Edogawa Hospital

BackgroundSodium-glucose cotransporter-2 (SGLT2) inhibitors can effectively improve blood glucose levels in patients with type 2 diabetes, reduce the risk of cardiovascular disease and heart failure, and prevent chronic kidney disease. Although they reduce uric acid (UA) levels, few studies have investigated the relationship between UA reduction and renal function. We evaluated the degree of reduction in UA levels, various metabolic parameters, and renal function in patients with type 2 diabetes mellitus treated with luseogliflozin in order to develop a better renal protection strategy.MethodsThis retrospective study analyzed 353 patients with type 2 diabetes who were newly treated with luseogliflozin. Patients were divided into two groups based on baseline UA levels, namely, the low group (< 6.0 mg/dL) and high group (≥ 6.0 mg/dL), with 74 patients in each group. Changes in metabolic parameters including glycated hemoglobin (HbA1c), UA levels, and estimated glomerular filtration rate (eGFR) were monitored over 12 months.ResultsBoth groups showed significant reductions in UA and HbA1c at 12 months. eGFR decreased significantly in the low group (− 3.1 ± 0.9 mL/min/1.73 m2, p = 0.002), whereas no significant change was observed in the high group (− 0.8 ± 1.3 mL/min/1.73 m2, p = 0.667). UA reduction was greater in the high group (− 1.0 ± 0.2 mg/dL vs. − 0.3 ± 0.1 mg/dL, p < 0.001). UA changes were significantly correlated with eGFR changes (p = 0.008) but not with HbA1c changes.ConclusionChanges in eGFR after luseogliflozin administration were significantly correlated with baseline eGFR, uACR, and changes in uric acid levels (Δ uric acid). The change in uric acid levels following SGLT2 inhibitor treatment was associated with metabolic parameters such as blood pressure and albuminuria, suggesting that it may function as a surrogate marker reflecting renal metabolic processes.

Target lesion calcification is known to influence the percutaneous coronary intervention (PCI) outcomes. This study aimed to assess the impact of calcium fractures after balloon angioplasty on the PCI results as well as the long-term clinical outcomes. We formed a prospective, multicenter registry that enrolled 268 patients who underwent PCI to lesions with moderate to severe calcification. Balloon dilatation and subsequent drug eluting stent implantation were performed with optical coherence tomography (OCT) guidance in every case. Serial OCT images just before and after balloon angioplasty, and after stent implantation were analyzed at 1-mm intervals by an independent core laboratory. The primary endpoint was the relationship between calcium fracture after balloon angioplasty and stent expansion. The secondary endpoint was target vessel failure (TVF) at 1 year, defined as a composite of cardiac death, target vessel-related myocardial infarction, and target vessel revascularization. A total of 242 patients were analyzed. Of these, OCT analysis was performed in 147 patients with a complete OCT data set. Calcium fractures were observed in 28 patients (19%) at the minimal lumen area site. The percent stent expansion was greater in lesions with calcium fracture than those without (99 ± 26% vs. 91 ± 18%, p = 0.039). In 229 patients who underwent clinical follow-up at 1 year, TVF occurred in 23 patients (10.0%). The OCT-guided PCI strategy demonstrated acceptable acute and 1-year clinical outcomes. The presence of calcium fractures after balloon angioplasty may have a potential impact on acute results after DES implantation in calcified lesions.

Symptomatic ulnar nerve (UN) dislocation is an under-recognized cause of medial elbow pain in overhead athletes. Traditionally, surgery has been considered when symptoms persist; however, advances in dynamic ultrasound (US) and US-guided targeted interventions may enable conservative treatment. Reports on long-term return to play (RTP) after US-guided physiotherapy remain scarce.A 20-year-old right-handed collegiate sidearm pitcher developed progressive medial elbow pain for one year, with acute worsening two weeks before presentation. Clinical examination suggested ulnar collateral ligament (UCL) strain and concomitant neurogenic thoracic outlet syndrome (N-TOS). Dynamic US revealed an anterior UN dislocation over the medial epicondyle during elbow flexion, which reproduced the patient’s pain.Management was performed using a stepwise strategy. Phase 1 targeted the proximal contributors (N-TOS) using scapular and chin retraction exercises combined with neural mobilization. Phase 2 addressed the primary distal pathology with US-guided perineural soft tissue mobilization, and skin-pinch traction was applied until movement of the myofascial trilaminar retinaculum (MTR) was confirmed under US, thereby improving the perineural tissue. This was followed by pain-free UN-sliding exercises.After 12 weeks, neural tension signs subsided, and pain during dynamic UN displacement diminished. A graded throwing program was completed, enabling RTP at five months. At the two-year follow-up, the athlete remained asymptomatic without recurrence, despite persistent painless dynamic subluxation on US.In this single-case report of an athlete with UN dislocation complicated by N-TOS, a stepwise, ultrasound-guided, target-specific physiotherapy approach is presented as a hypothesis-generating example of conservative management. The intervention, which included direct mobilization of the myofascial trilaminar retinaculum, facilitated a safe return to play, and no surgical intervention was required during the treatment course. In this case, ultrasound was used provisionally to monitor clinically relevant changes, such as visible improvement in neural gliding and reduction of perineural soft tissue irritation. Rather than serving as a generalized recommendation, these observations suggest a potential rationale for incorporating ultrasound into conservative management pathways.

