Report on the Regional Workshop on Image Reading Conducted by the Japanese Society of Nuclear Cardiology.

Since 2007, The Japanese Society of Nuclear Cardiology (JSNC) has been conducting regional training workshops on film reading for physicians and technologists who are just beginning their career in cardiac nuclear medicine examinations. JSNC will continue this workshop to expand the fields of cardiac nuclear medicine examinations.

Prognostic Implications of Sarcoidosis Granulomas　- Insights From the Multicenter Registry, the Japanese Cardiac Sarcoidosis Prognostic Study.

Background: Definitions of cardiac sarcoidosis (CS) differ among guidelines. Any systemic histological finding of CS is essential for the diagnosis of CS in the 2014 Heart Rhythm Society statement, but not necessary in the Japanese Circulation Society 2016 guidelines. This study aimed to reveal the differences in outcomes by comparing 2 groups, namely CS patients with or without systemic histologically proven granuloma. Methods and Results: This study retrospectively included 231 consecutive patients with CS. CS with granulomas in ≥1 organs was diagnosed in 131 patients (Group G), whereas CS without any granulomas was diagnosed in the remaining 100 patients (Group NG). Left ventricular ejection fraction (LVEF) was significantly reduced in Group NG compared with Group G (44±13% vs. 50±16%, respectively; P=0.001). However, Kaplan-Meier curves showed that major adverse cardiovascular events (MACE)-free survival outcomes were comparable between the 2 groups (log-rank P=0.167). Univariable analyses showed that significant predictors of MACE were Groups G/NG, histological CS, LVEF, and high B-type natriuretic peptide (BNP) or N-terminal pro BNP concentrations, but none of these was significant in multivariable analyses. Conclusions: Overall risks of MACE were similar between the 2 groups despite different manifestations in cardiac dysfunction. The data not only validate the prognostic value of non-invasive diagnosis of CS, but also show the need for careful observation and therapeutic strategy in patients with CS without any granuloma.

Agarose gel electrophoresis pattern of serum creatine kinase and lactate dehydrogenase isoenzymes in zoo-managed Asian elephants (Elephas maximus).

Serum levels of creatine kinase (CK) and lactate dehydrogenase (LDH) isoenzymes were evaluated in nine zoo-managed Asian elephants (Elephas maximus) using a commercial agarose gel electrophoresis (AGE) kit. CK was separated into two major fractions, CK-BB and CK-MM, along with a small fraction of macroenzyme-CK type 2 (mCK2); CK-MM was the largest fraction. LDH was separated into five fractions (LDH1-5); LDH3 was the largest fraction. Age was negatively and positively correlated with the percentages of CK-BB and CK-MM, respectively, and negatively correlated with CK-BB and mCK2 activities. These results indicate that an AGE kit can be used to evaluate CK and LDH isoenzymes. Routine isoenzyme testing may enable early detection of disease and physiological changes.

Direct detection of elephant endotheliotropic herpesvirus 1 (EEHV1) DNA in heparinized plasma by loop-mediated isothermal amplification.

Elephant endotheliotropic herpesvirus (EEHV) causes a fatal hemorrhagic disease and is a significant cause of mortality in juvenile Asian elephants. A loop-mediated isothermal amplification (LAMP) method was developed to rapidly diagnose EEHV viremia. However, extracting DNA from whole blood samples to perform LAMP hampers diagnosis in a field setting. Here, we established the Direct-LAMP method, using heparinized plasma without extracting the DNA to speed up and simplify the test. EEHV-positive specimens were tested using the Direct-LAMP. The detection limit was calculated to be 101.3 copies/µL using the mimetic samples, which was almost identical to the value determined in LAMP in which DNA was extracted. Hence, the Direct-LAMP provided a more rapid diagnosis to save, which could prevent elephant deaths.

The Correlation between the Vascular Calcification Score of the Coronary Artery and the Abdominal Aorta in Patients with Psoriasis.

