Municipal Tsuruga Hospital

Cardiac herniation is a rare but potentially fatal complication that may occur after surgery involving pericardial incision or resection. Most cases develop intraoperatively or in the early postoperative period, and delayed-onset cases after minimally invasive thoracic surgery have not been reported. A 48-year-old woman developed left shoulder pain and nausea six years after thoracoscopic thymectomy for myasthenia gravis. Electrocardiography indicated ST-segment elevation myocardial infarction. Computed tomography of the chest showed cardiac herniation into the left thoracic cavity and coronary angiography revealed stenosis corresponding to the hernial defect. The patient was diagnosed with coronary artery compression due to cardiac herniation and underwent hernia reduction and coronary artery bypass grafting. The postoperative course was uneventful. Cardiac herniation may occur even long after minimally invasive thoracic surgery and should be considered in patients presenting with chest symptoms or hemodynamic instability.

The impact of each factor and the number of positive criteria on pathogenesis and the diagnostic performance of non-invasive tests (NITs) in patients with metabolic dysfunction-associated steatotic liver disease (MASLD) remains unclear. This study aimed to investigate the association between the cardiometabolic criteria and the clinical features. This retrospective study investigated clinicopathological characteristics and the diagnostic performance of the Enhanced Liver Fibrosis (ELF) test, fibrosis-4 (FIB-4) index, and nonalcoholic fatty liver disease fibrosis score (NFS) according to the factors and the number of positive cardiometabolic criteria in 1,038 patients with biopsy-proven MASLD. Hypertension is a significant risk factor for progression to advanced fibrosis and at-risk metabolic dysfunction-associated steatohepatitis (MASH) in male patients. In contrast, no significant risk factor was identified in female patients. The incidence of advanced fibrosis increased significantly in patients with three or more positive criteria. Similarly, the incidence of at-risk MASH increased significantly in a stepwise manner with the number of positive cardiometabolic criteria. The diagnostic performance of the ELF test for advanced fibrosis exceeded that of the FIB-4 index and NFS for all factors except hypertension. Regardless of the number of positive cardiometabolic criteria, the ELF test demonstrated a superior diagnostic performance for advanced fibrosis. MASLD with hypertension in male patients or a higher number of positive cardiometabolic criteria constitutes a significant risk for advanced fibrosis or at-risk MASH. The ELF test is a valuable tool for diagnosing advanced fibrosis progression regardless of individual factors or the number of positive cardiometabolic criteria.

67歳男性．2年前に塞栓源不明の脳梗塞の診断となりアスピリン内服で再発予防をしていた．今回構音障害で発症し，右前頭葉に新規脳梗塞を認めた．CT angiogram （CTA）で右内頚動脈起始部にcarotid web （CW）を認め，CWによる脳塞栓症と診断した．経過中，CWの急速な形態変化と脳梗塞再発を来し，抗血小板薬2剤併用療法の上で頚動脈ステント留置術を施行した．抗血小板療法下に2年間脳梗塞の再発がないCWにおいても短期間にダイナミックな形態変化を来して脳梗塞を再発し得るため，CTAでの密な画像フォローを行い，変化を認めた場合には速やかな血行再建術を行う必要がある．

ABSTRACTIntroductionIsolated abdominal aortic dissection (IAAD) has been reported to account for 1.1%–4.1% of all aortic dissections. If detected late, it is associated with a risk of aortic rupture. We investigated the risk factors and characteristic imaging findings of incidentally discovered IAAD using abdominal ultrasonography (AUS) during health check‐up and hereby report our findings.MethodsThe study sample included 41 patients with abdominal aortic abnormalities identified by AUS performed during a health check‐up at our hospital and who were diagnosed with IAAD by contrast‐enhanced computed tomography (CT); in addition, 205 patients were included in the nonevent group. Furthermore, risk factors and characteristic imaging findings of IAAD were examined retrospectively.ResultsCompared with the nonevent group, smoking and fatty liver were observed significantly more frequently in the IAAD group. Ultrasound findings indicated an intimal flap in 35 cases (85.4%), whereas CT scan revealed displacement of intimal calcifications in 32 cases (78.0%).ConclusionCompared with the nonevent group, there were significantly more cases of fatty liver and smoking habits in the IAAD group. In older patients with risk factors for fatty liver and smoking habits, if IAAD is suspected, it is important to monitor the abdominal aorta using ultrasonography during health check‐ups.

