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Background/Aim: Lenvatinib is available as a molecular target agent for hepatocellular carcinoma (HCC). In this study, we investigated the popping phenomena in patients with HCC who underwent radiofrequency ablation (RFA) after taking lenvatinib. Patients and Methods: Fifty-nine patients with HCC between 21-30 mm in diameter and no history of systemic treatment were enrolled in the study. The patients underwent RFA using a VIVA RFA SYSTEM with an ablation tip of 30 mm in length. For the initial lenvatinib administration, 16 patients had an adequate course of treatment and were treated with RFA as add-on therapy (combination group). The other 43 patients were treated by RFA monotherapy (monotherapy group). The popping frequency during RFA was recorded and compared. Results: Popping frequency in the combination group (RFA combined with lenvatinib) was significantly higher than that in the monotherapy group. There was no significant difference between the combination group and the monotherapy group in ablation time, maximum output level, tumour temperature after ablation, or initial resistance value. Conclusion: Popping frequency was significantly higher in the combination group. It is possible that the intra-tumour temperature increased rapidly during RFA in the combination group due to the inhibitory effect of lenvatinib on tumour angiogenesis, leading to the occurrence of popping. Further studies are needed to investigate popping after RFA, and precise protocols need to be developed.

Background Cardiovascular disease (CVD) is a major cause of mortality worldwide. High-sensitivity cardiac troponin T (hs-cTnT) is released into the bloodstream due to cardiomyocyte damage and is associated with a high CVD risk. This study aimed to investigate hs-cTnT-related genetic variation and to examine whether this is an associated risk factor for CVD in the Japanese general population. Methods This was a genome-wide association study (GWAS) based on a cohort from the 2013 Tohoku Medical Megabank Project community study. The GWAS was performed using a HumanOmniExpressExome BeadChip array with 914,035 autosomal single-nucleotide polymorphisms. The Framingham Risk Score and the Suita score were used to evaluate the future risk of CVD. Results The GWAS identified 10 loci reaching suggestive significance in the discovery cohort. A replication analysis confirmed that one of the 10 loci, rs7798496, is associated with elevated hs-cTnT levels. The combined P value in the discovery and replication cohorts for the association between the rs7798496 and hs-cTnT levels was 3.4 × 10−8, which indicates that the novel variant reached genome-wide significance. The rs7798496 loci was located at an intergenic region between the retinoblastoma gene product (RB)-associated Kruppell-associated box (KRAB) zinc finger, zinc finger protein 890, and pseudogene (ZNF890P). Logistic regression analysis revealed that the presence of the rs7798496 T allele was strongly associated with a high risk for CVD. Conclusions This study provides insights into a link between a novel genetic variant, T allele of rs7798269, and elevated hs-cTnT levels as a future risk for CVD in the general Japanese population.

本研究は、2017年度から始まった本学の初年次教育を定着させるとともに、新入生が大学での教育を理解し、建学の精神に代表される理念やディプロマポリシーを自分のものとして捉え、その実現に向けた主体的な学修の基盤を構築するという初年次教育の目標の達成を図ることにある。このためには、彼らの特性をとらえるとともに、彼らが初年次教育をどのように捉え、理解したかを把握しなければならない。そこで初年次教育の科目の一つとして開設された「ホスピタリティ概論」を活用して、全受講生を対象とした2つの調査を3年間実施した。1つ目の調査は入学当初の学生像をとらえ授業展開に生かすために学生の特徴を把握するものであり、第1回目の授業で実施された。2つ目の調査は授業内容の理解度を評価するものであり、第10回目に実施された。これらの回答を年度と学科毎に集計、分析した。その結果、次のことが明らかになった。①オープンキャンパスへの参加や進学希望状況などの本学入学に至る経緯が学科によって異なること、そして、入学当初には心身に不安を抱いている学生が、どの学科にも相当数存在すること。3年間の調査によって各学科の学生の特色が明らかになり、学科毎の適切な学修支援方策の作成に向けた示唆が得られたこと。②この講義を受けて、建学の精神であるホスピタリティの獲得に大学が力を入れており、その実現が求められていると多くの学生が認識していること、及び、本科目の重点目標である多様性の理解力の育成につながる他学科の学生とのコミュニケーションの機会に意義を見出していること等から、授業の目標達成に向けた順調な歩みが見られること。これらの結果及び他の科目の報告から、初年次教育が定着しつつあること、そして、その目標達成に向けた歩みが順調であると判断した。ただ、更なる充実のための課題も浮かび上がっている。

