Background: Primary aldosteronism (PA) display a higher risk of cerebrovascular events (CVE) comp... more Background: Primary aldosteronism (PA) display a higher risk of cerebrovascular events (CVE) compared with essential hypertension (EH).On the one hand, it was also reported that the PA patients associated with autonomous cortisol secretion had high incidence of CVE. Objective: Our objective was to investigate the effect of autonomous cortisol secretion on the prevalence of CVE in the patients with PA and/or Cushing syndrome (CS). Design and Setting: This was a retrospective cross-sectional study from Tohoku University Hospital between 2008 and 2017. Patient: 291 patients were analyzed. In the patients with PA, the recent continuous cases performed adrenal venous sampling (AVS) were extracted. They were divided into four groups. Group A: 32 CS patients, Group B: 34 PA patients with autonomous cortisol secretion, Group C:121 PA patients with aldosterone producing adenoma (APA) and Group D: 104 PA patients with idiopathic hyperaldosteronism (IHA). They were also performed and analyzed ...
The renal resistive index (RI) calculated by Doppler ultrasonography has been reported to be corr... more The renal resistive index (RI) calculated by Doppler ultrasonography has been reported to be correlated with renal structural changes and outcomes in patients with essential hypertension or renal disease. However, little is known about this index in primary aldosteronism. In this prospective study, we examined the utility of this index to predict blood pressure (BP) outcome after adrenalectomy in patients with primary aldosteronism. We studied 94 patients with histopathologically proven aldosteronoma who underwent surgery. Parameters on renal function, including renal flow indices, were examined and followed up for 12 months postoperatively. The renal RI of the main, hilum, and interlobar arteries was significantly higher in patients with aldosteronoma compared with 100 control patients. BP, estimated glomerular filtration rate, and urinary albumin excretion significantly decreased after adrenalectomy. The resistive indices of all compartment arteries were significantly reduced 1 mo...
The aim of this study was to clarify the relationship between cardiac sympathetic nervous activit... more The aim of this study was to clarify the relationship between cardiac sympathetic nervous activity (SNA) assessed by radioiodinated metaiodobenzylguanidine (123I-MIBG), an analogue of norepinephrine and cardiovascular functions in patients with chronic heart failure (CHF). Subjects were 17 patients with CHF. A dose of 111 MBq of 123I-MIBG was administered intravenously, and 5-minute anterior planar images were obtained 15 minutes (early image) and 3 hours (delayed image) after the injection. The heart/mediastinum (H/M) count ratio was defined to quantify cardiac 123I-MIBG uptake. The washout ratio (WR) of 123I-MIBG from the heart was calculated as follows: (early counts-delayed counts)/early counts x 100 (%). Echocardiography was performed on all patients within 1 week of 123I-MIBG scintigraphy to measure stroke volume index (SVI). Blood pressure and heart rate (HR) in the resting state were also recorded to calculate cardiovascular functions including cardiac output, pulse pressure (PP), and mean blood pressure. Significant linear correlations were found between the early H/M ratio of 123I-MIBG and SVI, and between the delayed H/M ratio of 123I-MIBG and SVI, respectively. WR of 123I-MIBG was correlated with HR, and was inversely correlated with SVI and with PP, respectively. It is likely that a decrease in SVI is associated with enhanced cardiac SNA in severe CHF. 123I-MIBG scintigraphy is effective in assessing the cardiac functional status and SNA in patients with CHF in vivo. Moreover, changes in PP and HR indicate well alteration in SNA.
Radiographics a Review Publication of the Radiological Society of North America Inc, Aug 31, 2010
Ductal carcinoma in situ (DCIS) accounts for 20%-25% of breast cancers detected at screening mamm... more Ductal carcinoma in situ (DCIS) accounts for 20%-25% of breast cancers detected at screening mammography. The lesions are diverse and commonly are classified on the basis of their mammographic features and histologic characteristics such as nuclear grade and presence or absence of necrosis. The most common mammographic finding in DCIS is microcalcifications, but a low-grade lesion without necrosis is less likely to manifest with calcifications than either an intermediate- or a high-grade lesion. Other mammographic findings might include a mass or architectural distortion. Magnetic resonance (MR) imaging has higher sensitivity than mammography for the detection of DCIS and greater accuracy for depicting the extent of disease. The MR imaging appearance of DCIS depends primarily on the presence and extent of abnormal periductal or stromal vascularity. Nonmasslike enhancement, the most common MR imaging finding, is often seen in association with clumped internal enhancement. The enhancement kinetics in dynamic MR studies vary, and no kinetic pattern is pathognomonic of a particular nuclear grade of DCIS. However, the kinetic pattern at delayed imaging does appear to be correlated with the mammographic findings: Mass lesions show strong washout; fine pleomorphic, fine linear, and fine linear-branching calcifications demonstrate a plateau enhancement pattern; and amorphous calcifications exhibit persistent enhancement. Multidetector computed tomography might be a useful adjunct to MR imaging for preoperative mapping.
