Angiography-derived functional assessment of left main coronary stenoses

OBJECTIVES

We aimed to evaluate the diagnostic accuracy of quantitative flow ratio (QFR) in left main (LM) coronary stenoses, using Fractional Flow Reserve (FFR) as reference.

BACKGROUND

QFR has demonstrated a high accuracy in determining the functional relevance of coronary stenoses in non-LM. However, there is an important paucity of data regarding its diagnostic value in the specific anatomical subset of LM disease.

METHODS

This is a retrospective, observational, multicenter, international, and blinded study including patients with LM stenoses. Cases with significant ostial LM disease were excluded. QFR was calculated from conventional angiograms at blinded fashion with respect to FFR.

RESULTS

Sixty-seven patients with LM stenoses were analyzed. Overall, LM had intermediate severity, both from angiographic (diameter stenosis [%DS] 43.8 ± 11.1%) and functional perspective (FFR 0.756 ± 0.105). Mean QFR was 0.733 ± 0.159. Correlation between QFR and FFR was moderate (r = 0.590). Positive and negative predictive value, sensitivity and specificity were 85.4%, 64%, 85.4%, and 69.6% respectively. Classification agreement of QFR and FFR in terms of functional stenosis severity was 78.1%. Area under the receiver operating characteristics of QFR using FFR as reference was 0.82 [95% confidence interval [CI], 0.71-0.93], and significantly better than angiographic evaluation including %DS (area under the receiver-operating characteristic curve [AUC] 0.45 [95% CI, 0.32-0.58], p < 0.001) and minimum lumen diameter (AUC 0.60 [95% CI, 0.47-0.74], p < 0.001).

CONCLUSIONS

Compared with FFR, QFR has acceptable diagnostic performance in determining the functional relevance of LM stenosis, being better than conventional angiographic assessment. Nonetheless, caution should be taken when applying functional angiography techniques for the assessment of LM stenosis given its particular anatomical characteristics.

In-hospital pulmonary rehabilitation after completion of primary respiratory disease treatment improves physical activity and ADL performance: A prospective intervention study

INTRODUCTION

Pulmonary rehabilitation improves the physical condition of patients with chronic respiratory disease; however, there are patients who cannot leave the hospital because of their low activities of daily living (ADLs), despite the completion of primary respiratory disease treatment and rehabilitation during treatment. Therefore, this study demonstrated that those patients recovered their ADLs through in-hospital pulmonary rehabilitation after treatment completion.

METHODS

We prospectively studied 24 hospitalized patients who had some remaining symptoms and showed low ADL scores of 9 points or less on the short physical performance battery after undergoing treatment for respiratory disease in Fukujuji Hospital from October 2018 to October 2019, excluding 2 patients who had re-exacerbation and 1 patient who could not be examined using the incremental shuttle walk test (ISWT). After completion of the primary respiratory disease treatment, patients moved to the regional comprehensive care ward, and they received pulmonary rehabilitation for 2 weeks. In the ward, patients who could not yet leave the hospital could undergo pulmonary rehabilitation for up to 60 days. Data were evaluated three times: upon treatment completion (baseline), postrehabilitation, and 3 months after baseline. The main outcome was an improvement in the incremental shuttle walk test (ISWT) postrehabilitation.

RESULTS

The median age of the patients was 80 (interquartile range (IQR): 74.8-84.5), and 14 patients (58.3%) were male. The ISWT distance significantly increased postrehabilitation (median [IQR]: 60 m [18-133] vs 120 m [68-203], P < .001). The Barthel Index (BI) (P < .001), the modified Medical Research Council (P < .001), and other scale scores were also improved. Among patients with acute respiratory diseases such as pneumonia, chronic obstructive pulmonary disease, and interstitial pneumonia, ISWT and other data showed improvement at the postrehabilitation timepoint. Ten patients who could perform examinations at 3 months after baseline were evaluated 3 months after taking baseline data prior to starting rehabilitation. The ISWT showed significant improvement 3 months after baseline compared to baseline (P = .024), and the ISWT distance was maintained after rehabilitation.

DISCUSSION AND CONCLUSIONS

Physical activity, symptoms, mental health, and ADL status in patients who had not recovered after primary treatment completion for respiratory diseases could improve through in-hospital pulmonary rehabilitation.

Construction and commissioning of mid-infrared self-amplified spontaneous emission free-electron laser at compact energy recovery linac

The mid-infrared range is an important spectrum range where materials exhibit a characteristic response corresponding to their molecular structure. A free-electron laser (FEL) is a promising candidate for a high-power light source with wavelength tunability to investigate the nonlinear response of materials. Although the self-amplification spontaneous emission (SASE) scheme is not usually adopted in the mid-infrared wavelength range, it may have advantages such as layout simplicity, the possibility of producing a single pulse, and scalability to a short-wavelength facility. To demonstrate the operation of a mid-infrared SASE FEL system in an energy recovery linac (ERL) layout, we constructed an SASE FEL setup in cERL, a test facility of the superconducting linac with the ERL configuration. Despite the adverse circumstance of space charge effects due to the given boundary condition of the facility, we successfully established the beam condition at the undulators and observed FEL emission at a wavelength of 20 μm. The results show that the layout of cERL has the potential for serving as a mid-infrared light source.