Mac-2-binding protein glycosylation isomer (M2BPGi), a novel noninvasive biomarker for fibrosis, is a prognostic factor for liver disease; however, its relationship with hepatic function reserve and nutritional status remains unclear. Furthermore, the cut-off value of this marker varies with the underlying liver disease. This study aims to clarify that M2BPGi can be clinically used as a hepatic function reserve marker and nutritional index without pushing the search for alternative markers to the forefront in clinical practice as an important biomarker.Seven hundred and forty-three outpatients with chronic liver disease (CLD) were enrolled. We evaluated the relationship among M2BPGi, albumin-bilirubin (ALBI) grade, and Controlling Nutritional Status (CONUT) score as nutritional status markers. Diagnostic performance of M2BPGi values in distinguishing different modified ALBI (mALBI) grade and CONUT score were compared using receiver operating characteristic (ROC) curve analysis.The M2BPGi level increased with ALBI and mALBI grades. The correlation coefficient (r2) between M2BPGi and ALBI grade was 0.40 (r=0.63), indicating a positive correlation between M2BPGi and ALBI grade. The cut-off for M2BPGi to predict mALBI G1 vs. G2-G3 was 1.07, G1-2a vs. G2b-3 was 1.73, and mALBI G1-2 vs. G3 was 5.83 under the ROC curves. The cut-off for M2BPGi to predict CONUT score normal vs. light-severe was 1.60, normal-light vs. moderate-severe was 1.74, and normal-moderate vs. severe was 5.83 under the ROC curves. M2BPGi correlates with ALBI grade and is useful for diagnosing ROC analysis results, especially G2 and above. M2BPGi also correlates with the CONUT score and is useful for diagnosing ROC analysis results, especially moderate or higher. These results showed similar diagnostic performance regardless of the etiology of the background liver disease.Although the predictive cut-off value varied with the type of liver disease, M2BPGi was found to be a single predict biomarker of ALBI and CONUT, and thus, is an effective indicator of CLD status. Further investigation is warranted to determine the clinical utility of this marker.

Introduction Transjugular liver biopsy (TJLB) is indicated for patients in whom percutaneous liver biopsy is contraindicated, such as those with hematological diseases complicated by liver dysfunction. However, the clinical utility of TJLB in this group of patients has not been thoroughly investigated. The objective of this study is to evaluate the clinical efficacy of TJLB in patients with hematological diseases complicated by liver dysfunction. Methods We analyzed the data of patients who developed liver disorders during treatment for hematological diseases at our hospital and required tissue diagnosis via TJLB. The clinical features of patients were analyzed. Results Twenty-seven patients (mean age, 60.07 years; 12 men, 15 women) requiring tissue diagnoses via TJLB after developing liver disorders while undergoing treatment for hematological diseases were enrolled. One patient with autoimmune hemolytic anemia was diagnosed with drug-induced liver injury; two patients with amyloidosis had nonalcoholic steatohepatitis; one patient with acute promyelocytic leukemia had a drug-induced liver injury; one patient with chronic myelomonocytic leukemia had liver infiltration caused by an underlying disease; three patients with idiopathic thrombocytopenic purpura had autoimmune hepatitis; four patients with malignant lymphoma had liver infiltration by the underlying disease, and one patient with multiple myeloma had liver disorder caused by disseminated intravascular coagulation. Moreover, one patient had hepatitis B reactivation, another had hepatitis E, and six patients had a drug-induced liver injury. The treatment regimen was altered in cases of liver infiltration caused by the underlying disease, and the drug was changed for patients with drug-induced liver injury. Conclusion The etiology of liver disorders in patients with hematological diseases varies widely. Therefore, histological diagnosis using TJLB is useful to determine an appropriate therapeutic strategy for underlying hematological diseases.

Gastrointestinal duplications are congenital malformations that are usually observed in pediatric patients. Diagnosis in adulthood is quite rare, and preoperative diagnosis of gastrointestinal duplication is difficult, particularly in the small intestine. We encountered an extremely rare adult case of duplication of the jejunum, which showed a stomach-like form diagnosed using double-balloon enteroscopy (DBE). The patient was an 18-year-old male who had been experiencing upper abdominal pain and vomiting repeatedly without any triggers for 3 years. Various examinations were performed, but no cause of symptoms was found. DBE revealed a narrow opening of the lumen at the upper jejunum, and the lumen was covered with mucosal folds similar to those of the stomach. Enteroclysis via DBE showed a tubular structure on the mesenteric side of the jejunum. We diagnosed a jejunal tubular duplication with ectopic gastric mucosa and underwent partial small bowel resection. The patient's abdominal symptoms resolved. From this, DBE can be a useful tool for diagnosing intestinal duplication in adults. We believe that this case and literature review will facilitate the accurate and prompt diagnosis of small intestinal duplication.