BackgroundInflammatory cytokine levels exhibit a circadian rhythm in sera, peaking from late night to early morning in patients with rheumatoid arthritis (RA). This cytokine kinetics is a recognized therapeutic target. This clinical study aimed to evaluate the effectiveness of night-time baricitinib administration based on cytokine secretion.MethodsIn this 52-week multicenter non-randomized controlled study, 122 patients with RA were assigned to four groups: baricitinib 2 mg morning (BAR2MORN), 2 mg evening (BAR2EVE), 4 mg morning (BAR4MORN), or 4 mg evening (BAR4EVE). The primary endpoint was assessed using the 20% improvement in the American College of Rheumatology criteria (ACR20) at week 12. The secondary endpoints were ACR20/50/70 and changes in the clinical disease activity index (CDAI) through 52 weeks. The results were evaluated using the propensity score inverse probability of treatment weighted to reduce selection bias in patient background.ResultsBAR4EVE resulted in better primary endpoint improvement than BAR4MORN (78.2 vs. 43.3%; p < 0.001). No difference in improvement was observed in the primary endpoint between BAR2EVE and BAR2MORN (75.5 vs. 60.6%; p = 0.10). However, BAR2EVE demonstrated higher ACR20 at weeks 4, 24, and 52 and ACR50 at weeks 4 and 12 than BAR2MORN. BAR4EVE demonstrated higher ACR20/50 at weeks 4, 8, and 12 and ACR70 at weeks 8, 12, and 24 than BAR4MORN. CDAI changes were significantly reduced in BAR4EVE than in BAR4MORN at weeks 4 and 8.ConclusionChronotherapy targeting cytokine secretion resulted in rapid drug response, proposing a new potential application for JAK inhibitors.Trial registrationUMIN000040094, July 1, 2020.

Introduction Generative Pre-Training Transformer (ChatGPT) has become widely recognized for its capability to generate text, synthesize complex information, and perform a variety of tasks without requiring human specialists for data collection. The latest iteration, ChatGPT-4, is a large multimodal model capable of integrating both text and image inputs, rendering it particularly promising for medical applications. However, its efficacy in analyzing radiographic images remains largely unexplored. Aim This study aims to (i) address the lack of data on the accuracy of ChatGPT in radiographic fracture classification into stable or unstable under the revised Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association (AO/OTA) classification system, and this procedure is also performed by surgeons, and (ii) compare the agreement between surgeons or ChatGPT-based performance. The study hypothesizes that the use of ChatGPT would achieve moderate agreement with orthopedic surgeons. Materials and methods Patients diagnosed with pertrochanteric fractures were retrospectively collected. Patients with both preoperative two-directional plain radiographs and CT scans (3D-CT) images were conditioned for enrollment into the study. Two orthopedic surgeons (observer 1 and observer 2, respectively) and one resident (observer 3) were once assigned to dichotomized groups into A1 (stable) or A2 (unstable) based on AO/OTA classification using two-directional plain radiographs. Prior to the ChatGPT study, all the anteroposterior images trimmed at the fractured side, attached with figure names including gender, and age, were inputted into OpenAI ChatGPT-4. Radiological evaluation prompts were designed to initiate ChatGPT's classification analysis of the uploaded radiographic images. A single observer (MN) decided the classification patterns by examining 3D CT scan images as well as plain radiographs. This judgment of A1 (stable) and A2 (unstable) was set as a benchmark to mark the results of observers and ChatGPT based on plain radiographs. Results The cohort consisted of 29 males and 90 females, with a mean age of 87 years after the data exclusion. The fractures were classified into A1 (stable) and A2 (unstable) groups based on CT imaging. The A1 group included 50 patients (13 males, 37 females; mean age: 86.2 ± 7.8 years), while the A2 group included 69 patients (16 males, 53 females; mean age: 87.0 ± 7.9 years). Kappa values for fracture classification between plain radiographs evaluated by the three observers and ChatGPT, compared to the CT-based gold standard, showed fair to moderate agreement: Observer 1: 0.494 (95% CI: 0.337-0.650), Observer 2: 0.390 (95% CI: 0.227-0.553), Observer 3: 0.360 (95% CI: 0.198-0.521), and ChatGPT: 0.420 (95% CI: 0.255-0.585). ChatGPT demonstrated accuracy, sensitivity, specificity, and positive and negative predictable values comparable to the human observers, suggesting moderate reliability. Conclusion This study demonstrates that ChatGPT can classify pertrochanteric fractures into A1 (stable) and A2 (unstable) under the Revised AO/OTA Classification System. Its moderate agreement with CT-based assessments (κ = 0.420) is comparable to the performance of orthopedic surgeons. Moreover, ChatGPT is straightforward to integrate into clinical workflows, requiring minimal data collection for training.