Constraints on Cosmic Strings Using Data from the Third Advanced LIGO-Virgo Observing Run

We search for gravitational-wave signals produced by cosmic strings in the Advanced LIGO and Virgo full O3 dataset. Search results are presented for gravitational waves produced by cosmic string loop features such as cusps, kinks, and, for the first time, kink-kink collisions. A template-based search for short-duration transient signals does not yield a detection. We also use the stochastic gravitational-wave background energy density upper limits derived from the O3 data to constrain the cosmic string tension Gμ as a function of the number of kinks, or the number of cusps, for two cosmic string loop distribution models. Additionally, we develop and test a third model that interpolates between these two models. Our results improve upon the previous LIGO-Virgo constraints on Gμ by 1 to 2 orders of magnitude depending on the model that is tested. In particular, for the one-loop distribution model, we set the most competitive constraints to date: Gμ≲4×10^{-15}. In the case of cosmic strings formed at the end of inflation in the context of grand unified theories, these results challenge simple inflationary models.

Constraints on Cosmic Strings Using Data from the Third Advanced LIGO-Virgo Observing Run

We search for gravitational-wave signals produced by cosmic strings in the Advanced LIGO and Virgo full O3 dataset. Search results are presented for gravitational waves produced by cosmic string loop features such as cusps, kinks, and, for the first time, kink-kink collisions. A template-based search for short-duration transient signals does not yield a detection. We also use the stochastic gravitational-wave background energy density upper limits derived from the O3 data to constrain the cosmic string tension Gμ as a function of the number of kinks, or the number of cusps, for two cosmic string loop distribution models. Additionally, we develop and test a third model that interpolates between these two models. Our results improve upon the previous LIGO-Virgo constraints on Gμ by 1 to 2 orders of magnitude depending on the model that is tested. In particular, for the one-loop distribution model, we set the most competitive constraints to date: Gμ≲4×10^{-15}. In the case of cosmic strings formed at the end of inflation in the context of grand unified theories, these results challenge simple inflationary models.

Sex Differences in the Oxygenation of the Left and Right Prefrontal Cortex during Moderate-Intensity Exercise

INTRODUCTION

Differences in cognitive performance with exercise between men and women have previously been reported. In this study, we evaluated between-sex differences in oxygenation of the prefrontal cortex (PFC) with moderate-intensity aerobic exercise (AE), which could contribute to noted differences in cognitive function.

METHOD

The subjects were ten men (age, 21.5 ± 0.5 years; height, 171.7 ± 4.8 cm; weight, 65.6 ± 5.6 kg) and ten women (age, 21.4 ± 0.5 years; height, 157.6 ± 4.9 cm; weight, 51.3 ± 6.5 kg). They completed our AE protocol, consisting of a 30-min leg-ergometer cycling at an intensity of 50% peak oxygen uptake, with an initial 4-min rest period for baseline measurement. Measures of the dynamics of cerebral oxygenation included: oxygenated hemoglobin (O2Hb) in the left and right PFC (LR-PFC) and deoxygenated hemoglobin (HHb). The 30-min exercise period was subdivided into six 5-min phases, with the average and peak values determined in each phase.

RESULTS

A significant interaction was found between LR-PFC HHb and sex (p < 0.001), with significantly higher values in men than in women in phases 3-6 (p < 0.05).

CONCLUSION

We report a significant sex effect of HHb in the LR-PFC.

Real-World Safety Profile of Atrial Fibrillation Ablation Using a Second-Generation Cryoballoon in Japan: Insight From a Large Multicenter Observational Study

OBJECTIVES

This study sought to investigate the incidence and characteristics of the real-world safety profile of second-generation cryoballoon ablation (2nd-CBA) in Japan.

BACKGROUND

Pulmonary vein isolation using second-generation cryoballoons is an accepted atrial fibrillation ablation strategy.

METHODS

This multicenter observational study included 4,173 patients with atrial fibrillation (3,807 paroxysmal) who underwent a 2nd-CBA in 18 participating centers. The baseline data and details of all procedure-related complications within 3 months post-procedure in consecutive patients from the first case at each center were retrospectively collected.