The renal resistive index (RI) calculated by Doppler ultrasonography has been reported to be corr... more The renal resistive index (RI) calculated by Doppler ultrasonography has been reported to be correlated with renal structural changes and outcomes in patients with essential hypertension or renal disease. However, little is known about this index in primary aldosteronism. In this prospective study, we examined the utility of this index to predict blood pressure (BP) outcome after adrenalectomy in patients with primary aldosteronism. We studied 94 patients with histopathologically proven aldosteronoma who underwent surgery. Parameters on renal function, including renal flow indices, were examined and followed up for 12 months postoperatively. The renal RI of the main, hilum, and interlobar arteries was significantly higher in patients with aldosteronoma compared with 100 control patients. BP, estimated glomerular filtration rate, and urinary albumin excretion significantly decreased after adrenalectomy. The resistive indices of all compartment arteries were significantly reduced 1 mo...
PURPOSE We developed a new microporous covered stent graft with microporous polyurethane film, in... more PURPOSE We developed a new microporous covered stent graft with microporous polyurethane film, in which its luminal surface was flat and its outer surface coated with FK506 to prevent neointimal hyperplasia. We evaluated its physical properties, biocompatibility and feasibility in animal (dogs) study. METHOD AND MATERIALS Original self-expanding nitinol stent (SENDAI stent: 5∼6 mm in diameter, 20 mm long) was covered with a microporous 15 and 60 μm-thick polyurethane membrane. Micropores were formed with an excimer laser ablation. The pore size was 100 μm and the interpore distance was 250 μm. We measured its kink resistance, radial resistive force and chronic outward force. Bare stents (n=6), microporous covered stents (n=6) and microporous covered stents coated with FK506 (n=6) were implanted into external iliac arteries of adult female beagle dogs. Four weeks after stent implantation, we evaluated its angiographic and histological findings. RESULTS The microporous covered stents ...
PURPOSE/AIM The purpose of this exhibit is: 1. To display normal adrenal anatomy based on three-d... more PURPOSE/AIM The purpose of this exhibit is: 1. To display normal adrenal anatomy based on three-dimensional imaging and macroscopic anatomy. 2. To show normal and variant adrenal venous anatomy based on our 600 cases of adrenal CT, MRI and venous sampling cases. 3. To describe clinical impact of adrenal venous variant in the diagnosis of primary aldosteronism. CONTENT ORGANIZATION A. Normal anatomy, histology, function, and embryology of the adrenal gland B. Protocols and imaging findings of CT, MRI, and venography to visualize adrenal venous anatomy C. Various variants of adrenal vein based on our 600 cases of adrenal CT, MRI and venous sampling cases. D. Clinical impact of adrenal venous variants in performing and interpreting adrenal venous sampling for patients with primary aldosteronism E. Detailed morphology of adrenal venous tributaries for superselective adrenal venous sampling and treatment SUMMARY Adrenal venous sampling takes on increasing importance in line with increase...
PURPOSE To evaluate the clinical value of T2-weighted images (T2WI), diffusion-weighted images (D... more PURPOSE To evaluate the clinical value of T2-weighted images (T2WI), diffusion-weighted images (DWI), dynamic MRI, MR spectroscopy (MRS) and combination of these MR techniques to diagnose prostate cancer as correlated to histopathologic mapping. METHOD AND MATERIALS 31 patients who underwent preoperative 3T MRI with body-array coil and had no prior hormonal or radiation treatment were included in this study. 74 malignant lesions were found histopathologically in both transitional and peripheral zones. The size of tumor ranged from 1 to 32mm (mean: 9.2mm). Four interpretation protocols were analyzed (Protocol A: T2WI alone, Protocol B: T2WI and DWI, Protocol C: T2WI, DWI, and dynamic MRI, and Protocol D: T2WI, DWI, dynamic MRI along with MRS). Two radiologists retrospectively confirmed the presence of abnormal finding on each MR technique by consensus referring to the histopathologic mapping images. They started the session from protocol A to protocol D. Detectability of the prostate...
