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OBJECTIVES: This study aimed to evaluate the effectiveness of a cooperative healthcare model for early detection and diagnosis of chronic obstructive pulmonary disease (COPD). METHODS: This was a cross-sectional observational study. We performed diagnosis of COPD at 4 public health centres in Omuta, Japan from March 2015 to March 2016, by adding screening for COPD at the time of routine medical evaluations. All patients aged over 40 years were eligible to participate. Among 397 eligible patients, 293 agreed to participate in the study. RESULTS: The estimated prevalence of COPD in Omuta was 10% among patients aged over 40 years and was 17% among smokers. Among those who were screened, over half of them had questionnaire scores over the cut-off of 17 points and decreased FEV1/FVC%, indicating COPD (p>0.05). 30 patients with suspected COPD were referred for further investigation at a local central hospital, but only 6 underwent further medical examinations. CONCLUSIONS: The combination of a COPD questionnaire and medical examination is effective as a COPD screening tool. Future research should investigate behavioural interventions for smoking cessation that can be offered in a cooperative model, as well as for improving participation in COPD screening and for encouraging early presentation for treatment in those suspected of having COPD.

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The ratio of the number of patients with non-alcoholic steatohepatitis (NASH) to the total number of patients with liver dysfunction has increased in many countries around the world. Liver dysfunction is also caused by multiple blood transfusions in patients with leukemia and other hematological diseases, with liver dysfunction often accompanied by secondary hemochromatosis. This study describes a 25-year-old man with secondary hemochromatosis combined with NASH. Magnetic resonance imaging was useful for visualizing the distributions of both iron and fat in the liver of this patient in order to make a differential diagnosis and to evaluate the effect of treatment.

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A 39 years old woman was admitted to our hospital with a status epilepticus, with high fever of 41°C. Magnetic resonance Imaging (MRI) revealed high signal intensities of both sides of thalami and hypothalami in T2 weighted and fluid attenuated inversion recovery (FLAIR) images. A needle biopsy of the thalamic lesion was consistent with neuromyelitis optica spectrum disorder although her serum antibody to aquaporin-4 was negative. The level of orexin in celebrospinal fluid (CSF) was reduced. She presented hypersomnia, which didn't improve even after intravenous methylprednisolone 1 g daily for 3 days. Administration of oral modafinil extended her waking time. There is a number of reports about neuromyelitis optica (NMO) with hypothalamic lesions. We report this case as important suggestion of treatment of these cases.

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We investigated the diagnostic usefulness of brain magnetic resonance imaging (MRI) screening in HIV-1-infected patients without neurological symptoms in detecting intracranial diseases at early stages. In this retrospective analysis, the study patients were HIV-1-infected patients who underwent brain MRI scan in clinical practice between 2001 and 2013. We excluded patients with MRI for (1) follow-up examination for prediagnosed intracranial diseases, (2) cancer staging, (3) screening mycobacterium/bacteria/fungi disease proliferation in the brain, and (4) evaluation for meningitis/encephalitis. The study patients (n=485) were classified into two groups: those who underwent brain MRI scan without any neurological symptoms/signs (asymptomatic patients, n=158) and those who underwent MRI due to such symptoms (symptomatic patients, n=327). Asymptomatic patients had lower CD4 counts than symptomatic patients (median 78 versus 241/µl). Intracranial diseases were detected in three (2%) of the asymptomatic patients [two toxoplasmosis and one progressive multifocal leukoencephalopathy (PML)] compared to 58 (19%) of the symptomatic patients (the χ(2) test, p<0.01). The latter included toxoplasmosis (n=10), PML (n=7), cytomegalovirus encephalitis (n=3), primary central nervous system lymphoma (n=3), cryptococcoma/meningitis (n=3), and HIV-associated dementia (n=17). Among symptomatic patients, intracranial diseases were common in those with slurred speech (3/6, 50%), seizure (4/10, 40%), eyesight/vision abnormality (5/16, 31%), altered mental status (8/31, 26%), and hemiplegia/numbness (13/50, 26%). For patients with CD4 count <200/µl, intracranial diseases were detected in only 3 (3%) of 144 asymptomatic patients, compared with 46 (32%) of 113 symptomatic patients (p<0.01). Brain MRI screening for HIV-1-infected patients without neurological symptoms is of little value.

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We describe the case of a 60-year-old man suffering from an advanced thymic neuroendocrine tumor with left supraclavicular lymph node and multiple bone metastases. The patient initially underwent systemic therapy with somatostatin analogues. Thereafter, peptide receptor radionuclide therapy (PRRT) was considered because the lesions had remained stable despite the pharmacological therapy. PRRT was performed 10 months after the initial treatment in a European hospital. Eighteen months after the treatment, cranial nerve palsy arising from skull base metastases and Horner's syndrome induced by left supraclavicular lymph node metastases became exacerbated. Therefore, a course of external radiotherapy was performed with palliative intent in our hospital. During the radiotherapy planning, the biodistribution of 111In-octreotide was examined to determine whether the absorbed dose of the previous PRRT was acceptable. As a result, external radiotherapy was performed, and an acute radiation reaction was observed; the severity of the reaction was typical of reactions to neck radio-therapy. The treatment course of the present case was considered to be instructive because PRRT cannot be performed in Japan at present.

