Kushiro City General Hospital

This prospective multicenter cohort study aimed to compare the predictive accuracy of the Prognostic Nutritional Index (PNI) and the Geriatric Nutritional Risk Index (GNRI) for 1year mortality in older adult patients undergoing proximal femoral fracture surgery. We analyzed the data from 252 patients aged ≥ 65years who underwent surgery. Patients were classified based on their preoperative PNI (cutoff, 40) and GNRI (cutoff, 98). To minimize confounding, 1:1 propensity score matching (PSM) was performed for each index, adjusting for age, sex, body mass index, comorbidities, and inflammatory markers. Survival rates were estimated using the Kaplan-Meier method and compared using the log-rank test. The overall 1year mortality rate was 14.7%. After PSM, the low PNI group exhibited a significantly higher mortality rate than the control group (18.9% vs. 3.3%, p < 0.01). Similarly, the low GNRI group had a significantly higher mortality rate than the control group (14.1% vs. 4.2%, p = 0.04). Cox proportional hazards analysis confirmed that both indices were independent predictors of 1year mortality. Notably, the low-PNI group was significantly younger than the control group yet demonstrated higher mortality. Preoperative PNI and GNRI were associated with 1year mortality in older adult patients with proximal femoral fractures and remained independent prognostic indicators after adjustment for confounders. These findings suggest that PNI and GNRI may serve as supplementary prognostic markers beyond chronological age and could provide additional information to support multidisciplinary perioperative assessment and shared clinical decision-making in this vulnerable population.

We sincerely appreciate the interest and thoughtful comments of Vijayvergiya et al. [1] regarding our case series on the use of scoring balloons for acute stent underexpansion [2]. Their letter raises important points concerning intravascular imaging, lesion preparation, and device selection. We are grateful for the opportunity to clarify our rationale and highlight both areas of agreement and directions for future investigation. We emphasized that scoring balloons should not be regarded solely as predilatation tools but may also serve as effective rescue devices in the acute setting. Despite comprehensive predilatation and high-pressure non-complian balloon post-dilatation, our cases demonstrated persistent underexpansion, particularly in heavily calcified lesions [2]. In such real-world scenarios, scoring balloons facilitated controlled plaque fracture and provided meaningful additional stent expansion, where other options were limited [3]. Three of four patients presented with acute coronary syndromes, in whom urgent revascularization was prioritized over extensive calcium modification (e.g., atherectomy or intravascular lithotripsy). In this context, post-stenting scoring balloon use represented a practical and sometimes lifesaving solution. We stress that we do not advocate bypassing adequate lesion preparation when feasible; rather, our report highlights the utility of scoring balloons as a salvage option when conventional measures fail or advanced devices are unavailable. We fully acknowledge the lack of intravascular imaging (intravascular ultrasound and optical coherence tomography [IVUS/OCT]) as a limitation, which we clearly stated in our manuscript. Intravascular imaging is undoubtedly superior for calcium characterization, device sizing, and confirmation of stent expansion, and we strongly endorse its use whenever possible [4]. However, our series reflects acute settings where imaging was not available and broader contexts where resources remain limited. In such circumstances, we relied on detailed angiographic criteria, which although less precise provided reasonable guidance for identifying underexpansion. We support the view that future studies should integrate IVUS/OCT to refine mechanistic understanding and optimize outcomes. We concur that dedicated calcium-modifying strategies (atherectomy, intravascular lithotripsy, cutting/scoring balloons pre-stenting) remain the preferred approach when conditions allow [5]. In our series, the absence of these tools reflected urgent clinical needs and resource constraints, not lack of awareness. Once a stent is deployed, atherectomy is no longer feasible, and post-stent lithotripsy raises safety concerns. Thus, balloon-based strategies are often the only realistic rescue. Our cases illustrate that scoring balloons can effectively crack resistant plaque beneath an underexpanded stent, yielding significant luminal gain without resorting to more complex interventions. We acknowledge prior reports of complications such as balloon rupture or stent deformation. However, none occurred in our small cohort. All patients experienced smooth in-hospital courses and remained event-free during long-term follow-up (1–3.5 years). These findings support the safety and durability of acute scoring balloon optimization in selected patients, although larger studies are necessary to confirm this profile. In conclusion, we concur with Vijayvergiya et al. [1]. on the importance of intravascular imaging and optimal calcium modification whenever possible. At the same time, our case series highlights the pragmatic value of scoring balloons: they are widely available, cost-effective, and can serve as a safe and effective rescue strategy for acute stent underexpansion, particularly in urgent or resource-limited settings. Future randomized and imaging-guided studies are warranted to better define their role within therapeutic algorithms. The authors have nothing to report. The authors declare no conflicts of interest.