RESULTS

Adjunctive ablation after the pulmonary vein isolation was performed in 2,745 (65.8%) patients. Complications associated with the entire procedure were observed in 206 (4.9%) total patients, and in the multivariate analysis, the age (odds ratio: 1.015; 95% confidence interval: 1.001 to 1.030; p = 0.035) and study period were predictors. Air embolisms manifesting as ST-segment elevation and cardiac tamponade requiring drainage occurred in 63 (1.5%) and 15 (0.36%) patients, respectively. Six (0.14%) patients had strokes/transient ischemic attacks, among whom 5 underwent ablation under an interrupted anticoagulation regimen. No atrioesophageal fistulae occurred; however, 10 (0.24%) patients had symptomatic gastric hypomotility. Esophageal temperature monitoring did not reduce the incidence, and the incidence was significantly higher in patients with adjunctive posterior wall isolations or mitral isthmus ablation than those without (p = 0.004). Phrenic nerve injury occurred during the 2nd-CBA in 58 (1.4%) patients; however, all were asymptomatic and recovered within 13 months. One patient died of aspiration pneumonia.

CONCLUSIONS

This study had a high safety profile of 2nd-CBA despite including the early experience and high rate of adjunctive ablation. Care should be taken for air embolisms during 2nd-CBA.

Low prevalence of maternal microchimerism in peripheral blood of Japanese children with type 1 diabetes

AIM

To clarify the prevalence and degree of maternal microchimerism in Japanese children with type 1 diabetes, as well as its effect on phenotypic variation.

METHODS

We studied 153 Japanese children with type 1 diabetes, including 124 children positive for β-cell autoantibodies, and their 71 unaffected siblings. The number of circulating microchimeric cells per 10⁵ host cells was estimated by the use of quantitative-polymerase chain reaction targeting non-transmitted maternal human leukocyte antigen alleles. The results were compared to previous data from white European people. Phenotypic comparison was performed between maternal microchimerism carriers and non-carriers with diabetes.

RESULTS

Maternal microchimerism was detected in 15% of children with autoantibody-positive type 1 diabetes, 28% of children with autoantibody-negative type 1 diabetes, and 16% of unaffected siblings. There were no differences in the prevalence or levels of maternal microchimerism among the three groups or between the children with type 1 diabetes and their unaffected siblings. Furthermore, maternal microchimerism carriers and non-carriers exhibited similar phenotypes.

CONCLUSIONS

Maternal microchimerism appears to be less common in Japanese children with type 1 diabetes than in white European people. Our data indicate that maternal microchimerism is unlikely to be a major trigger or a phenotypic determinant of type 1 diabetes in Japanese children and that the biological significance of maternal microchimerism in type 1 diabetes may differ among ethnic groups.

Cardiac amyloidosis in patients undergoing aortic valve replacement for aortic stenosis

Background

Transthyretin cardiac amyloidosis (ATTR) has been increasingly recognized in patients with degenerative aortic stenosis (AS). In some reports, the uptake of Tc-99m labeled bone radiotracers in cardiac amyloidosis has been documented. Tc-99m pyrophosphate (PYP) scintigraphy in the absence of evidence of a monoclonal gammopathy was diagnostic for transthyretin cardiac amyloidosis, providing a cost-effective and non-invasive technique with a specificity and positive predictive value of nearly 100%. We sought to determine the prevalence of ATTR as detected by the bone scan tracer among the patients with severe AS requiring surgical valve replacement.

Methods

We retrospectively analyzed clinical and echocardiographical data for 44 patients with severe AS requiring surgical valve replacement between Jan. 2009 and Dec. 2016. All eligible patients were offered Tc-99m PYP scintigraphy. Retention of Tc-99m PYP in the heart was assessed using both a semiquantitative visual score (range, 0 [no uptake] to 3 [uptake greater than bone]). Positive uptake was defined score 2 and 3.

Results

Myocardial deposition of Tc-99m PYP (Score 2–3) was identified in 4 of 44 patients (9%), all &gt;70 years and 75% male. Patients with myocardial deposition of the tracer were older (78±8 years vs. 70±12 years), and had more mean interventricular septum thickness (18±3 mm vs. 14±5 mm). Both groups had at least ejection fraction and abnormal global longitudinal strain with no significant difference between groups. Pre-operative serum median NT-pro BNP level was similar between two groups, but post-operative improvement of NT-pro BNP was larger in non-deposition of the tracer group. During the post operative follow-up, survival was significantly worse if patients had amyloid deposition compared with no deposition subjects (25% vs. 7.5%).

Conclusion

Incidental transthyretin cardiac amyroidosis had a prevelance of 9% among patients undergoing surgical aortic valve replacement and was associated with a poor outcome.

