally acquired during mid-diastole period. However, T1 mapping tends to fail for patients with high heart rate or atrial fibrillation because of short or irregular R-R interval. Focusing on the evidence that the timing of systole is more stable than that of diastole from the R wave, we compared systolic T1 mapping with conventional diastolic T1 mapping for all participants (n = 58) by visual scoring of T1 calculation error. The systolic scores were significantly better than the diastolic scores (p

Introduction This prospective observational study aimed to investigate the incidence of symptomatic and silent cerebral embolisms after balloon-based ablation of atrial fibrillation (AF) in patients receiving periprocedural anticoagulation with direct oral anticoagulants (DOACs), and compare that between cryoballoon and HotBalloon ablation (CBA and HBA). Methods and results We enrolled 123 consecutive AF patients who underwent a balloon-based pulmonary vein isolation (PVI) and brain magnetic resonance (MR) imaging after the ablation procedure (CBA, n = 65; HBA, n = 58). The DOACs were continued in 62 patients throughout the periprocedural period and discontinued in 61 on the procedural day. Intravenous heparin was infused to maintain an activated clotting time of 300 to 400 seconds during the procedure. No symptomatic embolisms occurred in this series. Silent cerebral ischemic lesions (SCILs) were observed on MR imaging in 22 patients (17.9%), and the incidence of SCILs did not significantly differ between the CBA and HBA groups (21.5 vs 13.8%; P = 0.263). According to a multivariate logistic regression analysis, an older age was an independent positive predictor of SCILs (odds ratio, 1.062; 95% CI, 1.001-1.126; P = 0.046), but neither the balloon catheter type nor periprocedural continuation or discontinuation of the DOACs were significant predictors. The incidence of major and minor bleeding complications was comparable between the CBA and HBA groups (1.5 vs 0%, P = 0.528; 7.7 vs 5.2%, P = 0.424). Conclusions Both CBA and HBA of AF revealed a similar incidence of postablation cerebral embolisms. Elderly patients may be at a risk of SCILs after a balloon-based PVI with periprocedural DOAC treatment.

Background Periprocedural venous thromboembolisms (VTEs) area rare occurrence but a critical complication after catheter ablation of atrial fibrillation (AF).The aim of this study was to investigate the incidence of symptomatic deep vein thromboses (DVTs) and pulmonary thromboembolisms (PTEs) in patients who underwent AF catheter ablation and received periprocedural oral anticoagulation with direct oral anticoagulants (DOACs). Methods and results A total of 2,193 consecutive patients undergoing AF catheter ablation with periprocedural DOACs were retrospectively analyzed.Two patients (0.091%) experienced symptomatic DVTs after the ablation, and no patients had any PTEs. One patient was a 72-year-old female who underwent cryoballoon ablation with periprocedural apixaban at a dose of 2.5 mg twice daily. The other patient was a 74-year-old male who underwent a Hot Balloon ablation and thereafter radiofrequency catheter ablation for recurrent AF with edoxaban at30 mg once daily. Both DVT patients underwent AF ablation by the right femoral vein approach, and after discharge had right leg pain and swelling on post-procedural days 4 and 8, respectively. TheDVT was treated by increasing the dose of apixaban and changing it from 30 mg/day of edoxaban to 15-30 mg/day of rivaroxaban, and the thrombi completely disappeared in both patients without any thromboembolic and hemorrhagic complications. Conclusions AF catheter ablation with periprocedural DOAC treatment revealed anextremely low incidence of symptomatic VTEs, which may be successfully treated by increasing the DOAC dose or changing the DOAC type.

Here, we report a case of rapid eye movement sleep behavioural disorder in an elderly patient with dementia with Lewy bodies. Pretreatment polysomnography revealed atonia during rapid eye movement sleep, absence of sleep spindles and loss of slow-wave sleep. Administration of donepezil, an acetylcholinesterase inhibitor, markedly improved delusional symptoms and cognitive function. Pretreatment polysomnography performed after donepezil administration revealed a considerable number of sleep spindles. The effects of cholinergic modulation induced by donepezil seemed to cause remarkable improvement in mental status, incorporating associated with sleep spindles generated by the thalamocortical circuit involved in this patient.