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BACKGROUND: We report herein a case of cavernous sinus (CS)-dural arteriovenous fistula (DAVF) with brainstem venous congestion that was successfully treated by transarterial embolization, followed by radiotherapy. CASE DESCRIPTION: An 80-year-old woman presented with right eye chemosis and left hemiparesis. T2-weighted magnetic resonance imaging showed hyperintensity of the pons. Diagnostic cerebral angiography demonstrated CS-DAVF draining into the right superior orbital vein and petrosal vein, and fed by bilateral internal and external carotid arteries. Transarterial embolization was performed and followed by radiotherapy, resulting in resolution of the pontine lesion and neurological and ophthalmological symptoms within 5 months. CONCLUSIONS: We also review the literature regarding therapy for CS-DAVF with brainstem venous congestion. Once CS-DAVF with venous congestion of the brainstem has been definitively diagnosed, immediate therapy is warranted. Treatment with transarterial embolization followed by radiation may be an important option for elderly patients when transvenous or transarterial embolization is not an option.

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We present the F-18 FDG and ¹¹C-choline PET/CT images obtained in 2 cases of hemangioblastoma. Hemangioblastoma is a highly vascular benign tumor that typically arises in the cerebellum or spine. The characteristic findings of a hemangioblastoma on both CT and MR include a peripherally located cerebellar lesion with a central cystic region and a peripherally enhanced nodule. In both patients, the uptake in the lesion was relatively low on the F-18 FDG PET/CT images and relatively high on the ¹¹C-choline PET/CT images.

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Kaposi sarcoma is an acquired immunodeficiency syndrome-related disease that mainly involves the skin, gastrointestinal gut, and lungs. Whole-body 18F-fluorodeoxyglucose-positron emission tomography and computed tomography (FDG-PET/CT) scanning is useful for simultaneous detection of multiple lesions of Kaposi sarcoma. We present a 67-year-old man with a history of infection with human immunodeficiency virus who presented with numerous cutaneous lesions. FDG-PET/CT images showed lesions in the skin, lung, and lymph nodes. The gastrointestinal lesions were detected using gastric fiberscopy (GF) and colon fiberscopy (CF). After Kaposi sarcoma therapy, the uptake in the lesions of the skin, lung, and lymph nodes decreased, but new lesions were detected in the pancreas and lumbar spine. He had pancreatitis and Candida spondilitis. Whole-body FDG-PET/CT is useful for detecting lesions and determining the extension to which the disease has spread, adding the gastrointestinal lesions by GF and CF. After therapy, FDG-PET/CT can be used to demonstrate which lesions remain active and to determine the overall response to treatment. In this case, we show how useful FDG-PET/CT is and how difficult it is to treat Kaposi sarcoma.

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OBJECTIVE: The aim of this study was to evaluate the impact of (18)F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) on the management of patients with infectious spondylitis. MATERIALS AND METHODS: Twenty-nine patients with infectious spondylitis (9 with tuberculous spondylitis and 20 with pyogenic spondylitis) who had undergone an (18)F-FDG PET/CT examination were retrospectively evaluated; 42 lesions were detected. A useful impact on the clinical management of infection therapy (start or longer duration of antibiotic therapy, or surgical intervention, etc) was defined as a strong impact, whereas gaining new information not affecting the clinical management of infection therapy from (18)F-FDG PET/CT was defined as a weak impact. No impact was defined as not obtaining any new information influencing infection therapy. RESULTS: (18)F-FDG PET/CT had a strong impact on the clinical management of 52% (15 of 29) of the patients. (18)F-FDG PET/CT detected 10 cases of spondylitis and one artificial graft infection that the clinician had not recognized, and the therapeutic period was extended in these patients. In five patients with tuberculous spondylitis, the (18)F-FDG PET/CT images were used to decide the biopsy sites in three patients and to determine which lesions required surgery in two patients. CONCLUSION: (18)F-FDG PET/CT is useful for detecting infectious spondylitis.

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OBJECTIVE: It is important to differentiate human herpesvirus 6 (HHV-6)-associated encephalopathy from herpes simplex encephalitis (HSE). Although these conditions are similar with regard to involvement of the mesial temporal lobe, HSE is sensitive to acyclovir but HHV-6 encephalopathy is not. We compared the imaging findings of the two conditions. MATERIALS AND METHODS: We encountered eight cases of HHV-6 encephalopathy and nine cases of HSE. We divided an observation time into early, middle, and late periods defined as 0-2, 3-30, and more than 30 days from the onset of neurologic symptoms. Differences between HHV-6 encephalopathy and HSE on CT scans in the early period and in distribution and temporal changes in the affected regions on MR images in the three periods were analyzed. RESULTS: At MRI in the early and middle periods, all eight patients with HHV-6 encephalopathy had exclusive involvement of the mesial temporal lobes, and all nine patients with HSE had involvement of both the mesial temporal lobes and the extratemporal regions (p < 0.01). Among patients who underwent head MRI, six of six with HHV-6 encephalopathy but none of six with HSE had resolution of high signal intensity on T2-weighted and FLAIR images (p < 0.01). Among patients who underwent head CT in the early period, none of the four with HHV-6 encephalopathy and six of the seven with HSE had abnormal findings, including parenchymal swelling, decreased attenuation of affected regions, and abnormal gyral enhancement (p < 0.05). CONCLUSION: Serial MRI showed transient abnormal signal intensity in the mesial temporal lobes in patients with HHV-6 encephalopathy but persistent abnormal signal intensity in both the mesial temporal lobes and the extratemporal regions in patients with HSE. CT in the early period showed no abnormality in patients with HHV-6 encephalopathy but definite abnormal findings in patients with HSE. These differences may be useful in the differential diagnosis of the two conditions.