Funding Acknowledgement

Type of funding source: None

Diagnostic Performance and Pressure Stability of a Novel Myocardial Ischemic Diagnostic Index - The Intracoronary-Electrocardiogram-Triggered Distal Pressure/Aortic Pressure Ratio

Background: We hypothesized that the intracoronary-electrocardiogram (IC-ECG)-based pressure index would be more stable and precise than the instantaneous flow reserve (iFR). We investigated the usefulness of the IC-ECG-based pressure index for diagnosing myocardial ischemia. Methods and Results: Thirty-seven consecutive patients with coronary stenosis requiring physiological assessment were enrolled in the study. iFR was measured at rest and under hyperemia in 51 and 40 lesions, respectively. The IC-ECG-triggered distal pressure (Pd)/aortic pressure (Pa) ratio (ICE-T) was defined as the mean Pd/Pa ratio in the period corresponding to the isoelectric line. The ICE-T was significantly lower than the iFR both at rest and during hyperemia (P<0.00001 for both). Fluctuations in the ICE-T pressure parameters (Pd/Pa, Pa, and Pd) were significantly smaller than those of iFR both at rest and during hyperemia. The diagnostic accuracy of predicting a fractional flow reserve (FFR) ≤0.80 of the ICE-T at rest was significantly higher than that of iFR (P=0.008). Receiver operating characteristic curve analyses showed that the ICE-T predicts FFR ≤0.80 more accurately than the iFR (area under curve 0.897 vs. 0.810 for ICE-T and iFR, respectively). Conclusions: We identified the period in the IC-ECG in which resting Pd/Pa was low and constant. The IC-ECG-based algorithm may improve the accuracy of diagnosing myocardial ischemia, without increasing invasiveness, compared with pressure-dependent indices.

Analysis of risk factors for the development of a post-bronchoscopy respiratory infection in lung cancer patients

BACKGROUND

The development of pneumonia following bronchoscopy is a very important post-bronchoscopic complication, while lung abscesses after bronchoscopy are rare. However, bronchoscopic techniques have advanced, and recently, we have observed patients with lung abscess after bronchoscopy. Therefore, the risk factors might vary from those in past reports. This study was performed to identify the incidence of and risk factors for post-bronchoscopy respiratory infections.

METHODS

We retrospectively studied adult patients diagnosed with lung cancer by bronchoscopy at Fukujuji Hospital from January 2017 to June 2019. The infection and noninfection groups were compared. The incidence of lung abscess was compared between recent periods and 2013, when endobronchial ultrasonography with a guide sheath (EBUS-GS) was not yet used in our hospital.

RESULTS

We reviewed 327 patients, including 20 patients (6.1%) with infections. The risk factors for infection were necrosis and/or a cavity in the tumor (p < 0.001), a large tumor diameter (≥30 mm) (p = 0.010), and a low serum albumin level (<4.0 g/dL) (p = 0.010). We developed a predictive score with these risk factors, and the area under the curve was 0.737 (95% Cl: 0.610-0.864). No significant differences in age, current smoking status, or abnormal bronchoscopic findings were observed, although these were previously reported as risk factors. In total, 12 patients had lung abscesses (3.7%), which is a higher incidence than that in 2013 (0.8%).

CONCLUSIONS

The risk factors for developing post-bronchoscopy respiratory infection in our study varied from those in past reports, possibly because of the advancements in bronchoscopic techniques, such as EBUS-GS.

Effect of QTU prolongation on hyperemic instantaneous wave-free ratio value: a prospective single-center study

We hypothesized that in patients with QT prolongation, resistance might not decrease in the wave-free period, because QTU prolongation cannot be detected by instantaneous wave-free ratio (iFR) analysis software. We investigated whether corrected QTU (QTUc) prolongation affects the hyperemic iFR value. Forty-two consecutive patients with intermediate stenosis (≥ 50%) in the left anterior descending coronary artery (LAD) were analyzed. Fractional flow reserve (FFR) and hyperemic iFR were simultaneously and continuously recorded with intravenous adenosine triphosphate (ATP) and papaverine infusions. In 17 patients with stenosis in the proximal LAD, coronary flow was measured. Patients were divided into two groups according to the median absolute deviation of the QTUc by ATP administration/QTUc by papaverine administration. FFR, hyperemic iFR, and flow data were compared between each stimulus and group. Moreover, influences of pressure and electrocardiogram parameters on differences in iFR values under ATP and papaverine administration were compared between the following two groups (group 1: the absolute difference of hyperemic iFR values between ATP and papaverine administration is ≤ 0.05; group 2: that is > 0.05). The paired t test and t test were used in analysis. Hyperemic iFR values of patients under the use of papaverine were lower than those of patients under the use of ATP when QTUc was more prolonged by papaverine administration than by ATP administration (ATP 0.74 ± 0.14, papaverine 0.71 ± 0.15, P = 0.025). No significant differences were observed in the FFR value and flow data between the groups. Regarding QTU, QTUc, and QTUc by ATP/QTUc by papaverine, significant differences were observed between group 1 and group 2. Pressure parameters did not induce significant differences. QTUc prolongation induced by papaverine was associated with lower hyperemic iFR values. An iFR-based assessment might lead to inappropriate treatment of patients with QTUc prolongation.