Psoriasis is known as an independent risk factor for cardiovascular disease due to its chronic inflammation. Studies have been conducted to evaluate the progress of atherosclerotic plaques in psoriasis. However, inadequate efforts have been made to clarify the relationship between atherosclerosis progress in coronary arteries and other important blood vessels. For that reason, we investigated the correlation and development of the coronary artery calcification score (CACS) and the abdominal aortic calcification score (AACS) during a follow-up examination. Eighty-three patients with psoriasis underwent coronary computed tomography angiography (CCTA) for total CACS and abdominal computed tomography (AbCT) for total AACS. PASI score, other clinical features, and blood samples were collected at the same time. The patients' medical histories were also retrieved for further analysis. Linear regression was used to analyze the CACS and AACS associations. There was a moderate correlation between CACS and AACS, while both calcification scores relatively reflected the coronary plaque number, coronary stenosis number, and stenosis severity observed with CCTA. Both calcification scores were independent of the PASI score. However, a significantly higher CACS was found in psoriatic arthritis, whereas no similar phenomenon was recorded for AACS. To conclude, both CACS and AACS might be potential alternative tests to predict the presence of coronary lesions as confirmed by CCTA.

The serum activities of alkaline phosphatase isoenzymes measured using two approved methods in zoo-managed Asian elephants (Elephas maximus).

The approved Japanese measurement method of circulating alkaline phosphatase (ALP) has changed from that of the Japan Society of Clinical Chemistry (JSCC) to that of the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC). We measured the serum levels of total ALP (t-ALP) and those of the isoenzymes ALP2 and ALP3 in 50 Asian elephant (Elephas maximus) specimens using both methods. The activities determined by the IFCC method were roughly one-third lower than those determined by the JSCC method. We present conversion formulae. Our results enable comparisons of historical and current data on serum ALP activities in endangered, zoo-managed Asian elephants.

Multicenter Registry in the Japanese Cardiac Sarcoidosis Prognostic (J-CASP) Study: Baseline Characteristics and Validation of the Non-invasive Approach Using 18F-FDG PET.

Background: Recent advances in cardiac modalities contribute to the guidelines on the diagnosis of cardiac sarcoidosis (CS) updated by the Japanese Circulation Society. The multicenter registry, Japanese Cardiac Sarcoidosis Prognostic (J-CASP) study tried to reveal recent trends of diagnosis and outcomes in CS patients and to validate the non-invasive diagnostic approach, including cardiac 18F-fluorodeoxyglucose (FDG) study. Methods/results: Databases from 12 hospitals consisting of 231 CS patients (mean age, 64 years; female, 65%; LV ejection fraction, 47%) diagnosed by the guidelines with FDG positron emission tomography (PET) study were integrated to compile clinical information on the diagnostic criteria and outcomes. Cardiac 18F-FDG uptake and magnetic resonance imaging (CMR) was positive identically in the histology-proven and clinically-diagnosed groups. The histology-proven group more frequently had reduce LV ejection fraction, myocardial perfusion abnormality and low-grade electrocardiogram (ECG) abnormality (P=0.003 to 0.016) than did the clinical group. During a 45-month period, the histology-proven group more frequently underwent appropriate implantable cardioverter-defibrillator (ICD) treatment (14% versus 4%, P=0.013) and new electronic device implantation (30% versus 12%, P=0.007) than did clinical group, respectively. There, however, was no difference in all-cause or cardiac mortality or in new hospitalization due to heart failure progression between them. Conclusion: The J-CASP registry demonstrated the rationale and clinical efficacies of non-invasive approach using advanced cardiac imaging modalities in the diagnosis of CS even when histological data were available.

Relationship between Psoriasis and Prevalence of Cardiovascular Disease in 88 Japanese Patients.

Psoriasis is a systemic inflammatory disease known to affect survival in the presence of cerebral or cardiovascular comorbidities. However, no clear guidelines have been defined regarding the extent of vascular lesion testing that should be performed in patients with psoriasis. We therefore performed coronary computed tomography angiography (CCTA) in 88 Japanese patients with psoriasis who visited Kansai Medical University Hospital between 2015 and 2019 and determined the ankle-brachial pressure index (ABI) for 44 of these patients. CCTA abnormalities were found in 39 of the 88 patients, and a need for treatment was identified in 14 patients. The prevalence of cardiovascular lesions in these patients was 15.9%, significantly higher than that in the healthy Japanese population (6.38% according to the Suita Study). In the 44 patients with results for both ABI and CCTA, the rates of CCTA vascular lesions were significantly higher in cases with ABIs indicating hard vessels or above than in cases with supple, normal, or slightly stiff vessels. This is the first report to show a correlation between CCTA and ABI in psoriasis patients. ABI was considered useful as a preliminary test before CCTA. The univariate analysis of the abnormal and normal CCTA groups showed that the prevalence differed significantly among patients with psoriatic arthritis, erythrodermic psoriasis, older age, pre-existing conditions, drinking, and hypertension. The multivariate analysis showed correlations with arthritic or erythrodermic psoriasis.