Blood transfusion, splenectomy, and partial splenic embolization (PSE) are generally performed for thrombocytopenia in patients with cirrhosis. Recently, thrombopoietin (TPO) agonists have become available, and investigations of patients who would benefit from them are necessary. Therefore, it is important to understand the fluctuations in cytokine levels associated with PSE. Therefore, fluctuations in platelet-associated immunoglobulin G (PAIgG), interleukin 6 (IL-6), and TPO levels with PSE were analyzed in this study. The study included 110 patients with liver cirrhosis and thrombocytopenia, with the aim of improving platelet counts. Fluctuations in PAIgG, IL-6, and TPO levels were investigated. The average splenic embolization ratio was 58.0% in patients with PSE. The platelet count rose significantly from 6.95 [5.40, 8.60] × 104/mL to 14.05 [10.43, 18.05] × 104/mL (P .01), IL-6 rose significantly from 3.56 [2.53, 7.33] pg/mL to 18.90 [9.17, 32.95] pg/mL (P .01), TPO rose significantly from 0.82 [0.52, 1.21] fmol/mL to 1.58 [0.97, 2.26] fmol/mL (P .01), and PAIgG decreased significantly from 64.20 [38.33, 118.75] ng/107 cells to 37.50 [22.25, 70.00] ng/107 cells (P .01). On multivariate analysis of factors related to the rate of platelet increase with PSE, primary biliary cholangitis (B = 0.475, P .01), splenic embolization ratio (B = 0.75, P .01), IL-6 change ratio (B = 0.019, P .01), and PAIgG change ratio (B = -0.325, P .01) were significant. When attempting to improve thrombocytopenia with PSE, adequate splenic embolization needs to be obtained together with improvements in IL-6, PAIgG, and TPO levels. With unsatisfactory improvement in thrombocytopenia, TPO agonist administration was considered.

Background/Aim: Tumor biopsy are needed frequency for accurate diagnosis. However, percutaneous liver tumor biopsy presents a risk of complications such as bleeding and tumor seeding. We investigated the feasibility of liver tumor biopsy, followed by cauterization with expandable radiofrequency ablation. Patients and Methods: Tumor biopsies using a co-access needle were performed in 102 patients. Expandable radiofrequency ablation was used to ensure cauterization and hemostasis of the puncture route. We evaluated the clinical background and complications. Results: The average (±standard deviation) tumor diameter was 56.87±39.45 mm. Pathological diagnosis was possible in all cases. In 20 patients, the postoperative pathological diagnosis differed from the preoperative diagnosis. No significant anemia progression was observed in any patients after biopsy, and no peritoneal seeding was observed during a mean follow-up observation period of 18.5 months. Conclusion: Liver tumor biopsy, followed by cauterization with expandable radiofrequency ablation via a co-access needle, is safe and useful for obtaining reliable diagnoses.

Background Current guidelines recommend the temporary discontinuation of anticoagulants before colonoscopic polypectomy, but the effect of this practice on reducing the risk of delayed bleeding after hot snare polypectomy (HSP) and endoscopic mucosal resection (EMR) remains unclear. Our aim was to assess the impact of anticoagulants on the risk of colorectal delayed bleeding after HSP and EMR, and evaluate the necessity of drug withdrawal. Methods We reviewed the clinical data of patients with colorectal polyps using antithrombotic drugs who underwent HSP and/or EMR between January 2016 and September 2020 at Nagaoka Red Cross Hospital. After excluding antiplatelet users, patients were classified into those who continued anticoagulants [continuation group: 50 patients (93 lesions)] and those who discontinued anticoagulants [discontinuation group: 87 patients (190 lesions)]. Results Delayed bleeding occurred in 12 lesions, and there was no significant difference in the incidence rates between the continuation and the discontinuation groups (3.2% vs. 4.7%; P=0.756). Logistic regression analysis showed that continued use of anticoagulants was not a significant risk factor for delayed bleeding compared to anticoagulant discontinuation (odds ratio, 0.670; 95% CI, 0.177-2.537; P=0.556). There was no significant difference in the incidence rate and risk of delayed bleeding, regardless of the length of the anticoagulant withdrawal period. Conclusions Continued use of anticoagulants, compared to their discontinuation, did not increase the risk of colorectal delayed bleeding after HSP and EMR. Our results suggest that current guideline recommendations for anticoagulant withdrawal before colonoscopic polypectomy may be reconsidered. Trial registration UMIN000040449.