Adult axillary lymphangioma removal using indocyanine green fluorescence imaging system: A case report

•

Adult cystic lymphangioma is extremely rare.

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Diagnosis of lymphangioma is relatively easy based on the clinical image findings.

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Complete surgical excision is the most effective treatment for lymphangioma.

•

The ICG fluorescence imaging system is very useful for performing complete excision.

Introduction

Lymphangiomas are benign cystic tumors which arise from congenital malformations of the lymphatic system and are extremely rare in adulthood. We report a case of adult lymphangioma of the axilla that was removed after identifying the feeding lymphatic vessel using an indocyanine green (ICG) fluorescence imaging system.

Presentation of case

A 35-year old woman presented to our hospital with a rapidly growing mass on her left axilla. She had been pregnant once before and delivered at 34 years of age. Mammography, ultrasonography, and magnetic resonance imaging revealed a tumor that consisted of multiple cysts, which led to a diagnosis of cystic lymphangioma. The ICG fluorescence imaging system indicated that only one lymphatic vessel, which was completely removed with ligation of the feeding lymphatic vessel, was flowing to the tumor. An immunohistological study demonstrated that the cystic endothelia were positive for podoplanin (D2-40), a marker of lymphatic vessels.

Discussion

In addition to congenital factors, mechanical obstruction to lymphatic vessels by an external force, such as trauma or congestion of the lymphatic flow caused by increasing venous pressure during pregnancy or delivery might lead to lymphangioma in adulthood. Therefore, our patient’s pregnancy and delivery one year prior to discovery of the tumor seems to be the cause of her lymphangioma.

Conclusion

Based on our findings, we recommend the complete excision to successfully treat adult-onset lymphangioma. We also suggest that visualization with ICG fluorescence imaging system is very useful for detecting the feeding lymphatic vessel and performing complete excision of the lymphangioma.

Prospects for observing and localizing gravitational-wave transients with Advanced LIGO, Advanced Virgo and KAGRA

We present our current best estimate of the plausible observing scenarios for the Advanced LIGO, Advanced Virgo and KAGRA gravitational-wave detectors over the next several years, with the intention of providing information to facilitate planning for multi-messenger astronomy with gravitational waves. We estimate the sensitivity of the network to transient gravitational-wave signals for the third (O3), fourth (O4) and fifth observing (O5) runs, including the planned upgrades of the Advanced LIGO and Advanced Virgo detectors. We study the capability of the network to determine the sky location of the source for gravitational-wave signals from the inspiral of binary systems of compact objects, that is binary neutron star, neutron star-black hole, and binary black hole systems. The ability to localize the sources is given as a sky-area probability, luminosity distance, and comoving volume. The median sky localization area (90% credible region) is expected to be a few hundreds of square degrees for all types of binary systems during O3 with the Advanced LIGO and Virgo (HLV) network. The median sky localization area will improve to a few tens of square degrees during O4 with the Advanced LIGO, Virgo, and KAGRA (HLVK) network. During O3, the median localization volume (90% credible region) is expected to be on the order of 10 5 , 10 6 , 10 7 Mpc 3 for binary neutron star, neutron star-black hole, and binary black hole systems, respectively. The localization volume in O4 is expected to be about a factor two smaller than in O3. We predict a detection count of 1 - 1 + 12 ( 10 - 10 + 52 ) for binary neutron star mergers, of 0 - 0 + 19 ( 1 - 1 + 91 ) for neutron star-black hole mergers, and 17 - 11 + 22 ( 79 - 44 + 89 ) for binary black hole mergers in a one-calendar-year observing run of the HLV network during O3 (HLVK network during O4). We evaluate sensitivity and localization expectations for unmodeled signal searches, including the search for intermediate mass black hole binary mergers.

Positive Myocardial Uptake of Bone Scintigraphic Agents Associated with Cardiac Amyloidosis: Frequency of Positive Uptake Data Based on Daily Clinical Practice

Objective: The bone scan plays an important role for detecting number of conditions relating to bones, including: bone cancer or bone metastasis, bone inflammation. Extraosseous uptake, in particular, myocardial uptake, was observed in some patients examined with the bone scans. Positive uptake of ^99mTc-labeled bone radiotracers is associated with cardiac amyloidosis. However, the frequency and cause of positive cardiac ^99mTc-MDP uptake have not been fully studied. In this regard, the aim of this study was to assess the frequency and characteristics of patients with high myocardi-al uptake of bone scintigraphy in daily clinical practice setting. Methods: We retrospectively analyzed 4180 bone scintigraphies performed in daily clinical practice during 7-years period. The intensity of the myocardial uptake was graded based on a visual scale ranging from 0 to 3 points. Score 0 indicates the absence of uptake. Score 1 defined uptake less than that of bone (referred to as the adjacent rib). Uptake similar to that of bone was classified score 2. Score 3 was defined as uptake greater than that of reference bone. Positive myocardial uptake included a visual score 2 or 3. Result: Positive ^99mTc-MDP myocardial uptake occurred in 12 patients among 4180 patients (0.3%). 7 of 12 positive scan patients were consistent with amyloidosis confirmed by biopsy. In these patients, the mean age was 75.6 ± 5.2 years old. Ten cases showed biventricular uptake and 2 showed LV uptake only. Conclusion: Positive cardiac uptake of bone scintigraphic agents was present in 0.3% of bone scintigraphies in a clinical practice setting. This may be a sign of cardiac amyloidosis involvement which may give the presence of extraosseous bone tracer uptake its own importance and a new role.