Severe Hydroxyapatite Deposition Disease in Binturongs (Arctictis binturong).

In a collection of 6 young binturongs (Arctictis binturong), 3 presented with anorexia, lethargy, and footpad swelling diagnosed by surgical biopsy as calcinosis circumscripta. Despite supportive care over the next 4 years, affected binturongs had progressive weight loss, hyperphosphatemia, and hyperkalemia and developed large radiodense deposits in tissues adjacent to appendicular joints, thoracolumbar vertebrae, and the sternum. Two binturongs died and necropsies showed severe periarticular mineral deposition with fibrosis and granulomatous inflammation. Additionally, binturongs had mineralization of distal renal tubules, mineralization of the renal interstitium, and marked mineralization of the pulmonary interstitium and peribronchiolar smooth muscle. Foot biopsies from the surviving binturong were evaluated by spectroscopic microanalysis and were positive for hydroxyapatite, Ca10(PO4)6(OH)2. Periarticular and footpad mineralization in these binturongs is consistent with hydroxyapatite deposition disease, which is rarely described in humans and animals as a primary familial condition or a secondary condition often associated with renal injury.

Selective Adenosine A2A Agonists May Change Myocardial Perfusion Imaging.

In recent years, the requirement for pharmacological stress myocardial perfusion imaging (SPECT) has increased, and adenosine stress testing is now the mainstream. Selective adenosine A2A receptor agonists will be applied clinically in the future. By selectively activating only A2A receptors, it can reduce complications such as bronchospasm, hypotension, and bradycardia, which have been problems with adenosine stress tests. In addition, since this drug can be administered in bolus injection, it has the advantage of being able to perform the test at one root.

Anthropometric and blood data on a hand-reared captive Asian elephant (Elephas maximus) calf: A retrospective case report.

The anthropometric and blood data of an unsuccessfully hand-reared Asian elephant (Elephas maximus) calf were retrospectively compared with the data for calves raised by their real mothers or allomothers, to identify potential reasons for poor outcomes in the hand-reared case. The hand-reared calf grew normally in terms of body weight and withers height. However, blood biochemical data suggested reduced bone metabolism, low immune status, and malnutrition during its life. Blood bone markers were measured to determine whether a skeletal disorder was present in the Asian elephant calf, which was not clear from the anthropometric data. Monitoring these parameters in hand-reared Asian elephant calves, with the aim of keeping them within the normal range, may increase the success rate of hand-rearing of Asian elephant calves.

Standard Export Data Format for Extension Storage of Standardized Structured Medical Information Exchange.

Background: In the era of big data, the utilization and analysis of large amounts of clinical data are imperative. The standardized structured medical information exchange version 2 (SS-MIX2) is a standard data storage format used in Japan to share clinical data from various vendor-derived hospital information systems. This storage format is divided into 2 categories: standardized and extension storage. Although the standardized storage includes clinical data such as basic patient data, prescriptions, and laboratory results, all other data are stored in the extension storage, because their formats are not standardized. Methods and Results: In 2015, the Japanese Circulation Society developed the standard export data format (SEAMAT) for electrocardiography (ECG), ultrasound cardiography (UCG), and catheterization (CATH) data for the SS-MIX2 extension storage. Using physical examination and catheter report systems in accordance with the SEAMAT, specific cardiological data such as ECG, UCG, and CATH can be transferred to the SS-MIX2 extension storage, resulting in efficient secondary use of these data for research purposes. Conclusions: SEAMAT can aid in the effective establishment of a nationwide clinical database, and reduce tedious manual data input by clinicians and clinical research coordinators. Moreover, a program that enables the conversion of comma-separated data from information systems into SEAMAT can provide a useful and economical tool for transferring huge clinical data to the SS-MIX2.