Background:Tendon reconstruction is a difficult procedure with unpredictable results, and evaluating and selecting the appropriate muscle tendon is crucial. To improve the results of tendon reconstruction, the authors investigated active muscle contraction during wide-awake local anesthesia no tourniquet (WALANT) surgery, in which the patient can perform active movements.Methods:Among 213 WALANT tendon reconstructions, 148 muscle tendons were evaluated for active contraction distance and passive stretch distance of the muscle tendons, time elapsed before reconstruction, and characteristics and changes in muscle active contraction patterns after verbal instructions.Results:Active contraction and passive stretch distances showed significant positive correlations and flexor muscles displayed larger distances than extensor muscles. Time elapsed before reconstruction did not correlate with either distance. In the flexor digitorum superficialis muscle, active contraction distance was greater in the grip-related ulnar digits, but the late-phase pattern was more frequent. In the extensor indicis proprius muscle, contraction distance on instruction to extend the thumb was smaller than that when instructed to extend the index finger.Conclusion:WALANT surgery is the only procedure in which active contraction distance and characteristics of muscle tendons can be observed intraoperatively, and it appears useful for tendon transfer.

Programmed death ligand 1 (PD-L1) serves as a crucial biomarker for predicting the efficacy of immune checkpoint inhibitors in patients with non-small cell lung cancer (NSCLC). This study aimed to identify the most suitable first-line treatment regimen for patients with PD-L1 expression <1% (PD-L1-negative) NSCLC by comparing nivolumab plus ipilimumab (NI), NI combined with chemotherapy (NICT), and pembrolizumab and chemotherapy (PCT). We analyzed data from 141 patients with PD-L1-negative NSCLC treated with NI, NICT, or PCT at 14 Japanese institutions between December 2020 and November 2022. Propensity score analysis was employed to minimize selection bias, and Kaplan-Meier analysis and Cox proportional hazards regression were used to evaluate progression-free survival (PFS) and overall survival (OS). Neither NI nor NICT demonstrated superior PFS or OS than PCT. Subgroup analyses revealed no significant differences between treatment groups across age, histological subtypes, or clinical features. Results from propensity score matching and inverse probability of treatment weighting were consistent with those observed in the overall cohort. Moreover, safety profiles showed that PCT was associated with the lowest rates of treatment discontinuation and immune-related adverse events requiring systemic corticosteroid therapy. In patients with PD-L1-negative NSCLC, the efficacy of NI and NICT was not superior to that of PCT. Thus, we concluded that PCT could be a favorable treatment option for this patient population.

Cancer is a major global public health issue. Immune checkpoint inhibitors are increasingly used for managing advanced malignancies.However, their effect is limited by immune-related adverse events. Hence, a retrospective, single-institutional study found a 60%clinical benefit ratio among 30 patients receiving Immune checkpoint inhibitors therapy. Nonetheless, a small sample size, patientheterogeneity and retrospective design require further validation for more conclusive results.

To identify the most effective use of social media to increase the number of aspiring surgeons, we evaluated the impact of social media on the career choices of medical students and junior residents. We conducted a single-center prospective observational questionnaire-based study on medical students and junior residents from March, 2023 to August, 2024. Following overall aggregation, statistical intergroup comparisons were made between students and junior residents, as well as between those who were, or were not influenced by social media. Among the 101 participants (77 students, 24 junior residents), approximately 75% reported that social media influenced their career choices. The most frequently used platforms were YouTube (85.1%), Instagram (71.3%), and X (67.3%). A total of 46.5% of the respondents expressed an interest in surgical specialties. Junior residents were more likely than students to gather information related to medicine (p = 0.0442). The group influenced by social media showed a higher interest in surgical specialties (p = 0.0475), and many desired parental leave policies to increase the number of surgeons (p = 0.0376). Social media influences the career choices of medical students and junior residents, and its effective use could increase the number of aspiring surgeons.