P2725Transthyretin cardiac amyloidosis in heart failure with preserved ejection fraction: Imaging by Tc-99m bone scan

Background

Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous clinical syndrome with multiple underlying causes. Transthyretin amyloidosis (ATTR) is an underdiagnosed cause of HFpEF. Extraosseous uptake, in particular, myocardial uptake, was observed in a number of ATTR patients examined with the bone scan tracers.

Objectives

We sought to determine the prevalence of ATTR as detected by the bone scan among the patients admitted due to HFpEF.

Methods

We screened all consecutive patients ≥60 years old admitted due to HFpEF (left ventricular ejection fraction ≥50%). All eligible patients were offered an echocardiogram and a bone scan (a 99mTc-DPD/MDP/HMDP scintigraphy). Echocardiographic and clinical variables were gathered in all the subjects. The intensity of the myocardial uptake was graded according to a visual scale ranging from 0 to 3 points, in which the absence of uptake was assigned a score of 0 points; uptake less than that of bone (referred to as the adjacent rib), 1 point; uptake similar to that of bone, 2 points; and uptake greater than that of bone, 3 points. The distribution of the uptake in myocardium was defined as focal uptake, diffuse uptake, uptake in a ventricular wall segment, diffuse ventricular uptake, or diffuse biventricular uptake.

Results

The study included 62 HFpEF patients (52% women, 73±9 years). The bone scintigraphic analysis revealed relatively intense myocardial uptake in 7 of 62 patients (11.2%). 7 patients had intense Tc-99m uptake (score of 2–3) in the cardiac region, showing deposition in both right and left ventricles in every case. Patients with amyloid deposition were older (78±6 vs. 70±12 years, p<0.05), had a lower systolic blood pressure (118±23 vs. 148±28 mmHg, p<0.05), and left ventricular ejection fraction (52±11 vs. 58±6%, p<0.05). Both groups had at least moderate left ventricular hypertrophy and abnormal global longitudinal strain with no significant difference between groups. In 6 all the cases, the final diagnosis of amyloidosis was based on the results of abdominal fat aspiration biopsy.

Conclusion

ATTR is an underdiagnosed disease that accounts for a significant number (11.2%) of HFpEF cases. These findings create an opportunity for further investigation in the targeted therapy of patients with HFpEF.

A case of accessory pathway between the coronary sinus musculature and the left ventricle

A 64-year-old female underwent catheter ablation of long R-P' tachycardia. Ventricular pacing exhibited retrograde conduction with an identical atrial activation sequence as during tachycardia because of an accessory pathway (AP) with a long VA conduction. A radiofrequency application within the posterior coronary sinus (CS) could achieve a change of activation pattern from distal-to-proximal to proximal-to-distal within CS proximal to the ablation site, caused by conduction block of CS musculature (CSM) at the proximal site. This phenomenon could explain that this AP was connected between the CSM and the left ventricle, in site far away from the discrete connection between the left atrium and CSM.

Multiple fungus balls in a patient with chronic pulmonary aspergillosis

Typically, radiological examination in chronic pulmonary aspergillosis reveals cavities with fungus balls within the upper lobes. This case showed that multiple fungus balls can also be present in the lower lobes.

[A case of resected synchronous hepatocellular and cholangiolocellular carcinoma in the background of resolved hepatitis B virus infection]

An 85-year-old male patient was referred to our hospital for further examination of a liver tumor. Imaging examination revealed a 90-mm tumor in segment 4/8 and 30-mm tumor in segment 6 of the liver. Histopathological examination revealed that the tumor in segment 4/8 was cholangiolocellular carcinoma (CLC) and the tumor in segment 6 was hepatocellular carcinoma (HCC). This case shows that although the frequency of CLC is very low, recent studies have indicated the novel knowledge of CLC. Herein, we report a surgical case of CLC and HCC in the background of resolved hepatitis B virus infection.

Urogenital symptoms in mitochondrial disease: overlooked and undertreated

Background and purpose

Bowel symptoms are well documented in mitochondrial disease. However, data concerning other pelvic organs is limited. A large case–control study has therefore been undertaken to determine the presence of lower urinary tract symptoms (LUTS) and sexual dysfunction in adults with genetically confirmed mitochondrial disease.