The Annals of otology, rhinology, and laryngology, 2015
The first objective was to describe a novel case of migration of a broken dental needle into the ... more The first objective was to describe a novel case of migration of a broken dental needle into the parapharyngeal space. The second was to address the importance of simulation elucidating visualization of such a thin needle under X-ray fluoroscopy. Clinical case records (including computed tomography [CT] and surgical approaches) were reviewed, and a simulation experiment using a head phantom was conducted using the same settings applied intraoperatively. A 36-year-old man was referred after failure to locate a broken 31-G dental needle. Computed tomography revealed migration of the needle into the parapharyngeal space. Intraoperative X-ray fluoroscopy failed to identify the needle, so a steel wire was applied as a reference during X-ray to locate the foreign body. The needle was successfully removed using an intraoral approach with tonsillectomy under surgical microscopy. The simulation showed that the dental needle was able to be identified only after applying an appropriate compens...
To evaluate visualization of the right adrenal vein (RAV) with multidetector CT and non-contrast-... more To evaluate visualization of the right adrenal vein (RAV) with multidetector CT and non-contrast-enhanced MR imaging in patients with primary aldosteronism. A total of 125 patients (67 men) scheduled for adrenal venous sampling (AVS) were included. Dynamic 64-detector-row CT and balanced steady-state free precession-based non-contrast-enhanced 3-T MR imaging were performed. RAV visualization based on a four-point score was documented. Both anatomical location and variation on cross-sectional imaging were evaluated, and the findings were compared with catheter venography as the gold standard. The RAV was visualized in 93.2 % by CT and 84.8 % by MR imaging (p = 0.02). Positive predictive values of RAV visualization were 100 % for CT and 95.2 % for MR imaging. Imaging score was significantly higher in CT than MR imaging (p < 0.01). The RAV formed a common trunk with an accessory hepatic vein in 16 % of patients. The RAV orifice level on cross-sectional imaging was concordant with ca...
Adrenal venous sampling is currently the only reliable method to distinguish unilateral from bila... more Adrenal venous sampling is currently the only reliable method to distinguish unilateral from bilateral diseases in primary aldosteronism. In this study, we attempted to determine whether peripheral plasma levels of 18-oxocortisol (18oxoF) and 18-hydroxycortisol could contribute to the clinical differentiation between aldosteronoma and bilateral hyperaldosteronism in 234 patients with primary aldosteronism, including computed tomography (CT)-detectable aldosteronoma (n=113) and bilateral hyperaldosteronism (n=121), all of whom underwent CT and adrenal venous sampling. All aldosteronomas were surgically resected and the accuracy of diagnosis was clinically and histopathologically confirmed. 18oxoF and 18-hydroxycortisol were measured using liquid chromatography tandem mass spectrometry. Receiver operating characteristic analysis of 18oxoF discrimination of adenoma from hyperplasia demonstrated sensitivity/specificity of 0.83/0.99 at a cut-off value of 4.7 ng/dL, compared with that bas...
Aldosterone-producing adenoma is a major subtype of primary aldosteronism. The number of cases of... more Aldosterone-producing adenoma is a major subtype of primary aldosteronism. The number of cases of these adenomas, which are below the detection limit of computed tomography but diagnosed by adrenal venous sampling, has recently been increasing. However, the pathophysiology of these adenomas, especially those manifesting clinically overt hyperaldosteronism despite their small size, remains unknown. Therefore, we examined the correlation between tumor size and the status of intratumoral steroidogenic enzymes involved in aldosterone biosynthesis using immunohistochemistry. Forty patients with surgically proven aldosterone-producing adenomas were retrospectively studied. Multidetector computed tomography, adrenal venous sampling, and laparoscopic adrenalectomy were performed in all of the patients studied. The tumor area at the maximum diameter of the sections was precisely measured by ImageJ software. The status of the steroidogenic enzymes was immunohistochemically analyzed, and the f...