BACKGROUND Pulmonary tumor thrombotic microangiopathy (PTTM) is a rare condition in patients with hepatocellular carcinoma (HCC); to date, few cases have been reported. While hepatic dysfunction has been focused on the later stages of HCC, the management of symptoms in PTTM is important for supportive care of the cases. For the better understanding of PTTM in HCC, the information of our recent case and reported cases have been summarized. CASE SUMMARY A patient with HCC exhibited acute and severe respiratory failure. Radiography and computed tomography of the chest revealed the multiple metastatic tumors and a frosted glass–like shadow with no evidence of infectious pneumonia. We diagnosed his condition as acute respiratory distress syndrome caused by the lung metastases and involvement of the pulmonary vessels by tumor thrombus. Administration of prednisolone to alleviate the diffuse alveolar damages including edematous changes of alveolar wall caused by the tumor cell infiltration and ischemia showed mild improvement in his symptoms and imaging findings. An autopsy showed the typical pattern of PTTM in the lung with multiple metastases. CONCLUSION PTTM is caused by tumor thrombi in the arteries and thickening of the pulmonary arterial endothelium leading to the symptoms of dyspnea in terminal staged patients. Therefore, supportive management of symptoms is necessary in the cases with PTTM and hence we believe that the information presented here is of great significance for the diagnosis and management of symptoms of PTTM with HCC.

本研究は、初年次教育の深化を図るために、その一つの科目である「ホスピタリティ概論」を対象として、受講生の感想等を分析し、授業の改善を図ることを目的としている。2017年度に開設された「ホスピタリティ概論」は、2年目を迎えるにあたって、前回の調査で明らかになった課題の幾つかに改善を加えて実践された1）。加えられた改善点は、上級生を学生スタッフとして雇用し、受講生の学修活動の促進を図ること、そして各課割り当てからボランティアの事務職員を担当にし、教職協働体制の円滑化を図ることの2点である。昨年度同様のクリッカー調査とアンケート調査を実施し、2年間の結果の比較・分析を行った。この結果、次のことが明らかになった。クリッカー調査 ①平成30年度の方が29年度よりも、心身の不安を訴える1年生が多いこと。 ②入学の動機づけとなるオープンキャンパスへの参加に関しては、平成30年度の方が、複数回参加や家族の参加が多くなっており、参加しなかった割合が低くなっていること。③全学オリエンテーションと学科別オリエンテーションの理解度に関しては、共に平成29年度の方が高い数値を示していること。アンケート調査 ④「他学科の人とおしゃべりする機会が持てた」や、「他学科の人の意見を聞くことができて有意義だった」という授業内でのコミュニケーション関しては、平成30年度の方が高い評価が得られていること。⑤「ホスピタリティを理解する上で、この授業に合格点を与えることができる」に関しては、平成30年度の方が高い評価が得られていること。 ⑥自由記述欄の文字数の調査では、平成30年度の方が高い数値になっていること。上述の①～③に示されているように、年度によって学生の質的な変化が生じているように見え、今後の動向を注視しなければならないことが明らかになった。また、④～⑥の結果からは、今年度の改善点である学生スタッフの活用によって、「ホスピタリティ概論」における学生の学修活動の活性化をもたらしたと判断する事ができる。しかし、他の項目では学科による差も見られ、課題が生じているといえる。

The purpose of this study was to investigate the association between xanthine oxidoreductase (XOR) activity and a high risk of cardiovascular disease (CVD) in a general Japanese population. The Iwate Tohoku Medical Megabank Organization pooled individual participant data from a general population-based cohort study in Iwate prefecture. The cardiovascular risk was calculated using the Framingham risk score (FRS). A total of 1605 of the 1631 participants (98.4%) had detectable XOR activity. Multiple regression analysis demonstrated that XOR activity was independently associated with body mass index (β = 0.26, p &lt, 0.001), diabetes (β = 0.09, p &lt, 0.001), dyslipidemia (β = 0.08, p = 0.001), and uric acid (β = 0.13, p &lt, 0.001). Multivariate analysis showed that the highest quartile of XOR activity was associated with a high risk for CVD (FRS ≥15) after adjustment for baseline characteristics (OR 2.93, 95%CI 1.16–7.40). The area under the receiver operating characteristic curves of the FRS with XOR activity was 0.81 (p = 0.008). XOR activity is associated with a high risk for CVD, suggesting that high XOR activity may indicate cardiovascular risk in a general Japanese population.