Background: Unstable thoracic spine pathology from trauma, infection, tumor, or degenerative collapse can cause neurological deficits, bowel-bladder dysfunction, loss of ambulation, and severe pain, significantly affecting quality of life. Posterior decompression with pedicle screw-rod fixation restores stability and neurological function. This study aims to evaluate the Impact of Posterior Decompression and Pedicle Screw-Rod Fixation on Bowel-Bladder Function, Ambulation, and Pain in Unstable Thoracic Spine Pathology. Methods: This study was conducted from July 2021 to May 2023 at the Department of Orthopaedic, Bangladesh Medical University, including 57 patients with unstable thoracic spine pathology undergoing posterior decompression and pedicle screw-rod fixation. Baseline data on demographics, neurological status, pain, and mobility were collected. Postoperative follow-up was conducted at 1, 3, 6, and 12 months. Functional outcomes were assessed using modified Macnab criteria. Changes in bowel-bladder function, ambulation, and pain were analysed using paired proportion tests, with absolute risk differences and 95% confidence intervals calculated. Results: The cohort had a mean age of 39.6 ± 15.8 years, with 56.1% females. Preoperatively, bowel-bladder dysfunction was present in 77.2%, diminished motor function in 75.4%, impaired sensory status in 91.2%, inability to ambulate in 77.2%, and pain in 94.7%. Perioperative complications included dural tear (12.3%) and haemorrhage (15.8%), while postoperative complications included donor site pain (10.5%) and residual pain (8.8%). At 12 months, bowel-bladder dysfunction decreased to 3.5% (absolute risk reduction 73.7%, 95% CI 61.8-85.6, p &lt; 0.001), pain to 15.8% (78.9%, 95% CI 67.8-90.0, p &lt; 0.001), inability to ambulate to 0% (77.2%, 95% CI 66.3-88.1, p &lt; 0.001), and satisfactory functional outcomes (Macnab excellent + good) increased from 0% to 78.9% (95% CI 68.4-89.5, p &lt; 0.001). Conclusion: Posterior decompression with pedicle screw-rod fixation effectively restores autonomic function, mobility, and reduces pain in unstable thoracic spine pathology.

Because it is unclear whether implantable cardioverter-defibrillators (ICDs) are equally effective in patients of all ages, we investigated the association of age with long-term clinical outcomes of patients who underwent ICD implantation. A total of 416 consecutive patients (mean age: 69 years) from 4 tertiary hospitals who underwent ICD implantation or were upgraded from an existing permanent pacemaker between January 2011 and November 2022 were enrolled and divided into 3 groups based on age: <65 years (n=158), 65-74 years (n=138), and ≥75 years (n=120). We compared the incidence of all-cause death and adverse cardiovascular events, including cardiac death, appropriate ICD therapy, and heart failure hospitalization. During a median follow-up period of 3.2 years (interquartile range: 1.1-5.6 years), 120 patients died. Older patients had a higher cumulative incidence of all-cause death and composite adverse cardiovascular events. The cumulative incidence of cardiac death and appropriate ICD therapies did not differ significantly; however, the incidence of hospitalization for heart failure increased with age. In multivariate analysis, age was independently associated with all-cause death but not composite adverse outcomes. Age had a significant effect on subsequent all-cause death, but not on adverse cardiovascular events in patients with ICDs, suggesting that age should not be the only indication considered for ICD implantation.

Background: Heart failure with reduced ejection fraction (HFrEF), defined as a left ventricular ejection fraction (LVEF) of &lt;40%, after acute coronary syndrome (ACS) is associated with increased mortality rates. However, the long-term prognostic impact of HF in patients with mildly reduced EF (HFmrEF), defined as a LVEF of 40–49%, who undergo primary percutaneous coronary intervention (PCI) remains unclear. Hypothesis: Patients with HFmrEF have a better prognosis than those with HFrEF and a worse prognosis than patients with HF with preserved EF (HFpEF), defined as a LVEF of ≥ 50%. Aims: We compared the long-term prognosis among HFpEF, HFmrEF, and HFrEF patients. Methods: A total of 836 consecutive ACS patients who underwent emergency PCI at our hospital between April 2014 and March 2024 were retrospectively recruited. We compared all-cause mortality and adverse cardiovascular events, including cardiac death and heart failure hospitalization. Patients were divided into three groups based on LVEF assessed by echocardiography within 1 month after PCI: HFpEF, HFmrEF, and HFrEF. Results: After excluding 117 patients who lacked echocardiographic data, 719 patients were included (HFpEF, 443; HFmrEF, 180; HFrEF, 96). Patients with lower EF were older and had higher plasma brain natriuretic peptide levels at admission. During a median follow-up period of 3.8 years (interquartile range: 1.5–6.3), 105 patients (13%) died. Patients with lower EF had a higher incidence of all-cause mortality and adverse cardiovascular events (Figure). Multivariate analysis indicated no difference in all-cause mortality between HFrEF and HFmrEF groups (adjusted hazard ratio (HR) 1.07, 95% confidence interval (CI) 0.44–2.60), although adverse cardiovascular events were significantly different (adjusted HR 0.44, 95% CI 0.24–0.82). On the other hand, there was no difference in all-cause mortality between HFmrEF and HFpEF groups (adjusted HR 0.49, 95% CI 0.31–0.79), although adverse cardiovascular events were significantly different (adjusted HR 0.35, 95% CI 0.18–0.69). Conclusion: In patients with ACS following emergency PCI, HFmrEF is associated with a better prognosis compared with HFrEF, but with a worse prognosis than HFpEF.