Aims Catheter ablation is a potentially curative treatment for atrial fibrillation (AF). However, complications such as ischaemic stroke are more frequent and more severe compared with ablation procedures for other arrhythmias. Irrigated-tip catheters have been reported to reduce the risk of stroke. The present study aimed to evaluate predictors of asymptomatic cerebral infarction (CI) after AF ablation using an irrigated-tip catheter. Methods and results A total of 70 consecutive AF patients who underwent catheter ablation were subjected to brain magnetic resonance imaging (MRI) 1 day after the procedure. In 10 (14.3%) of 70 patients, MRI revealed acute CI, but neither symptoms nor abnormal neurological findings were present in these patients. In univariate analysis, a history of persistent AF, left atrial dimension, presence of spontaneous echo contrast (SEC), procedure duration prior to heparin injection, and electrical cardioversion during the procedure differed significantly between the two groups, those with and without CI ( P = 0.02, 0.05, 0.01, 0.01, and 0.05, respectively). Multivariate logistic regression analysis identified SEC [odds ratio (OR), 9.39; 1.60–55.2; P = 0.01] and procedure duration prior to heparin injection (OR, 1.19; 1.04–1.36; P = 0.01) as predictive of acute asymptomatic CI after AF ablation. Conclusion The presence of SEC and procedure duration prior to heparin injection are determinants of asymptomatic CI during AF ablation despite the use of an irrigated-tip catheter.

Objectives: Hypertension impairs coronary endothelial cell function, coronary microvascular function and the coronary flow (CF) reserve (CFR). Angiotensin II receptor blockers (ARBs) have been reported to possibly improve coronary endothelial function and coronary microvascular function. The purpose of this study was to determine whether treatment with the ARB olmesartan was more effective for improving CFR than the calcium channel blocker amlodipine. Methods: Twenty patients with untreated essential hypertension (M/F = 13/7, aged 55.6 ± 11.6 years) were randomly assigned to treatment with either olmesartan (n = 10) or amlodipine (n = 10) for 6 months. CF was measured in the proximal left anterior descending artery by magnetic resonance imaging before and during intravenous infusion of adenosine. CFR was calculated as the ratio of the hyperemic to baseline diastolic peak flow before and after 6 months of treatment. Results: The extent of systolic blood pressure reduction was similar in both groups (–40.0 ± 19.1 vs. –48.8 ± 14.7 mm Hg, p = 0.26). The olmesartan group showed significant improvement of CFR (from 1.9 ± 1.0 to 3.1 ± 1.1, p = 0.005), but this did not occur in the amlodipine group. Conclusion: Olmesartan, but not amlodipine, improves CFR in hypertensive patients.

Psychosis is common and often medically intractable in Parkinson disease (PD). Sometimes, its management is essential for the determination of the prognosis of PD. There have been several lines of studies demonstrating the effectiveness of electroconvulsive therapy (ECT) for depression in PD but very few for psychosis. The purpose of this retrospective study was to examine the effects of acute ECT on PD-associated psychosis.The subjects were 5 elderly PD patients (duration, 2-10 years); 4 of whom were diagnosed as "other substance (antiparkinsonian medications)-induced psychotic disorder, with hallucinations," and as 1 "psychotic disorder due to PD, with hallucinations," according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Two patients had comorbidity of major depressive disorder, single episode. The psychosis, being refractory to antipsychotics, was treated with a course of acute ECT. Psychiatric conditions were evaluated using the Brief Psychiatric Rating Scale (BPRS), the Hamilton Depression Rating Scale (HDRS), and the Global Assessment of Functioning (GAF) scale. Motor function was assessed using the Hoehn and Yahr staging.The total BPRS and GAF scores after ECT improved significantly compared with those just before ECT. The Hoehn and Yahr staging also showed significant improvement. No marked adverse effects were seen. Duration of the improvement was between 5 and 30 weeks in followed-up patients.Acute ECT was effective for medically refractory psychosis in patients with PD regardless of the comorbidity of depression. Our results suggest a possible indication of acute ECT for refractory psychosis in patients with PD.

Summary Objective 2-[18F] fluoro-2-deoxy- d -glucose (18F-FDG) began to be supplied commercially to our hospital, which does not have a cyclotron, in autumn of 2005. The purpose of this study was to compare the utility of a dual-head positron coincidence detection (PCD) gamma camera in the detection of myocardial viability using 18F-FDG with that of dedicated positron emission tomography (PET) and with that of thalium-201 (201Tl) single photon emission computed tomography (SPECT). Methods A total of 15 patients (14 men and 1 woman, mean age: 60 ± 7 years, range: 46–73) with a large acute myocardial infarction (AMI) underwent 18F-FDG PET, 18F-FDG PCD imaging after oral glucose loading (75 g) and 201Tl SPECT imaging. We divided the SPECT and PET images into a total of 20 segments, and semiquantitative visual analysis was performed by assessing regional tracer activities on a 4-point scoring system (DS): 0 = normal uptake, 1 = mildly reduced uptake, 2 = severely reduced uptake, and 3 = no uptake. We summed the DS in each patient as the total DS (TDS). Results The TDS of the 18F-FDG PET image was 14.4 ± 7.7. The TDS of the 18F-FDG PCD image was 18.7 ± 7.7. The TDS of the 201Tl SPECT image was 24.1 ± 11.5. The TDS of the 18F-FDG PET image was significantly smaller than that of the 18F-FDG PCD image. The TDS of the 18F-FDG PET image was significantly smaller than that of the 201Tl SPECT image. The TDS of the 18F-FDG PCD image was significantly smaller than that of the 201Tl SPECT image. Conclusion The findings of the project suggest that 18F-FDG PCD is a good modality based on its accuracy, convenience, and cost-performance for detecting myocardial viability in hospitals that do not have a PET system.