Sarcopenia is characterized by progressive and generalized loss of skeletal muscle mass and strength that occurs with aging or in association with various diseases. The condition is prevalent worldwide and occurs more frequently in patients with chronic diseases owing to the intrinsic relationship of muscles with glucose, lipid, and protein metabolism. Liver cirrhosis is characterized by the progression of necro-inflammatory liver diseases, which leads to fibrosis, portal hypertension, and a catabolic state, which causes loss of muscle tissue. Sarcopenia is of significant concern in the state of liver cirrhosis because sarcopenia has been associated with higher mortality, increased hospital admissions, worse post-liver transplant outcomes, decreased quality of life, and increased risk for other complications associated with cirrhosis. Therefore, sarcopenia is also an important feature of liver cirrhosis, representing a negative prognostic factor and influencing mortality. An increased understanding of sarcopenia could lead to the development of novel therapeutic approaches that could help improve the cognitive impairment of cirrhotic patients; therefore, we present a review of the mechanisms and diagnosis of sarcopenia in liver disease and existing therapeutic approaches.

Considering the increase in cases of non-alcoholic steatohepatitis (NASH), the use of appropriate animal model of NASH is essential to understand the underlying pathogenesis mechanism. To date, several mice models have been used; however, significant differences in the etiologies and food administered affected the results, with inconsistent conclusions. Therefore, it is necessary to understand these models and their differences to be able to choose appropriate models. Inspired by the fact that mitochondrial (mt)DNA content is changed in non-alcoholic fatty liver disease in humans, we investigated the mtDNA copy number in the NASH mice models induced by high-fat diet (HFD) and methionine/choline-deficient diet (MCD) to understand the differences between these models. Megamitochondria were observed in both MCD and HFD groups. However, the MCD group showed significant decrease in liver mtDNA content compared with that in the HFD group. These changes were associated with significant upregulation of mitochondrial biogenesis- and degradation-related genes in MCD model than in HFD model. Thus, stability of mtDNA is associated with the differences between MCD and HFD-induced NASH models often used in studies; these findings could help in choosing appropriate models for studies on NASH.

Background The impact of sarcopenia on the prognosis of patients with hepatocellular carcinoma (HCC) who receive transcatheter intra-arterial therapies, including transcatheter arterial chemoembolization and transcatheter arterial infusion chemotherapy, remains unclear. We investigated the prognostic value of skeletal muscle loss (SML) stratified by cutoffs for sarcopenia and rate of change in skeletal muscle mass over 6 months. Methods We retrospectively evaluated 102 patients with HCC treated with transcatheter intra-arterial therapies between 2005 and 2015. Computed tomography images of the third lumbar vertebra (L3) were analyzed to obtain the skeletal muscle area normalized for the height squared, defined as the skeletal muscle index at L3 (L3 SMI), before and 6 months after treatment. Low or high SMI was defined using cutoff values of 42 cm2/m2 in men and 38 cm2/m2 in women. The rate of change in skeletal muscle mass (ΔL3 SMI) over 6 months was calculated. Overall survival (OS) was compared in groups classified by baseline L3 SMI and ΔL3 SMI; prognostic significance was assessed with univariate and multivariate analyses, using Cox proportional hazards models. Results OS did not differ significantly between groups with low (n = 31) and high (n = 71) SMI at baseline (P = 0.172), but OS was significantly poorer in patients with SML (n = 41), defined as ΔL3 SMI

Background Esophageal squamous cell carcinoma (ESCC) invading the muscularis mucosae (MM) and submucosa up to 200 µm (SM1) has a risk of metastasis. The aims of this study were to investigate the long-term outcome of endoscopic submucosal dissection (ESD) for MM/SM1 ESCC and to assess the management after ESD in our hospital. Methods This was a retrospective cohort study conducted at a single institution. Patients with MM or SM1 ESCC who were treated with ESD were included. Additional prophylactic therapy was added if lymphovascular involvement (LVI) was noted in the ESD specimens. Results A total of 102 patients were analyzed. The median length of follow-up was 71.5 months (range 9 – 144 months) and the median number of CTs was 6 (range 0 – 24). LVI was found in 21 patients (20.6 %), and 12 patients underwent additional prophylactic therapy. The 5-year overall survival, disease-specific survival, and tumor-free survival rates were 84.1 %, 97.5 %, and 82.1 %, respectively. A total of 26 patients died, but only 2 of them died from ESCC. The cumulative metastasis rate was 11.8 %, and LVI was a significant predictor of metastasis (hazard ratio 5.42, 95 % confidence interval 1.39 – 21.18; P = 0.02). There were no differences between patients with MM ESCC and those with SM1 ESCC. Conclusions The long-term outcome after ESD for MM/SM1 ESCC was favorable with additional prophylactic therapy and strict adherence to follow-up. These results indicate that our management decision based on LVI is a valid approach and that ESD can be offered as a therapeutic option to MM/SM1 ESCCs.