Background: Primary aldosteronism (PA) display a higher risk of cerebrovascular events (CVE) comp... more Background: Primary aldosteronism (PA) display a higher risk of cerebrovascular events (CVE) compared with essential hypertension (EH).On the one hand, it was also reported that the PA patients associated with autonomous cortisol secretion had high incidence of CVE. Objective: Our objective was to investigate the effect of autonomous cortisol secretion on the prevalence of CVE in the patients with PA and/or Cushing syndrome (CS). Design and Setting: This was a retrospective cross-sectional study from Tohoku University Hospital between 2008 and 2017. Patient: 291 patients were analyzed. In the patients with PA, the recent continuous cases performed adrenal venous sampling (AVS) were extracted. They were divided into four groups. Group A: 32 CS patients, Group B: 34 PA patients with autonomous cortisol secretion, Group C:121 PA patients with aldosterone producing adenoma (APA) and Group D: 104 PA patients with idiopathic hyperaldosteronism (IHA). They were also performed and analyzed ...
The renal resistive index (RI) calculated by Doppler ultrasonography has been reported to be corr... more The renal resistive index (RI) calculated by Doppler ultrasonography has been reported to be correlated with renal structural changes and outcomes in patients with essential hypertension or renal disease. However, little is known about this index in primary aldosteronism. In this prospective study, we examined the utility of this index to predict blood pressure (BP) outcome after adrenalectomy in patients with primary aldosteronism. We studied 94 patients with histopathologically proven aldosteronoma who underwent surgery. Parameters on renal function, including renal flow indices, were examined and followed up for 12 months postoperatively. The renal RI of the main, hilum, and interlobar arteries was significantly higher in patients with aldosteronoma compared with 100 control patients. BP, estimated glomerular filtration rate, and urinary albumin excretion significantly decreased after adrenalectomy. The resistive indices of all compartment arteries were significantly reduced 1 mo...
The aim of this study was to clarify the relationship between cardiac sympathetic nervous activit... more The aim of this study was to clarify the relationship between cardiac sympathetic nervous activity (SNA) assessed by radioiodinated metaiodobenzylguanidine (123I-MIBG), an analogue of norepinephrine and cardiovascular functions in patients with chronic heart failure (CHF). Subjects were 17 patients with CHF. A dose of 111 MBq of 123I-MIBG was administered intravenously, and 5-minute anterior planar images were obtained 15 minutes (early image) and 3 hours (delayed image) after the injection. The heart/mediastinum (H/M) count ratio was defined to quantify cardiac 123I-MIBG uptake. The washout ratio (WR) of 123I-MIBG from the heart was calculated as follows: (early counts-delayed counts)/early counts x 100 (%). Echocardiography was performed on all patients within 1 week of 123I-MIBG scintigraphy to measure stroke volume index (SVI). Blood pressure and heart rate (HR) in the resting state were also recorded to calculate cardiovascular functions including cardiac output, pulse pressure (PP), and mean blood pressure. Significant linear correlations were found between the early H/M ratio of 123I-MIBG and SVI, and between the delayed H/M ratio of 123I-MIBG and SVI, respectively. WR of 123I-MIBG was correlated with HR, and was inversely correlated with SVI and with PP, respectively. It is likely that a decrease in SVI is associated with enhanced cardiac SNA in severe CHF. 123I-MIBG scintigraphy is effective in assessing the cardiac functional status and SNA in patients with CHF in vivo. Moreover, changes in PP and HR indicate well alteration in SNA.
Radiographics a Review Publication of the Radiological Society of North America Inc, Aug 31, 2010
Ductal carcinoma in situ (DCIS) accounts for 20%-25% of breast cancers detected at screening mamm... more Ductal carcinoma in situ (DCIS) accounts for 20%-25% of breast cancers detected at screening mammography. The lesions are diverse and commonly are classified on the basis of their mammographic features and histologic characteristics such as nuclear grade and presence or absence of necrosis. The most common mammographic finding in DCIS is microcalcifications, but a low-grade lesion without necrosis is less likely to manifest with calcifications than either an intermediate- or a high-grade lesion. Other mammographic findings might include a mass or architectural distortion. Magnetic resonance (MR) imaging has higher sensitivity than mammography for the detection of DCIS and greater accuracy for depicting the extent of disease. The MR imaging appearance of DCIS depends primarily on the presence and extent of abnormal periductal or stromal vascularity. Nonmasslike enhancement, the most common MR imaging finding, is often seen in association with clumped internal enhancement. The enhancement kinetics in dynamic MR studies vary, and no kinetic pattern is pathognomonic of a particular nuclear grade of DCIS. However, the kinetic pattern at delayed imaging does appear to be correlated with the mammographic findings: Mass lesions show strong washout; fine pleomorphic, fine linear, and fine linear-branching calcifications demonstrate a plateau enhancement pattern; and amorphous calcifications exhibit persistent enhancement. Multidetector computed tomography might be a useful adjunct to MR imaging for preoperative mapping.