Background: Left ventricular (LV) postero-lateral scar and total scar burden are factors responsible for a poor response to cardiac resynchronization therapy (CRT). Contrast-enhanced magnetic resonance imaging (CMR) and 99mTc-2-methoxy isobutyl isonitrile single photon emission computed tomography (SPECT) perfusion imaging are widely used to detect myocardial scar tissue; however, their ability to detect regional scars and predict a positive response to CRT has not been fully evaluated. Methods: CMR and SPECT were performed in 17 patients with dilated cardiomyopathy (DCM) and seven patients with ischemic cardiomyopathy (ICM) before CRT. All images were scored, using a 17-segment model. To analyze the LV scar regions by CMR, we assessed the transmural delayed enhancement extent as the transmural score in each segment (0 = no scar, 4 = transmural scar). Similarly, a perfusion defect score was assigned to each segment by SPECT (0 = normal uptake, 4 = defect). Results: By both SPECT and CMR imaging, the total scar score was significantly higher in the ICM than in the DCM group. An LV postero-lateral wall scar region was detected using both imaging modes. By SPECT imaging, the percentage of regional scar score in the LV inferior wall was significantly higher in the DCM than in the ICM group. Conclusions: By SPECT imaging in the DCM group, severe perfusion defects, due to attenuation artifacts, were frequently observed in the LV inferior wall, resulting in the overestimation of scar tissue. CMR identified nonresponders to CRT more reliably than SPECT in patients with DCM.

Objectives: To comparel-3-[18F]-fluoro-α-methyltyrosine (FMT)-positron emission tomography (PET) and 2-[18F]-fluoro-2-deoxy-d-glucose (FDG)-PET in the differential diagnosis of maxillofacial tumors.Methods: This study included 36 patients (16 males, 20 females; 31–90 years old) with untreated malignant tumors (34 squamous cell carcinoma, one mucoepidermoid carcinoma, one rhabdomyosarcoma) and seven patients (five males, two females; 32–81 years old) with benign lesions. In all patients, both FMT-PET and FDG-PET were performed within two weeks before biopsy or treatment of the lesions. To evaluate the diagnostic usefulness of FMT-PET and FDG-PET, visual interpretation and semiquantitative analysis were performed. PET images were rated according to the contrast of tumor uptake as compared with background, and were statistically analyzed. As a semiquantitative analysis, standardized uptake values (SUV) of the primary tumors were measured, and the SUV data were analyzed using receiver operating characteristic (ROC) curves.Results: The mean SUV of the malignant lesions were significantly higher than those of the benign lesions in both FMT-PET (2.62±1.58 vs. 1.20±0.30, p

Administration of vitamin B12 and folic acid for 7 days prior to the administration of the first dose of pemetrexed is recommended. However, vitamin supplementation rarely is initiated less than 7 days prior to the first dose of pemetrexed. Therefore, we analyzed the safety of pemetrexed with vitamin supplementation for less than 7 days prior to the first dose of pemetrexed.Patients were classified into 2 groups according to the duration of vitamin supplementation prior to the first dose of pemetrexed: group A received vitamin supplementation for 7 days or more, and group B received vitamin supplementation for less than 7 days. We analyzed adverse effects, such as myelosuppression, rash, and diarrhea, after 1 cycle of pemetrexed therapy.A total of 70 patients were administered pemetrexed; 40 patients were men and 30 were women with a median age of 64.5 years(range, 43-86 years). A total of 57 patients were classified into group A and 13 into group B; 33 patients were administered pemetrexed as a first-line treatment. Neutropenia of Grade 3 or more was observed in 4/49(8.2%)patients in group A and 2/13(15.4%)patients in group B(p=0.60). There were no significant differences in the rates of occurrence of neutropenia, rash, and diarrhea.This retrospective study indicated that patients could be safely treated with pemetrexed if vitamin supplementation is initiated for less than 7 days prior to the first administration of pemetrexed. However, further studies are needed because of a lack of statistical power and adjustment for confounding factors.