Malignant bowel obstruction is a complication of colorectal carcinoma or metastasis from other carcinoma, and it causes significant damage on the condition of elderly patients; however, the self-expandable metallic stents (SEMSs) have been effectively used either for palliation or for bridging to the surgical procedure for this condition. The aim of this study was to investigate the factors influencing long-term outcomes of old-aged patients with SEMS for large bowel obstruction to develop the strategy for those patients in the community medicine. We performed a retrospective review of 42 patients with a median age of 83.0 years (range, 65–99 years), who underwent SEMS placement for malignant colorectal obstruction between 2006 and 2015 in our hospital. Univariate and multivariate logistic regressions were performed on data from the patients to assess the factors affecting 6-month survival without stent dysfunction. The study population comprised 24 females (57.1%) and 18 males (42.9%). Of these, 38 patients (90.5%) received SEMS as palliation, whereas 4 patients (9.5%) underwent subsequent surgery. SEMSs were successfully inserted in 97.6% of patients. The median duration of follow-up was 205.0 days (range, 20–1377 days). On multivariate analysis, shorter stents (

Takamasa Kobayashi, Hirokazu Kawai, Oki Nakano, Satoshi Abe, Hiroteru Kamimura, Akira Sakamaki, Kenya Kamimura, Atsunori Tsuchiya, Masaaki Takamura, Satoshi Yamagiwa,† Shuji Terai Division of Gastroenterology and Hepatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan †Dr Satoshi Yamagiwa passed away on May 4, 2018 Background: Prognosis of patients with hepatocellular carcinoma (HCC) who undergo transcatheter intra-arterial therapies, including transcatheter arterial chemoembolization and transcatheter arterial infusion chemotherapy, is affected by many clinical factors including liver function and tumor progression. However, the effect of body composition such as skeletal muscle and visceral and subcutaneous adipose tissues (VAT and SAT, respectively) on the prognosis of these patients remains unclear. We investigated the prognostic value of body composition in HCC patients treated with transcatheter intra-arterial therapies. Patients and methods: This study retrospectively evaluated 100 HCC patients treated with transcatheter intra-arterial therapies between 2005 and 2015. Areas of skeletal muscle, VAT, and SAT were measured on computed tomography images at third lumbar vertebra level and normalized by the height squared to calculate the skeletal muscle index, VAT index, and SAT index (SATI). The visceral to subcutaneous adipose tissue area ratio was also calculated. Overall survival (OS) was compared between high- and low-index groups for each body composition. Furthermore, prognostic significance was assessed by univariate and multivariate analyses using Cox proportional hazards models. Results: Among the body composition indexes, only SATI could significantly differentiate OS (p=0.012). Multivariate analysis showed that SATI (low- vs. high-SATI: HR, 2.065; 95% CI, 1.187–3.593; p=0.010), serum albumin (

The purposes of this study were to evaluate clinical and electrocardiographic characteristics in patients with fulminant myocarditis. Total seventy-two patients were selected from 7,235 consecutive patients with admitted to coronary care unit. Patients of this study were divided into three groups

An 80-year-old woman being treated with anti-hypertensive drugs developed eruption and itching of the skin. High fever and lymph node enlargement subsequently developed in spite of discontinuing all antihypertensive drugs, and she was admitted to our hospital. At the initial examination, multiple papules were noted over the entire body, and the skin showed thickening and lichenification with scratch marks. There was also generalized enlargement of the superficial lymph nodes. From these findings, her condition was diagnosed as chronic prurigo due to drug allergy. Laboratory tests showed inflammatory findings, anemia and a high serum level of IgE. Analysis of the surface marker of peripheral lymphocytes revealed no abnormalities. Bacteriologic cultures of blood revealed methicillin-resistant Staphylococcus aureus (MRSA). Histologic examination of the lymph nodes revealed chronic reactive lymphadenitis with a follicular pattern. She was strongly suspected of having MRSA septicemia, and so combination chemotherapy with vancomycin, minocycline and cefoperazone/sulbactam was started. However, 1 month after initiation of chemotherapy, the low-grade fever, eruption and moderate inflammatory findings persisted, and culture of the eruptions revealed MRSA. The prurigo was therefore considered to be the source of the septicemia, and daily application of diflucortolone ointment containing 3% acetic acid was started. Thereafter, the clinical and laboratory findings showed a rapid improvement. MRSA infections usually occur in compromised patients who are receiving antibiotics during prolonged hospitalization. The present case, who did not have any underlying disease, indicates that old-age is also an important factor for the development of MRSA septicemia.