The renal resistive index (RI) calculated by Doppler ultrasonography has been reported to be corr... more The renal resistive index (RI) calculated by Doppler ultrasonography has been reported to be correlated with renal structural changes and outcomes in patients with essential hypertension or renal disease. However, little is known about this index in primary aldosteronism. In this prospective study, we examined the utility of this index to predict blood pressure (BP) outcome after adrenalectomy in patients with primary aldosteronism. We studied 94 patients with histopathologically proven aldosteronoma who underwent surgery. Parameters on renal function, including renal flow indices, were examined and followed up for 12 months postoperatively. The renal RI of the main, hilum, and interlobar arteries was significantly higher in patients with aldosteronoma compared with 100 control patients. BP, estimated glomerular filtration rate, and urinary albumin excretion significantly decreased after adrenalectomy. The resistive indices of all compartment arteries were significantly reduced 1 mo...
PURPOSE We developed a new microporous covered stent graft with microporous polyurethane film, in... more PURPOSE We developed a new microporous covered stent graft with microporous polyurethane film, in which its luminal surface was flat and its outer surface coated with FK506 to prevent neointimal hyperplasia. We evaluated its physical properties, biocompatibility and feasibility in animal (dogs) study. METHOD AND MATERIALS Original self-expanding nitinol stent (SENDAI stent: 5∼6 mm in diameter, 20 mm long) was covered with a microporous 15 and 60 μm-thick polyurethane membrane. Micropores were formed with an excimer laser ablation. The pore size was 100 μm and the interpore distance was 250 μm. We measured its kink resistance, radial resistive force and chronic outward force. Bare stents (n=6), microporous covered stents (n=6) and microporous covered stents coated with FK506 (n=6) were implanted into external iliac arteries of adult female beagle dogs. Four weeks after stent implantation, we evaluated its angiographic and histological findings. RESULTS The microporous covered stents ...
PURPOSE/AIM The purpose of this exhibit is: 1. To display normal adrenal anatomy based on three-d... more PURPOSE/AIM The purpose of this exhibit is: 1. To display normal adrenal anatomy based on three-dimensional imaging and macroscopic anatomy. 2. To show normal and variant adrenal venous anatomy based on our 600 cases of adrenal CT, MRI and venous sampling cases. 3. To describe clinical impact of adrenal venous variant in the diagnosis of primary aldosteronism. CONTENT ORGANIZATION A. Normal anatomy, histology, function, and embryology of the adrenal gland B. Protocols and imaging findings of CT, MRI, and venography to visualize adrenal venous anatomy C. Various variants of adrenal vein based on our 600 cases of adrenal CT, MRI and venous sampling cases. D. Clinical impact of adrenal venous variants in performing and interpreting adrenal venous sampling for patients with primary aldosteronism E. Detailed morphology of adrenal venous tributaries for superselective adrenal venous sampling and treatment SUMMARY Adrenal venous sampling takes on increasing importance in line with increase...
PURPOSE To evaluate the clinical value of T2-weighted images (T2WI), diffusion-weighted images (D... more PURPOSE To evaluate the clinical value of T2-weighted images (T2WI), diffusion-weighted images (DWI), dynamic MRI, MR spectroscopy (MRS) and combination of these MR techniques to diagnose prostate cancer as correlated to histopathologic mapping. METHOD AND MATERIALS 31 patients who underwent preoperative 3T MRI with body-array coil and had no prior hormonal or radiation treatment were included in this study. 74 malignant lesions were found histopathologically in both transitional and peripheral zones. The size of tumor ranged from 1 to 32mm (mean: 9.2mm). Four interpretation protocols were analyzed (Protocol A: T2WI alone, Protocol B: T2WI and DWI, Protocol C: T2WI, DWI, and dynamic MRI, and Protocol D: T2WI, DWI, dynamic MRI along with MRS). Two radiologists retrospectively confirmed the presence of abnormal finding on each MR technique by consensus referring to the histopathologic mapping images. They started the session from protocol A to protocol D. Detectability of the prostate...