Positron emission tomography (PET) using 2-(18)F-fluoro-2-deoxy-D-glucose (FDG), a radioactive derivative of glucose, is an advanced imaging tool, based on the increased glucose consumption of cancer cells. FDG-PET provides information that is not obtainable with other imaging modalities, and is very effective in the diagnosis and management of patients with various types of cancers. However, there are some limitations, such as low FDG uptake in some cancers, substantial FDG uptake in inflammatory cells, and the lack of anatomical information and poor imaging quality of PET. A recently developed integrated PET/computed tomography (CT) system, which combines a PET camera and CT scanner in a single session, has overcome these drawbacks by providing both anatomical and functional imaging at the same position. PET and/or PET/CT using FDG is clinically useful in the detection of cancer, the differentiation of malignant and benign lesions, the staging of cancer before therapy, and the assessment of cancer therapy, as well as for determining the recurrence after therapy of most cancers, including lung cancer, gastrointestinal cancer, breast cancer, and malignant lymphoma. PET/CT has become the new standard approach to imaging in the diagnosis and management of many cancer patients.

The National Adult Reading Test (NART) is widely used as a measure of premorbid IQ of the English-speaking patients with dementia. The purpose of the present study was to develop a Japanese version of the NART (JART), using 50 Japanese irregular words, all of which are Kanji (ideographic script) compound words. Reading performance based on JART and IQ as measured by the Wechsler Adult Intelligence Scale–Revised (WAIS-R) was examined in a sample of 100 normal elderly (NE) persons and in 70 age-, sex-, and education-matched patients with Alzheimer’s disease (AD). The NE group was randomly divided into the NE calculation group (n = 50) and the NE validation group (n = 50). Using the NE calculation group, a linear regression equation was obtained in which the observed full-scale IQ (FSIQ) was regressed on the reading errors of the JART. When the regressed equation computed from the NE calculation group was applied to the NE validation group, the predicted FSIQ adequately fit the observed FSIQ (R2 = 0.78). Further, independent t-tests showed that the JART-predicted IQs were not significantly different between the NE and AD groups, whereas the AD group performed worse in the observed IQs. The reading ability of Kanji compound words is well-preserved in Japanese patients with AD. The JART is a valid scale for evaluating premorbid IQ in patients with AD.

Background: The morphology of the pulmonary veins (PVs) before and after segmental isolation of the PVs has not been sufficiently characterized. Methods and Results: Multi-slice computed tomography was performed before and 3 ± 1 months after ablation in 30 patients with atrial fibrillation who underwent PV isolation. Before ablation, PV narrowing (≥25% luminal reduction) was found in nine (8%) PVs. After ablation, de novo PV narrowing was found in 24 PVs (26%) and was detected only in the supero-inferior direction in 14 PVs (58%). The diameter reduction inside the PVs after ablation was greater in the supero-inferior direction (14 ± 12%) than in the antero-posterior direction (9 ± 13%; P < 0.0001). In the ablated PVs, the PV trunk was shorter than before ablation (P < 0.0001). The reduction in the diameters of both the PV ostium and the ablation site in the ablated PVs, as well as the diameter of the PV ostium in the nonablated PVs, correlated with the decrease in the left atrial diameter. Shortening of the PV trunk correlated with the severity of PV narrowing, but it was not related to the percent diameter reduction of the left atrium. PV narrowing before or after ablation did not result in any clinical consequences. Conclusions: PV narrowing is present in about 10% of PVs before ablation. Asymmetric luminal reduction and longitudinal shrinkage of the PV trunk occur after ablation. Reverse remodeling of the PV and contraction of the PV wall may contribute to the reduction in the PV diameter. PV morphology should be assessed with multi-directional views to avoid missing heterogeneous legions.

A reversible salicylic acid decarboxylase (Sdc), found in the yeast Trichosporon moniliiforme WU-0401, is applicable for the production of p-aminosalicylic acid (PAS) from m-aminophenol (m-AP). For...

OBJECTIVES After five years of using our unique "school style" technique, we were able to increase the number of home discharges and decrease the number of days spent in the facility. In order to identify the factors underlying these results, a survey was conducted regarding changes of the physical and cognitive function while in the facility. METHODS The subjects included 41 patients who newly began using our facility. All subjects participated in both group and individual programs and were evaluated using the Mini Mental State Examination (MMSE), Frontal Assessment Battery at the bedside (FAB), Vitality Index and Functional Independence Measure (FIM) determined monthly starting the first day of entry into our facility. We compared the results using the Friedman test. RESULTS The rate of participation in the group program was 81.9%. The average duration of participation in functional training as an individual program was 5.94 days, while that for Kumon learning therapy was 3.27 days. Effective improvements were noted in all four evaluation measurements: MMSE・FAB・Vitality Index・FIM. CONCLUSIONS Improvements in the physical and cognitive function were obtained despite the status of the subjects as elderly individuals with chronic disease. Against this background, we applied interventions with rehabilitation using an intensive program for individuals and noted a pleasant experience during all activities in our unique "school style" protocol, which seeks to improve the subject's motivation. These factors are therefore important for improving the physical and cognitive function.