Influence of transfixation pinning and casting (TPC) configurations on treatment outcomes in bovine tibial fracture.

The aim of this study was to examine the treatment outcomes of tibial fracture using different configurations of transfixation pinning and casting (TPC) in eight cattle. After pins were inserted to stabilize the fracture site, cast material was placed from the level of the stifle to the hoof (full TPC) in six cases and from the stifle to the proximal metatarsus (partial TPC) in two cases. Five cattle (three full TPC and two partial TPC cases) underwent TPC removal 36-86 days after surgery and resumed productivity. The other three cattle which underwent full TPC suffered from irreversible orthopedic complications within 5 weeks of surgery, while a prolonged healing process was observed in the partial TPC cases. Although TPC is an effective method for treating bovine tibial fracture, full TPC may result in a guarded prognosis in some cattle. However, partial TPC can delay healing. Surgeons should choose the optimal TPC configuration while considering the various factors that affect the healing process.

Determination of serum bone-specific alkaline phosphatase isoenzyme activity in captive Asian elephants (Elephas maximus) using an agarose gel electrophoresis method.

The bone-specific alkaline phosphatase (ALP) isoenzyme activity was measured in 51 serum samples from four captive Asian elephants (Elephas maximus) using a conventional method with wheat germ lectin precipitation and a commercial agarose gel electrophoresis (AGE) kit; the isoenzymes were designated as bone-specific ALP (BAP) and ALP isoenzyme 3 (ALP3), respectively. This study examined the suitability of the AGE kit for analyzing blood biochemistry in Asian elephants. The serum ALP3 and BAP activities were strongly positively correlated and met the evaluation criteria for agreement using Bland-Altman analysis. The results indicate that the AGE kit can be used to examine the blood biochemistry in Asian elephants instead of the conventional method.

Rapid and sensitive detection of elephant endotheliotropic herpesvirus 1 (EEHV1) in blood by loop-mediated isothermal amplification (LAMP).

Elephant endotheliotropic herpesvirus type 1 (EEHV1) is the most important causative agent of an acute fatal hemorrhagic disease in Asian elephants (Elephas maximus). We employed loop-mediated isothermal amplification (LAMP) to develop a rapid and simple detection method for EEHV1 in blood. When used to test 21 clinical samples collected in Japan, the EEHV1 assay correctly identified one positive and 20 negative clinical samples. It was observed that when samples were spiked with synthetic DNA plasmids including EEHV1 polymerase gene, the detection limit of the LAMP assay was 101.2 copies/µl and 100-fold higher than that of conventional PCR. These advantages of the LAMP assay for EEHV1 detection may facilitate better veterinary practices for treating elephants suffering from the acute disease.

Prognostic study of cardiac events in Japanese patients with chronic kidney disease using ECG-gated myocardial Perfusion imaging: Final 3-year report of the J-ACCESS 3 study.

BACKGROUND: Myocardial perfusion imaging (MPI) is considered useful for risk stratification among patients with chronic kidney disease (CKD), without renal deterioration by contrast media. METHODS AND RESULTS: The Japanese Assessment of Cardiac Events and Survival Study by Quantitative Gated SPECT (J-ACCESS 3) is a multicenter, prospective cohort study investigating the ability of MPI to predict cardiac events in 529 CKD patients without a definitive coronary artery disease. All patients were assessed by stress and rest MPI with 99mTc-tetrofosmin and data were analyzed using a defect scoring method and QGS software. Major cardiac events were analyzed for 3 years after registration. The mean eGFR was 29.0 ± 12.8 (mL/minute/1.73 m2). The mean summed stress/rest/difference (SSS, SRS, SDS) scores were 1.9 ± 3.8, 1.1 ± 3.0, and 0.8 ± 1.8, respectively. A total of 60 cardiac events (three cardiac deaths, six sudden deaths, five nonfatal myocardial infarctions, 46 hospitalization cases for heart failure) occurred. The event-free survival rate was lower among patients with kidney dysfunction, higher SSS, and higher CRP values. Multivariate Cox regression analysis independently associated SSS ≥8, eGFR <15 (mL/minute/1.73 m2), and CRP ≥0.3 (mg/dL) with cardiac events. CONCLUSIONS: Together with eGFR and CRP, MPI can predict cardiac events in patients with CKD.