The Annals of otology, rhinology, and laryngology, 2015
The first objective was to describe a novel case of migration of a broken dental needle into the ... more The first objective was to describe a novel case of migration of a broken dental needle into the parapharyngeal space. The second was to address the importance of simulation elucidating visualization of such a thin needle under X-ray fluoroscopy. Clinical case records (including computed tomography [CT] and surgical approaches) were reviewed, and a simulation experiment using a head phantom was conducted using the same settings applied intraoperatively. A 36-year-old man was referred after failure to locate a broken 31-G dental needle. Computed tomography revealed migration of the needle into the parapharyngeal space. Intraoperative X-ray fluoroscopy failed to identify the needle, so a steel wire was applied as a reference during X-ray to locate the foreign body. The needle was successfully removed using an intraoral approach with tonsillectomy under surgical microscopy. The simulation showed that the dental needle was able to be identified only after applying an appropriate compens...
To evaluate visualization of the right adrenal vein (RAV) with multidetector CT and non-contrast-... more To evaluate visualization of the right adrenal vein (RAV) with multidetector CT and non-contrast-enhanced MR imaging in patients with primary aldosteronism. A total of 125 patients (67 men) scheduled for adrenal venous sampling (AVS) were included. Dynamic 64-detector-row CT and balanced steady-state free precession-based non-contrast-enhanced 3-T MR imaging were performed. RAV visualization based on a four-point score was documented. Both anatomical location and variation on cross-sectional imaging were evaluated, and the findings were compared with catheter venography as the gold standard. The RAV was visualized in 93.2 % by CT and 84.8 % by MR imaging (p = 0.02). Positive predictive values of RAV visualization were 100 % for CT and 95.2 % for MR imaging. Imaging score was significantly higher in CT than MR imaging (p < 0.01). The RAV formed a common trunk with an accessory hepatic vein in 16 % of patients. The RAV orifice level on cross-sectional imaging was concordant with ca...
Adrenal venous sampling is currently the only reliable method to distinguish unilateral from bila... more Adrenal venous sampling is currently the only reliable method to distinguish unilateral from bilateral diseases in primary aldosteronism. In this study, we attempted to determine whether peripheral plasma levels of 18-oxocortisol (18oxoF) and 18-hydroxycortisol could contribute to the clinical differentiation between aldosteronoma and bilateral hyperaldosteronism in 234 patients with primary aldosteronism, including computed tomography (CT)-detectable aldosteronoma (n=113) and bilateral hyperaldosteronism (n=121), all of whom underwent CT and adrenal venous sampling. All aldosteronomas were surgically resected and the accuracy of diagnosis was clinically and histopathologically confirmed. 18oxoF and 18-hydroxycortisol were measured using liquid chromatography tandem mass spectrometry. Receiver operating characteristic analysis of 18oxoF discrimination of adenoma from hyperplasia demonstrated sensitivity/specificity of 0.83/0.99 at a cut-off value of 4.7 ng/dL, compared with that bas...
Aldosterone-producing adenoma is a major subtype of primary aldosteronism. The number of cases of... more Aldosterone-producing adenoma is a major subtype of primary aldosteronism. The number of cases of these adenomas, which are below the detection limit of computed tomography but diagnosed by adrenal venous sampling, has recently been increasing. However, the pathophysiology of these adenomas, especially those manifesting clinically overt hyperaldosteronism despite their small size, remains unknown. Therefore, we examined the correlation between tumor size and the status of intratumoral steroidogenic enzymes involved in aldosterone biosynthesis using immunohistochemistry. Forty patients with surgically proven aldosterone-producing adenomas were retrospectively studied. Multidetector computed tomography, adrenal venous sampling, and laparoscopic adrenalectomy were performed in all of the patients studied. The tumor area at the maximum diameter of the sections was precisely measured by ImageJ software. The status of the steroidogenic enzymes was immunohistochemically analyzed, and the f...
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Papers by Kazumasa Seiji