Progressive supranuclear palsy (PSP) is a neurodegenerative disorder with diverse clinical phenotypes characterized by supranuclear gaze palsy, parkinsonism with postural instability, and frontal dementia. The early and accurate diagnosis of PSP remains difficult because of the variable combination of symptoms and frequent lack of gaze abnormalities early in the disease course. Moreover, a subset of PSP shows behavioral changes as the initial presentation, which considerably overlaps with the clinical picture of frontotemporal dementia (FTD). Thus, this subgroup possibly needs psychiatric assessments. Here, we describe a clinical case of PSP difficult to differentiate from FTD because the frontal presentation persisted without gaze palsy until the late stage of the clinical course. A 58-year-old man was admitted to our hospital for the reconsideration of a diagnosis of FTD. Disinhibited and gambling behaviors inconsistent with his previous personality first appeared at around the age of 45, with gradual progression, followed by memory deficits, executive dysfunction, and a slowing of mental processes. Recurrent sexual disinhibition led him to undergo psychiatric consultation at the age of 57. Downward gaze palsy and postural instability with recurrent falls emerged 8 months after the first psychiatric examination, and he was clinically diagnosed with PSP 13 years after the initial frontal presentation. PSP should be considered in the differential diagnosis of patients presenting with frontal lobe symptoms, even in psychiatric practice.

To compare the diagnostic potential of whole-body positron emission tomography (PET) with fluorine 18 alpha-methyl tyrosine (FMT) with that of whole-body PET with 2-[fluorine 18]fluoro-2-deoxy-D-glucose (FDG).Nineteen patients with or suspected of having malignant tumors and five healthy volunteers underwent whole-body PET with FMT and FDG.In comparison with FDG uptake, FMT uptake was significantly less in the brain, heart, lung, liver, and spine. On a lesion-by-lesion basis, the sensitivity of whole-body FMT PET for depicting malignant tumors was inferior to that of whole-body FDG PET, but this difference was not statistically significant (74% [26 of 35 lesions] vs 91% [32 of 35 lesions], P.05). The positive predictive value of FMT PET was superior to that of FDG PET (87% [26 of 30 lesions] vs 63% [32 of 51 lesions], P.001). The difference in uptake between benign and malignant lesions was significant with FMT PET (mean +/- SD, 1.64 +/- 0.96 vs 0.79 +/- 0.23; P.001) but not with FDG PET (5.02 +/- 3.56 vs 4.02 +/- 2.90, P.05).Whole-body FMT PET is clinically useful in the diagnosis of malignant tumors and may be effective in the depiction of primary and metastatic lesions in the cardiac region or in the brain.

Aim: A comparative study of the images obtained with a dual-head coincidence gamma camera with thick NaI crystals (19 mm), a dedicated PET camera with BGO crystals and a conventional gamma camera with thin NaI crystals (9.5 mm) was conducted to clarify the clinical feasibility of a dualhead coincidence gamma camera with thick NaI crystals.Methods: FDG images of 27 patients with malignant tumors were obtained by means of a dual-head coincidence gamma camera with thick NaI crystal and a dedicated PET camera with BGO crystals. The images of bone scintigraphy in 10 cancer patients obtained with the dual-head coincidence gamma camera were compared with those taken by a conventional dual-head gamma camera with thin NaI crystals.Results: Patient-basis sensitivity in 27 patients with neoplasms and lesion-basis sensitivity of the dual-head coincidence gamma camera and the dedicated PET camera were 74.1% and 85.2% (n.s.), 66.7% and 72.2% (n.s.), respectively. The tumor to background FDG uptake ratio derived from the coincidence gamma camera was significantly lower than that derived from the dedicated PET camera (mean ±s.d.; 3.48±3.77 vs. 8.12±8.92, p

There were 23,104 suicides in Japan in 1996, making the suicide rate 18.4 per 100,000, which is not much higher than those of some European countries. This paper focuses on current trends of suicide in Japan. In addition, the problem of suicide among the elderly and some characteristic forms of suicide found in Japan, such as shinju (suicide pact) and inseki-jisatsu (suicide committed in order to take responsibility) are discussed. Future strategies are also proposed for suicide prevention in Japan.

Whether legal restriction of access to methods which can be used for suicide will actually reduce the suicide rate has been an issue of debate for years. Among the various methods of suicide, those at the center of debate have been firearms, prescription psychotropic drugs, herbicides, home gas, and automobile exhaust fumes. The opinions on this debate seem to be classified into three: 1) restriction is effective, 2) the effect of restriction is limited or only temporary, 3) restriction is ineffective. This paper reviews the debate briefly and gives some of our considerations on this issue.