Several transcatheter tricuspid valve (TV) repair devices for tricuspid regurgitation (TR) have emerged. However, few studies have compared transcatheter TV repair with medical therapy (MT) alone or isolated TV surgery. PubMed and EMBASE were searched in February 2024. Studies comparing at least any of the following 2 were included: MT, surgical TV repair, surgical TV replacement, or transcatheter TV repair. The primary outcome was long-term mortality (≧ 1year). The secondary outcomes were short-term mortality (30-day or in-hospital mortality) and periprocedural complications. We performed a network meta-analysis using a random effects model. A total of 25,831 patients from 22 studies (one randomized trial and 21 observational studies) were included. MT alone was associated with higher long-term mortality compared to surgical TV repair (HR [95% CI] 1.72 [1.34-2.23]), surgical TV replacement (HR [95% CI] 1.49 [1.14-1.96]), and transcatheter TV repair (HR [95% CI] 1.52 [1.30-1.78]). Long-term mortality was comparable between transcatheter and surgical interventions. Transcatheter TV repair had a lower risk of short-term mortality (versus surgical TV repair; RR [95% CI] 0.40 [0.22-0.72], versus surgical TV replacement; RR [95% CI] 0.35 [0.19-0.66]) and lower rates of periprocedural complications, including new pacemaker implantation, renal complications, cardiogenic shock than surgical interventions. MT alone for TR was associated with higher long-term mortality compared to surgical or transcatheter TV interventions. Transcatheter TV repair had better periprocedural outcomes compared to surgical interventions with similar long-term mortality. Despite the possibility of selection bias, transcatheter TV repair appears to be an attractive option for TR treatment.

Background: It is uncertain whether the efficacy and safety of dual antiplatelet therapy (DAPT) in patients with high bleeding risk (HBR) vary according to DAPT duration and stent type (e.g., durable polymer drug-eluting stents (DP-DESs), biodegradable polymer DESs (BP-DESs), or polymer-free drug-coated stents (PF-DCSs)). Objectives: We aimed to study the stent type and DAPT duration appropriate for patients with HBR. Methods: PubMed and EMBASE were searched until October 2023. Randomized controlled trials (RCTs) involving patients with HBR that compared standard DAPT (6-12 months) with DP- or BP-DES versus short DAPT (≤3 months) with DP- or BP-DES or PF-DCS or bare-metal stent (BMS) were identified (Figure). The primary efficacy outcome was major adverse cardiovascular events (MACEs), defined as cardiovascular death, myocardial infarction (MI), and stroke. The primary safety outcome was major bleeding. Secondary outcomes included MI and stent thrombosis (ST). We performed a network meta-analysis using a random effects model. Results: Thirteen RCTs with a total of 19,418 patients with HBR were included. Compared to standard DAPT with DP-DES, short DAPT with BMS was associated with a higher risk of MACE and MI. For major bleeding, short DAPT strategies were associated with a lower risk than standard DAPT strategies (e.g. short DAPT with DP-DES versus standard DAPT with DP-DES; HR[95% CI]: 0.48[0.28-0.82]). Interestingly, the use of BP-DES was associated with a higher risk of ST than DP-DES (e.g. standard DAPT with BP-DES versus short DAPT with DP-DES; HR[95% CI]: 2.65[1.03-6.79]). Conclusions: In patients with HBR who underwent PCI, a short DAPT strategy with DP-DES should be used since it offers the best combination of efficacy and safety.

The Japanese Society of Hypertension have established a blood pressure (BP) target of 130/80 mmHg for patients with coronary artery disease (CAD). We evaluated the data of 8793 CAD patients in the Clinical Deep Data Accumulation System database who underwent cardiac catheterization at six university hospitals and the National Cerebral and Cardiovascular Center (average age 70 ± 11 years, 78% male, 43% with acute coronary syndrome [ACS]). Patients were divided into two groups based on whether or not they achieved the guideline-recommended BP of <130/80 mmHg. We analyzed the relationship between BP classification and major adverse cardiac and cerebral event (MACCE) separately in two groups: those with ACS and those with chronic coronary syndrome (CCS). During an average follow-up period of 33 months, 710 MACCEs occurred. A BP below 130/80 mmHg was associated with fewer MACCEs in both the overall (hazard ratio [HR] 0.83, 95% confidence interval [CI] 0.70-1.00, p = 0.048) and the ACS group (HR 0.67, 95%CI 0.51-0.88, p = 0.003). In particular, stroke events were also lower among those with a BP below 130/80 mmHg in both the overall (HR 0.69, 95%CI 0.53-0.90, p = 0.006) and ACS groups (HR 0.44, 95%CI 0.30-0.67, p < 0.001). In conclusion, the achievement of BP guidelines was associated with improved outcomes in CAD patients, particularly in reducing stroke risk among those with ACS.

It is a clear fact that many complications in surgical treatment, not just in cardiovascular surgery, are caused by things related to surgical techniques. In other words, postoperative problems are already determined by preoperative surgical management and intraoperative surgical operations. This describes strategies to avoid the surgical complications of distal bypass using the autogenous veins for each item. (This is a translation of Jpn J Vasc Surg 2024; 33: 67–72)