Familial nonobstructive hypertrophic cardiomyopathy in 78-year-old woman was diagnosed in 1988. Since then she has been treated with a beta-blocking drug and a calcium antagonist. Her clinical condition was NYHA I or II for several years. Echocardiography revealed asymmetric septal hypertrophy in 1988 (interventricular septal thickness = 21 mm, posterior wall thickness = 10 mm). Systolic anterior motion of the mitral valve was first observed at the end of 1992. The left ventricular pressure gradient also gradually increased; it was about 138 mmHg in 1993 (age 82 yrs). The left ventricular ejection time index increased from 376 msec in May, 1992 to 459 msec in May, 1994. In September, 1994, the patient's condition gradually deteriorated (NYHA IV), and she was admitted to our hospital. To attenuate the left ventricular pressure gradient, 150 mg of disopyramide was administered. Her condition markedly improved: the left ventricular pressure gradient decreased from 180 mmHg to 76 mmHg, and the left ventricular ejection time index decreased from 485 msec to 419 msec. These results indicate that a left ventricular pressure gradient can be generated rapidly even in a very old patient, and that disopyramide may be useful to attenuate the left ventricular pressure gradient.

The purpose of this study is to elucidate factors determining the release of atrial natriuretic peptide (ANP) in normal volunteers at rest. Ten normal volun teers were included in this study. Ages ranged between twenty-seven and thirty- three years (mean twenty-seven). The authors measured plasma levels of ANP, and four cardiac chamber volumes, and their functions by cine magnetic reso nance imaging using the rephased gradient-echo method. Plasma levels of ANP in 10 normal subjects were 15.0-37.1 pg/mL (mean 23.6 pg/mL). No significant relationship was seen between ANP level and heart rate or blood pressure. The level of ANP was positively correlated with left atrial (LA) emptying fraction and negatively correlated with LA minimal volume (r=0.85, P < 0.01; r = 0.64, P < 0.05, respectively). No significant relationship was observed between plasma ANP level and left ventricular, right ventricular, or right atrial parame ters. These results suggest that LA systolic function is one of the major determi nants for ANP release in normal subjects at rest.

A 66-year-old woman with a 7-year history of Parkinsons' disease was admitted to our hospital because of a high fever and disturbance of consciousness. She had been treated with levodopa/benserazide hydrochloride and trihexyphenidyl hydrochloride until admission. On admission, the patient was comatose, her temperature was 40.5 degrees C, her blood pressure was 54/-mmHg, and her pulse rate was 130 beats/min. Laboratory tests showed leukocytosis, a high level of creatine kinase in serum and evidence of hyperosmolar non-ketotic diabetic coma (blood glucose, 1,080 mg/dl) and of disseminated intravascular coagulation (DIC). A continuous insulin infusion, antibiotics, nafamostat mesilate, and urinastatin were given, after which the DIC, hyperglycemia, and the level of consciousness were improved. However, levels of creatine kinase, myoglobin, transaminase, and amylase in serum continued to increase, and multiple organ failure was suspected. Furthermore, she became less responsive, diaphoretic, and tremulous; fever and mild rigidity developed. The peak creatine kinase and myoglobin were 11,095 U/l and 12,520 ng/ml, respectively. A diagnosis of malignant syndrome was made, and treatment with levodopa/carbidopa and dantrolene was begun. Within several days, the clinical and laboratory findings improved. We report here a rare case of malignant syndrome associated with DIC followed by diabetic coma in an elderly patient with Parkinsons' disease during L-dopa therapy. Timely diagnosis and treatment of malignant syndrome are important in the management of elderly patients with Parkinsons' disease, because DIC and multiple organ failure may occur in the early stages of malignant syndrome.