To clarify the effect of normal aging on the EEG in the elderly, relative EEG power and coherence were studied in 68 elderly subjects (age range 61-90 years) as well as in 20 young subjects (age range 23-38 years). Relative beta power was significantly higher in the elderly subjects, while no significant differences were seen among the elderly groups. Therefore it may be assumed that EEG power in the centrooccipital region among the normal elderly remains almost unchanged. Also, age had no effect on interhemispheric coherence. However, intrahemispheric coherence was found to decrease with age in all bands almost linearly. Thus, intrahemispheric coherence is a more sensitive indicator of normal aging than relative power.

Here, we report a case of rapid eye movement sleep behavioural disorder in an elderly patient with dementia with Lewy bodies. Pretreatment polysomnography revealed atonia during rapid eye movement sleep, absence of sleep spindles and loss of slow-wave sleep. Administration of donepezil, an acetylcholinesterase inhibitor, markedly improved delusional symptoms and cognitive function. Pretreatment polysomnography performed after donepezil administration revealed a considerable number of sleep spindles. The effects of cholinergic modulation induced by donepezil seemed to cause remarkable improvement in mental status, incorporating associated with sleep spindles generated by the thalamocortical circuit involved in this patient.

A 59-year-old male patient with general paresis was hospitalized because of personality changes and memory disturbances without any neurological deficits. His Mini Mental State score was 11, and his total IQ on the WAIS-R was 56. TPHA titers in serum and the CSF were over 40960x and 640x respectively. Both the white blood cell count as well as total protein were found to be increased in the CSF and FTA-ABS in the CSF was positive. The patient was treated with penicillin, one million units per day intramuscularly for 14 days, and four million units per day intravenously for 10 days. The abnormal findings in the CSF, his unstable mood and agitation improved, as well as his scores on the Mini Mental State (17) and total IQ (74), and the patient was able to once again function socially. This case emphasizes the importance of early diagnosis and treatment of general paresis.

Dementia with Lewy bodies (DLB) has recently often been reported to exhibit various psychiatric symptoms. However, some DLB patients do not present typical clinical courses or psychiatric symptoms. We report two DLB patients with characteristic psychiatric symptoms: a depressive state and anxiety in the early stage, and auditory hallucination, delusion of guilt, and catatonia in the later stage. Pharmacotherapy was ineffective, but electroconvulsive therapy proved to have a marked effect. The clinical course represents the symptomatic concept of "late catatonia," which Sommer first reported in 1910 and Kocha later reappraised. In Japan, this has been prevailing as a useful concept in the field of clinical geriatric psychiatry. We discuss what to consider and how to treat DLB patients including those with atypical courses and psychiatric symptoms. We consider and treated them as "late catatonia", with a favorable response to treatment. There is an important viewpoint which helps us understand the process. The viewpoint is to distinguish between "genera" and "types" of mental illnesses as inherited from classical psychopathology to modern psychiatry. DLB corresponds to "genera" and late catatonia to "types." In treating DLB patients with atypical symptoms and courses, it appears clinically very important to think more about late catatonia, exhibiting characteristic symptoms. This also reveals the usefulness of understanding and treating such cases based on the concept of "genera" and "types."Authors' abstract

With neuropathological diagnosis as the point of reference, the validity of clinical diagnosis was studied in 50 patients who had met DSM-III-R criteria for dementia. Clinical diagnosis of ATD (dementia of Alzheimer type) was made in 14 cases, of VD (vascular dementia) in 14 cases, of others in 5 cases and of undefined in 16 cases. At necropsy, 16 cases fulfilled the histological criteria for ATD, while 15 cases were VD, 3 cases were mixed dementia and 14 cases were other CNS disorders. In 2 other cases, the neuropathological picture was considered to be nondiagnostic. The accuracy of clinical diagnosis of VD was higher than that of ATD. Clinical diagnostic sensitivity was 81.8% for ATD and 91.7% for VD; corresponding specificity was 78.3% and 86.4%. With our clinical criteria, slowly evolving VD with no clinical evidence of stroke would not be identified as VD. On the other hand, AD patients who happened to have a stroke would be diagnosed as VD. These results suggest that further investigations as to VD (its clinical course, findings of computed tomographic scan and magnetic resonance imaging) are needed for more appropriate clinical criteria.