Imatinib therapy is the gold standard for the treatment of unresectable and metastatic gastrointestinal stromal tumors (GISTs). However, few studies have reported the long-term outcomes of the treatment. Seventy patients who underwent imatinib therapy for unresectable and metastatic GISTs were enrolled between 2001 and 2009, and follow-up data were collected until October 2023. One hundred and sixty-eight months had passed since the final enrollment. The outcome measures were patient survival and the status of GIST and imatinib therapy. The cumulative incidence of disease progression (PD) and the chronological changes in PD hazard rate (HR) were also analyzed. The 5-, 10-, 15-, and 20-year overall survival rates were 64.3%, 30.0%, 16.8%, and 12.2%, respectively. Sixty of the 70 enrolled patients died before the data cutoff date: 47 (78.3%) patients died of GIST progression while the remaining 13 (21.7%) died of diseases other than GISTs. The cumulative incidence of PD logarithmically increased, and PD continued even after 10years of treatment. PD HR decreased over time to reach the lowest value at 9.6years after the initiation of treatment (HR 0.00027; 95% CI 0.00007-0.00174) and after that formed a small peak at 13years (HR 0.00144; 95% CI 0.00043-0.00436). Imatinib therapy showed high clinical efficacy in terms of long-term survival in GIST patients. However, patients undergoing imatinib therapy were at continuous risk of PD even after the 10-year treatment. Long-term treatment and follow-up beyond 10years are necessary for unresectable and metastatic GIST patients.

BackgroundHemophilia significantly impacts joint health, necessitating innovative strategies for early detection and management of joint damage. ObjectivesThis study assessed the impact of incorporating musculoskeletal ultrasound (MSKUS) into shared decision-making processes on prophylaxis regimens for patients with hemophilia over a 3-year period. MethodsThe “Joint Damage Monitoring by Ultrasonography in Patients with Hemophilia in Japan” study was a long-term prospective observational study conducted at Ogikubo Hospital, Tokyo, Japan. It enrolled 174 participants with moderate-to-severe hemophilia A or B. Participants underwent 6 monthly MSKUS evaluations, generating 3582 images from 682 joints; the findings guided adjustments of prophylaxis. ResultsOver the 3-year period, 69.3% of participants adjusted their prophylaxis regimen at least once. Adherence, defined as the ratio of the prescribed to the actual frequency of prophylaxis administration as agreed upon by physicians and patients, was high at the beginning of the study, with an average of 91.6%, and remained high after 3 years at 94.7%. The HEAD-US scores for elbows, knees, and ankles significantly improved (all P < .0001). The spontaneous annual joint bleeding rate and Hemophilia Joint Health Scores also significantly improved (P = .001 and P = .004, respectively). Synovitis detection decreased from 12.9% to 1.6%, with the majority of identified synovitis being subclinical (11.7%) and not associated with bleeding events in the 6 months preceding detection. ConclusionIntegrating MSKUS into hemophilia care as a shared decision-making tool significantly facilitates the early detection of joint damage and supports personalized prophylaxis adjustments, markedly improving patient outcomes.

The influence of metabolic dysfunction-associated fatty liver disease on gallstone development remains unclear. We aimed to investigate the longitudinal association between metabolic dysfunction-associated fatty liver disease and gallstone development in both men and women. This observational cohort study included 5398 patients without gallstones who underwent >2 health check-ups between April 1, 2014, and March 31, 2020. A generalized estimation equation model was used to analyze the association between metabolic dysfunction-associated fatty liver disease and gallstone development according to repeated measures at baseline and most recent stage. After adjustment, the odds ratios of metabolic dysfunction-associated fatty liver disease for gallstone development in men and women were 3.019 (95% confidence interval [CI]: 1.901-4.794) and 2.201 (95% CI: 1.321-3.667), respectively. Among patients aged ≥50years, the odds ratio for gallstone development was significantly enhanced with increasing metabolic dysfunction-associated fatty liver disease component numbers in both sexes; however, no significance was observed in those aged <50years. Other significant risk factors for gallstone development were age (odds ratio: 1.093, 95% CI: 1.060-1.126) and waist circumference (odds ratio: 1.048, 95% CI: 1.018-1.079) in men and age (odds ratio: 1.035, 95% CI: 1.003-1.067) and current smoking (odd ratio: 5.465, 95% CI: 1.881-15.88) in women. Although the risk factors for gallstone development differed between sexes, metabolic dysfunction-associated fatty liver disease was common. Paying attention to an increase in the number of metabolic dysfunction-associated fatty liver disease components in patients aged ≥50years is important for gallstone prevention.

Thymic carcinoma (TC) presenting with cardiac tamponade has a poor prognosis because of the difficulty in controlling malignant pericardial effusion using conventional chemotherapy. Lenvatinib, a multitargeted kinase inhibitor of vascular endothelial growth factor receptor and other kinases, has recently been proven effective against TC. As the inhibition of vascular endothelial growth factor signaling is effective in malignant pericardial effusion, lenvatinib may also be effective in TC presenting with cardiac tamponade. However, no reports have shown that lenvatinib is effective in such cases. Herein, we present a case of successful treatment with lenvatinib in a patient with TC presenting with cardiac tamponade. The present case suggests that lenvatinib should be considered an effective treatment option for such cases.