Methods

Adults with genetically confirmed mitochondrial disease and control subjects were recruited from a specialist mitochondrial clinic. The presence and severity of LUTS and their impact on quality of life, in addition to sexual dysfunction and bowel symptoms, were captured using four validated questionnaires. Subgroup analysis was undertaken in patients harbouring the m.3243A>G MT‐TL1 mitochondrial DNA mutation. A subset of patients underwent urodynamic studies to further characterize their LUTS.

Results

Data from 58 patients and 19 controls (gender and age matched) were collected. Adults with mitochondrial disease had significantly more overactive bladder (81.5% vs. 56.3%, P = 0.039) and low stream (34.5% vs. 5.3%, P = 0.013) urinary symptoms than controls. Urodynamic studies in 10 patients confirmed that bladder storage symptoms predominate. Despite high rates of LUTS, none of the patient group was receiving treatment. Female patients and those harbouring the m.3243A>G MT‐TL1 mutation experienced significantly more sexual dysfunction than controls (53.1% vs. 11.1%, P = 0.026, and 66.7% vs. 26.3%, P = 0.011, respectively).

Conclusions

Lower urinary tract symptoms are common but undertreated in adult mitochondrial disease, and female patients and those harbouring the m.3243A>G MT‐TL1 mutation experience sexual dysfunction. Given their impact on quality of life, screening for and treating LUTS and sexual dysfunction in adults with mitochondrial disease are strongly recommended.

Conduction Delay-Induced J-Wave Augmentation in Patients With Coronary Heart Disease

Electrocardiogram records were surveyed for the presence of an atrial premature beat (APB) and J waves in patients with coronary heart disease and patients with noncardiac diseases. The prevalence and response of J waves to sudden shortening of the RR interval on the conducted APB were determined and compared between the 2 patients groups. The change in the QRS complexes on the APB was also determined. Among 17,013 patients, 243 patients who underwent percutaneous coronary intervention for acute myocardial infarction or angina pectoris had an APB, and J waves were observed in 16 patients (6.6%). In an additional 729 patients with noncardiac diseases and APB, 19 patients showed J waves (2.6%; p = 0.010). The clinical features were almost similar between the ischemic and nonischemic groups. J waves were located more often in inferior and high lateral leads in the ischemic group. When the RR interval shortened from 942 ± 228 to 621 ± 175 ms and 869 ± 158 to 570 ± 118 ms at baseline and in the conducted APB (p<0.001 for both), the J-wave amplitude increased from 0.16 ± 0.04 to 0.19 ± 0.06 mV (p<0.001) and 0.21 ± 0.07 to 0.24 ± 0.08 mV (p = 0.010) in the ischemic and nonischemic groups, respectively. J waves in patients with chronic coronary heart disease and in patients with noncardiac diseases were augmented at short RR intervals together with distinct changes in the QRS complexes, and an augmentation of J waves at short RR interval may represent a conduction delay.

Stimulated Excitation of an Optical Cavity by a Multibunch Electron Beam via Coherent-Diffraction-Radiation Process

With a low emittance and short-bunch electron beam at a high repetition rate realized by a superconducting linac, stimulated excitation of an optical cavity at the terahertz spectrum range is shown. The electron beam passes through small holes in the cavity mirrors without being destroyed. A sharp resonance structure which indicates wideband stimulated emission via coherent diffraction radiation is observed while scanning the round-trip length of the cavity.

Esophageal Carcinosarcoma that Was Diagnosed as a Granulocyte-colony Stimulating Factor and Interleukin-6-producing Tumor with a Tumor Fever

A 51-year-old man visited our hospital with a main complaint of precordial pain, difficulty swallowing, and pyrexia. The patient was diagnosed with esophageal carcinosarcoma, based on the characteristic morphology noted on upper gastrointestinal endoscopy and histology tests, and he underwent surgical treatment. His preoperative blood granulocyte-colony stimulating factor (G-CSF) and interleukin-6 (IL-6) levels were high, and the surgical specimens were positive in both immunohistochemical tests; therefore, he was diagnosed with a G-CSF- and IL-6-producing tumor. When pyrexia is seen as a paraneoplastic symptom, it is important to consider and investigate the possibility of a cytokine-producing tumor.

Coronary arterial spasm detected by coronary computed tomography angiography and confirmed by intravascular ultrasound

A 40-year-old man was admitted to our hospital for chest pain after smoking. Coronary computed tomography angiography showed severe stenosis in the left anterior descending artery. The stenosis site had no plaque on stretched curved multiplanar reconstruction and short-axis images. Coronary angiography revealed improvement of the severe stenosis after the intracoronary administration of isosorbide dinitrate in the left anterior descending artery. Intravascular ultrasound demonstrated negative remodeling without a plaque and diffuse intima with media thickening at the stenosis site. The chest pain was likely caused by coronary spastic angina, which was treated with diltiazem hydrochloride.