Background: Inflammatory responses following atrial fibrillation (AF) ablation may aggravate arrhythmogenic activity and cause an early recurrence of AF (ERAF). Methods and Results: In 56 patients who underwent circumferential pulmonary vein ablation (CPVA) for paroxysmal AF, cardiovascular magnetic resonance imaging (CMRI) was evaluated in 5 subdivided left atrial (LA) regions before the CPVA and at 1 day and 1 month after. At a mean of 7±10 days after the CPVA, 23 patients (41%) developed 1 or more episodes of AF (ERAF group), while 33 patients (59%) remained free from AF during the first month of follow up (no-ERAF group). LA wall thickness increased 1 day after the CPVA in both groups, as demonstrated by high T2-weighted signal. The LA roof thickness and its increase, however, were greater in the ERAF group than in the no-ERAF group (P

Pain is a common symptom among older residents of nursing homes and can lead to adverse effects such as a decrease in the activities of daily living and quality of life. Existing literature on the prevalence of pain among older residents of nursing homes was reviewed. Of the studies that were reviewed here, 27 met the criteria of this study, and these were selected for further analysis. These studies were published from 1990 to 2009. There was a slight increase in the number of studies on this topic from 2004 onwards. It was clear that older residents commonly suffer from pain and other serious problems related to pain. The prevalence of pain in these studies appeared to be related to the research methods and data sources used as well as to the time frame of pain detection. Therefore, the results of such prevalence studies should be interpreted cautiously. It was also reported that higher pain intensity led to greater limitations in the activities of daily living. Insufficient use of analgesics for treating residents with pain was often reported, particularly in residents with a low cognitive status. Health professionals should be aware of the serious issues related to pain among nursing home residents and the fundamental right to have pain assessed and treated to the greatest extent possible.

Radiofrequency (RF) ablation produces thermal necrosis and electrophysiological conduction block when lesions are transmural. However, the phenomenon of endocardial edema may prevent the ablative energy from reaching the deeper layers of the myocardium.Sixty-seven patients underwent RF ablation of the cavotricuspid isthmus (CTI) for isthmus-dependent atrial flutter (AFL; 54 males, 61±9 years). Cardiac magnetic resonance (CMR) imaging was performed 1 day before ablation, and the length and morphology of the CTI were determined. In addition, 1 day and 1 month after ablation, the change in the wall thickness, prevalence of a high signal in the delayed enhancement (DE) and T2-weighted images at the CTI were evaluated.Before ablation, DE regions at the CTI were found in 2 patients with a concave type and 1 with a pouch type. No region with a high T2 signal at the CTI was observed in any of the 67 patients. One day after ablation, high T2 signals were detected at the CTI, and the wall thickness was significantly augmented (p0.0001). CMR also revealed a DE at the CTI in 46 patients (69%). One month after ablation, the thickened wall with a high T2 signal recovered to baseline, and a DE at the CTI was found in 56 patients (84%).CMR is useful for assessing the creation of endocardial edema and scar tissue resulting from CTI ablation. These results may correlate with the anatomical isthmus block after ablation in a large portion of the patients with isthmus-dependent AFL.

Background: Contrast-enhanced magnetic resonance imaging (CMR) identifies scar tissue as hyperenhanced areas. We sought to clarify the relationship between the scar characteristics and occurrence of sustained ventricular tachycardia (VT) in patients with advanced heart failure. Methods: CMR was performed in 29 patients with dilated cardiomyopathy (DCM group) and 18 patients with ischemic cardiomyopathy (ICM group). The characteristics, volume, and distribution of the hyperenhanced areas were analyzed by CMR. The CMR parameters and clinical arrhythmic events were compared between the two groups. Results: In the DCM group, almost all hyperenhanced areas were nontransmural, and presented frequently in the midwall layer. The volume of the hyperenhanced areas and total number of hyperenhanced segments were greater in patients with sustained VT than in those without. On the other hand, in the ICM group, transmural or subendocardial hyperenhanced areas were detected in the territory of the coronary arteries. The volume of the hyperenhanced areas and total number of transmural hyperenhanced segments in patients with sustained VT were unexpectedly smaller than in those without. However, the percentage of nontransmural hyperenhanced segments was greater in patients with sustained VT than in those without. Conclusions: The presence and magnitude of the nontransmural scar tissue may predict sustained VT in patients with advanced heart failure. There was the possibility that a recruitment bias was responsible for the finding of the smaller scars in the ICM patients with sustained VT.

Background: Contrast-enhanced magnetic resonance imaging (CMR) identifies scar tissue as an area of delayed enhancement (DE). The scar region might be the substrate for ventricular tachycardia (VT). However, the relationship between the occurrence of VT and the characteristics of scar tissue has not been fully studied. Methods: CMR was performed in 34 patients with monomorphic, sustained VT and dilated cardiomyopathy (DCM, n = 18), ischemic cardiomyopathy (ICM, n = 10), or idiopathic VT (IVT, n = 6). The VT exit site was assessed by a detailed analysis of the QRS morphology, including bundle branch block type, limb lead polarity, and precordial R-wave transition. On CMR imaging, the transmural score of each of the 17 segments was assigned, using a computer-assisted, semiautomatic technique, to measure the DE areas. Segmental scars were classified as nontransmural when DE was 1–75% and transmural when DE was 76–100% of the left ventricular mass in each segment. Results: A scar was detected in all patients with DCM or ICM. Nontransmural scar tissue was often found at the VT exit site, in patients with DCM or ICM. In contrast, no scar was found in patients with IVT. Conclusions: CMR clarified the characteristics and distribution of scar tissue in patients with structural heart disease, and the presence and location of scar tissue might predict the VT exit site in these patients.