To clarify psychological factors related to white coat hypertension, we examined personality characteristics of patients with mild essential hypertension by psychological testing. Patients with essential hypertension were taught to measure their own blood pressure (BP) with a semi-automatic oscillometric BP measuring device and were asked to measure BP at home in the sitting position before going to sleep. The duration of the study was 8wk. Patients were defined as "white coat" hypertensive patients (WCHT) (n=49) if home systolic BP was 135mmHg or less and home diastolic BP was 85mmHg or less, and as "sustained" hypertensive patients (SHT) (n=53) if home systolic BP was 140mmHg or more or home diastolic BP was 90mmHg or more. All the patients underwent the following psychometric tests: self-rating questionnaire for depression, MMPI alexithymia scale, type A behavior pattern check list, general health questionnaire (GHQ), and egogram check list. WCHT did not differ from SHT in the scores for depression, alexithymia, type A behavior pattern, or GHQ. However, WCHT showed an abnormal pattern on egograms, as compared with SHT. On egograms, SHT showed a normal hill-shaped pattern with a peak in "nurturing parent (NP)", and "free child (FC)" was higher than "adapted child (AC)" in both genders. In contrast, WCHT showed significantly lower FC and significantly higher AC than SHT, and AC was higher than FC in both genders. These findings suggested that WCHT tend to suppress their own emotions and become over-adaptive to their surroundings, as compared with SHT. (Hypertens Res 1997; 20: 99-104)

We assessed the changes in cardiac condition in a patient with cardiac amyloidosis, by means of dual nuclei single photon emission computed tomographic (SPECT) images with technetium-99m-hydroxymethylene diphosphonate (99mTc-HMDP) and thallium-201 (201Tl). Dual SPECT showed a marked increase in myocardial 99mTc-HMDP accumulation along with deterioration of symptoms and signs, while 201Tl scintigraphy remained almost unchanged.

Cardiac chamber volumes (both atria and ventricles) in 19 healthy volun teers were measured noninvasively by cine magnetic resonance imaging (MRI). First, cardiac localization was determined from the coronal image by 0.5-T superconducting magnetic imager. Then, transaxial ECG gated multislice spin echo images were obtained from the bottom to the top of the heart. In the last step, cine MRI was performed at each level of all these transaxial spin echo MR images involving the heart. Each cardiac chamber volume at the same phase was calculated by adding chamber areas in each anatomic section multiplied by slice thickness. Left ventricular (LV) end-diastolic volume (EDV) (132.0±26.9 mL) and LV end-systolic volume (ESV) (47.8 ±13.9 mL) were smaller than right ventricular (RV) EDV (141.1 ±24.8 mL) and RVESV (57.0± 12.6 mL), respec tively (p < 0.01). LV stroke volume (84.3±17.9 mL) was equivalent to RV stroke volume (84.2±17.6 mL) (r=0.91, p < 0.01). Left atrial (LA) and right atrial (RA) maximal volumes were 75.8 ±15.4 mL and 84.4±18.7 mL, respectively. LA minimal volume (37.5 ± 10.7 mL) was smaller than RA minimal volume (47.8 ± 12.2 mL). These values measured by cine MRI are satisfactory and cine MRI will be a useful method of determining cardiac chamber volumes, espe cially atrial volumes.

Hypertrophic cardiomyopathy sometimes progresses to dilated cardiomyopathy-like features [1–5]. The etiology of the progression remains to be determined. Recently, we reported a patient with hypertrophic cardiomyopathy who showed a persistent elevation of serum creatine kinase (CK)-MB and lactate dehydrogenase 1 (LDH1) activities for several years and developed dilated cardiomyopathy-like features [6]. Thus, the persistent elevation of cardiac enzymes might be closely related to the progression from a typical hypertrophic cardiomyopathy to a dilated left ventricle in the patient. To elucidate the prognosis of hypertrophic cardiomyopathy it is very important to know whether the cardiac enzymes elevation occurs usually in patients with hypertrophic cardiomyopathy or only in the specific type. The total CK activity of myocardial origin is composed of three different components, CK-MM, CK-MB and a lesser amount of CK-BB. CK-MM itself is also composed of three main isoforms, MMa, MMb and MMc. CK activity in the myocardium is primarily MMa, and in acute myocardial infarction a rapid and transient rise in MMa activity in the serum is observed. The serum MMa/MMc activity ratio is useful to estimate the process of myocardial injury due to myocardial infarction [7,8]. We recently reported that the measurement of MMa/MMc ratio was also useful to estimate the myocardial condition in patients with hypertrophic cardiomyopathy [9].

Objective : This study was undertaken to clarify whether the myocardial dysfunction observed in the hypertensive heart is an intrinsic property of the myocyte or not. Materials and methods : We investigated left ventricular function and contractile function of myocytes from 30-week-old spontaneously hypertensive rats (SHR) and Wistar-Kyoto rats (WKY). We also evaluated the effect of angiotensin II on contractile function of myocytes from both rats. Results : The time constant of isovolumic pressure fall was significantly greater in SHR (13.2 ± 0.6 ms) than in WKY (10.3 ± 0.5 ms). The extent of shortening in isolated myocytes was significantly higher in SHR (11.3 ± 0.4%) than in WKY (9.8 ± 0.4%, P