The Serum Ferritin Level Is Associated with the Treatment Responsivity for Rapidly Progressive Interstitial Lung Disease with Amyopathic Dermatomyositis, Irrespective of the Anti-MDA5 Antibody Level

We report the case of a 61-year-old woman with rapidly progressive interstitial lung disease caused by clinically amyopathic dermatomyositis. Both the serum ferritin and anti-melanoma differentiation-associated gene 5 (MDA5) antibody levels were elevated at the time of admission. Despite intensive treatment with corticosteroids, immunosuppressants, immunoglobulins and polymyxin B direct hemoperfusion, the patient died 75 days after symptom onset. Over the course of treatment, the anti-MDA5 antibody level continually decreased, while the serum ferritin level increased, suggesting that sequential measurements of the serum ferritin level might be useful for evaluating the treatment responsivity, irrespective of the anti-MDA5 antibody level.

Prospects for observing and localizing gravitational-wave transients with Advanced LIGO, Advanced Virgo and KAGRA

We present possible observing scenarios for the Advanced LIGO, Advanced Virgo and KAGRA gravitational-wave detectors over the next decade, with the intention of providing information to the astronomy community to facilitate planning for multi-messenger astronomy with gravitational waves. We estimate the sensitivity of the network to transient gravitational-wave signals, and study the capability of the network to determine the sky location of the source. We report our findings for gravitational-wave transients, with particular focus on gravitational-wave signals from the inspiral of binary neutron star systems, which are the most promising targets for multi-messenger astronomy. The ability to localize the sources of the detected signals depends on the geographical distribution of the detectors and their relative sensitivity, and [Formula: see text] credible regions can be as large as thousands of square degrees when only two sensitive detectors are operational. Determining the sky position of a significant fraction of detected signals to areas of 5-[Formula: see text] requires at least three detectors of sensitivity within a factor of [Formula: see text] of each other and with a broad frequency bandwidth. When all detectors, including KAGRA and the third LIGO detector in India, reach design sensitivity, a significant fraction of gravitational-wave signals will be localized to a few square degrees by gravitational-wave observations alone.

Comparative Study of Vanadate- and Phorbol Ester-induced Cyclo-oxygenase-2 Expression in Human Endothelial Cells

Our previous study showed that vanadate, an inhibitor of protein tyrosine phosphatases, induced the expression of cyclo-oxygenase (COX)-2 in a protein-tyrosine-kinase (PTK)-dependent manner in human umbilical vein endothelial cells (HUVEC). Here, we further compared the actions of vanadate and phorbol 12-myristate 13-acetate (PMA), an activator of protein kinase C (PKC), on induction of COX-2 with special reference to mitogen-activated protein kinases (MAPKs) in HUVEC. Vanadate induced activation of three families of MAPKs, extracellular signal-regulated kinases 1 and 2 (ERK1/2), p38, and c-Jun amino-terminal kinase (JNK) 1, while activation of ERK1/2 alone was induced by PMA. The former activation by vanadate and the latter one by PMA were inhibited by tyrphostin-47, an inhibitor of PTKs, and by Ro31-8220, a PKC inhibitor, respectively. Either tyrphostin-47, PD98059, a specific inhibitor of the upstream kinase toward ERK1/2, or SB203580, a specific inhibitor of p38, completely suppressed vanadate-induction of COX-2 mRNA and protein. On the other hand, PMA-induction of COX-2 mRNA and protein was abolished by Ro31-8220 or PD98059 but not by SB203580. These data indicate that PMA-induced and PKC-dependent expression of COX-2 requires mainly activation of ERK1/2 among MAPKs, while activation of both ERK1/2 and p38 or possibly of all three families of MAPKs is necessary for vanadate-induced and PTK-dependent expression of COX-2.

Oral esomeprazole vs injectable omeprazole for the prevention of hemorrhage after endoscopic submucosal dissection

AIM

To evaluate the effectiveness of oral esomeprazole (EPZ) vs injectable omeprazole (OPZ) therapy to prevent hemorrhage after endoscopic submucosal dissection (ESD).

METHODS

A case-control study was conducted using a quasi-randomized analysis with propensity score matching. A total of 258 patients were enrolled in this study. Patients were treated with either oral EPZ or injectable OPZ. The endpoint was the incidence of hemorrhage after ESD.

RESULTS

Data of 71 subjects treated with oral EPZ and 172 subjects treated with injectable OPZ were analyzed. Analysis of 65 matched samples revealed no difference in the incidence of hemorrhage after ESD between the oral EPZ and injectable OPZ groups (OR = 0.89, 95%CI: 0.35-2.27, P ≥ 0.99).

CONCLUSION

We conclude that oral EPZ therapy is a useful alternative to injectable PPI therapy for the prevention of hemorrhage after ESD.