An inflammatory response following thermal injury from catheter ablation of atrial fibrillation (AF) may aggravate arrhythmogenic activity and cause early AF recurrences (ERAFs). In 56 patients with drug-refractory, paroxysmal AF (14 women, 60±10 years) who underwent circumferential pulmonary vein ablation (CPVA), cardiovascular magnetic resonance (CMR) was performed before, and 1 day and 1 month after the CPVA. The wall thickness, delayed enhancement (DE) and T2-weighted images of the LA wall were evaluated in 6 subdivided regions of the left atrium (LA; PV ostia, roof, anterior wall, posterior wall, septum, and mitral isthmus). Twenty-three patients (41 %) had AF recurrence within 1 month after the CPVA (ERAF-Gr), whereas the remaining 33 did not (No-ERAF-Gr). Before the CPVA, no region with a high T2 signal was found in any of the patients in either group, and no difference was observed in the total number of DE regions between the 2 groups (2±1 vs. 2±1, p=0.31). One day after the CPVA, high T2-weighted images were detected around the LA wall, and augmentation of the wall thickness of the LA roof was greater in the ERAF-Gr than No-ERAF-Gr group (see Table ). One month after the CPVA, the thickened LA wall with a high T2 signal recovered to baseline. On the other hand, the change in the total number of DE regions after the CPVA did not differ between the 2 groups. Shortly after the CPVA, the LA wall was characterized by interstitial edema concomitant with thermal injury, and an edematous change in the LA roof may predict an ERAF. CMR is useful for assessing the distribution and extent of the edematous changes of the LA wall after CPVA. Change in the wall thickness and total number (no.) of scar regions 1 day after CPVA.

Although several branching patterns of pulmonary veins (PVs) were reported, their prevalence and characterization were not sufficiently clarified. Multislice computed tomography was performed in 428 patients who underwent catheter ablation for drug-refractory atrial fibrillation. Size and branching pattern of PVs were analyzed. A typical pattern of 4 PVs with 4 separate ostia was found in 326 patients (76%). However, a common PV trunk, defined as a PV with coalescence of superior and inferior PVsor =1.5 cm proximal to the junction with the left atrium, was found on the left side in 34 patients (8%) and right side in 3 patients (0.76%). A discrete middle PV was found on the right side in 54 patients (13%) and left side in 9 patients (2%). A right top PV, defined as an anomalous insertion of a branch of the right superior PV into the left atrial body, was also found in 16 patients (4%). In conclusion, 24% of our patients with atrial fibrillation had PV anomalies and 3% had coexistence of 2 PV variants, indicating that PV variants are not rare.

Introduction: Contrast-enhanced magnetic resonance imaging (CMR) reveals scar tissue as an enhanced area. Non-transmural scar regions may link to a scar-related reentrant ventricular tachycardia (VT). Methods: CMR was performed in 46 patients with advanced heart failure (dilated cardiomyopathy [DCM]-30, ischemic cardiomyopathy [ICM]-16; 36 males, 65±12 yrs; EF 28±12 %). Twenty-one patients (46 %) had documented sustained VTs. The scar volume (%; the percentage of the total scar volume) was obtained using MRI software. CMR images were also scored visually according to a 17-segment model (transmural score: 0= no damage, 4= transmural scar). The total number (No.) of segments with a transmural score of 4 (transmural scar) and transmural score of 1–3 (non-transmural scar), and the percentage of segments with non-transmural scar were obtained. The CMR parameters and clinical arrhythmic events were compared between the patients with DCM (DCM-Gr) and ICM (ICM-Gr). Results ( Table ): In the DCM-Gr, the scar was usually non-transmural, which presented mainly in the mid-wall layer and was characterized by a patchy distribution. The scar volume and total No. of segments with non-transmural scar were greater in DCM patients with VT than in those without. In contrast, patients in the ICM-Gr had transmural or subendocardial enhancement in the territory of coronary arteries, and the scar volume was smaller in ICM patients with VT than in those without. However, the total No. of segments with non-transmural scar and percentage of segments with non-transmural scar were greater in ICM patients with VT than in those without. In the VT patients in both Grs, non-transmural scar was always found at the VT exit site. Conclusions: CMR is useful for assessing the characteristics and distribution of myocardial scar. A wider and greater distribution of the non-transmural scar may provide the potential substrate for reentrant VTs in patients with advanced heart failure. Table: CMR-parameters in Patients with DCM and ICM