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OBJECTIVE: The purpose of this study was to evaluate the usefulness of 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) in differentiating pulmonary artery sarcoma from pulmonary embolism. MATERIALS AND METHODS: We evaluated three patients with pulmonary artery sarcoma and 10 patients with proximal pulmonary embolism (6 men and 7 women, ranging in age from 35 to 94 years). All the patients had evidence of perfusion defects in their proximal pulmonary arteries on contrast-enhanced computed tomography (CT) scans performed prior to PET/CT. The maximum standardized uptake value (SUV(max)) of FDG uptake in all the lesions was measured using PET/CT. The location of lesions, background uptake or thrombi in the legs were evaluated in both groups as basic characteristics. RESULTS: The mean SUV(max) of the pulmonary artery sarcomas (7.63 +/- 2.21, n = 3) and the pulmonary embolisms (2.31 +/- 0.41, n = 10) were significantly different (P < 0.05). The mean times between the initial contrast-enhanced CT scan and PET/CT scan were similar in both groups (P = 0.7804). The differences in the locations in lesions between the three groups (right, left and bilateral) or background uptakes were not significant. CONCLUSION: FDG PET/CT could distinguish pulmonary artery sarcoma from pulmonary embolism based on the SUV(max) value.

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A 55-year-old Japanese man was admitted to our hospital with severe weakness. Without measurement of serum electrolyte concentrations, diuretic therapy for hypertension was started 2 weeks prior to admission. Laboratory findings showed profound hypokalemia (1.4 mEq/L), and extreme elevation of the serum creatinine phosphokinase levels (15,760 IU/L), suggesting that the patient had hypokalemic paralysis and hypokalemia-induced rhabdomyolysis. Further evaluations, including adrenal venous sampling strongly suggested that he had primary aldosteronism. He was treated successfully by laparoscopic adrenalectomy. This case provides an important lesson that serum electrolyte concentrations should be measured in hypertensive patients before the administration of antihypertensive agents.

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We report three cases of percutaneous osteoplasty for the treatment of hypervascular bone metastasis. Four hypervascular bone metastases were treated in three consecutive patients by percutaneous osteoplasty under fluoroscopic or computed tomographic guidance. Primary malignant tumors included pheochromocytoma and renal cell carcinoma. Pain relief after osteoplasty was achieved in all three patients. There was no major complication. Projectile bleeding and subcutaneous hematoma were noted during or after osteoplasty but were easily controlled conservatively. Percutaneous osteoplasty for hypervascular bone metastases is not only a highly effective but also a minimally invasive technique that provides immediate pain relief without major complication.

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A 68-year-old female consulted our hospital, complaining of a large mass on the left side of the neck. Computed tomography and magnetic resonance imaging revealed the characteristic internal architecture of the mass, in which a small cyst was located within a cystic mass, showing a "cyst-within-cyst" appearance. A final diagnosis of second branchial cleft cyst was made pathologically. A "cyst-within-cyst" appearance is not usually seen in a second branchial cleft cyst. This appearance may be attributed to several fine-needle aspiration biopsies for diagnostic purposes.

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OBJECTIVE: In the developed countries, elderly population is rapidly increasing, but outcomes of elderly patients with subarachnoid hemorrhage (SAH) remain unclear. PATIENTS AND METHODS: We retrospectively reviewed the medical records of non-traumatic SAH patients aged 80 years or older, who were hospitalized in a single center between 2000 and 2005. RESULTS: There were 24 patients (80-92 years old and 83% female), representing 8.8% of all non-traumatic SAHs (n=272). Of those, six patients received an intervention (five clipping and one endovascular coiling) and the remaining 18 patients were managed conservatively. The patients who received an intervention were younger and had a better consciousness at presentation. Early mortality rate within 30 days after SAH was higher in the conservative group (61% [11/18] and 17% [1/6], p=0.155). At 6 months, mortality rate was significantly higher in the conservative group (83% [15/18] and 33% [2/6], p=0.038), and independence rate was higher in the intervention group (33% [2/6] and 0% [0/18], p=0.054). Logistic regression analysis showed that age and degree of consciousness on admission were significant predictor of outcome in 4 weeks, and that receiving intervention was significant predictor of outcome in 6 months. CONCLUSION: In elderly SAH patients with good clinical condition at presentation, an active intervention may improve the outcome.

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