Ogikubo Hospital

Morton’s neuroma (MN) is frequently refractory to conventional conservative therapies, and surgical excision carries the risk of recurrent pain. While extracorporeal shock wave therapy (ESWT) has emerged as a potential non-invasive intervention for MN, a standardized clinical protocol for its application remains to be established. This review aims to elucidate the physiological validity of ESWT for MN and propose an optimized clinical protocol. Existing randomized controlled trials of ESWT for MN were analyzed, and findings from other entrapment neuropathies were extrapolated to critically appraise interventional factors influencing therapeutic outcomes. ESWT exerts a biphasic effect: immediate analgesia via the degeneration of free nerve endings, and radical pathophysiological improvement through the promotion of neovascularization and tissue repair. The present analysis suggests that the use of local anesthesia may inhibit mechanotransduction, potentially reducing success rates. Furthermore, considering the dynamics of growth factors involved in tissue regeneration, multiple sessions at one-week intervals are more rational than a single application. Optimizing ESWT through repetitive sessions without anesthesia at the maximum tolerable energy flux density may maximize therapeutic efficacy. ESWT is expected to become an integral, minimally invasive standard therapy that precludes the necessity for surgical intervention.

This study applies the attractor reconstruction method to photoplethysmography (PPG) signals to explore their potential in preventive health monitoring. Conventional PPG analysis methods typically rely on beat-by-beat segmentation and feature point detection, both of which are highly sensitive to noise, waveform distortion, and individual variability. To address these limitations, we applied attractor reconstruction trajectories (ACTs) as an alternative analytical approach to PPG signal analysis. ACTs utilize the entire waveform to reconstruct signal dynamics, facilitating a more holistic and noninvasive assessment of vascular health. Fifty-five participants aged 20-89 years, comprising healthy individuals and patients with chronic liver or kidney disease were studied. Three-dimensional ACTs were constructed from fingertip PPG signals and their first (DPPG) and second (SDPPG) derivatives. ACT morphologies were classified using a template-matching approach, and their distributions were compared across age groups and signal types. ACT classification revealed distinct structural characteristics across signal types. For PPG ACTs, Approximate Triangle (40.5%) and Three Points (29.5%) were the most frequent patterns, while Three Points pattern was observed only in younger and healthy middle-aged groups and exhibited the lowest uncertainty rate (14.3%). DPPG ACTs showed the greatest structural diversity, with Radiating pattern predominating in younger participants and a clear transition toward dominance of Three-lobed pattern in older groups (60.7% in participants aged 80-89 years). In contrast, SDPPG ACTs were dominated by Irregular pattern (48.6%) across all age groups and showed the highest variability and uncertainty (17.6-20.7%). These results demonstrate that ACTs can capture age-dependent differences in PPG-derived signals, with DPPG ACTs exhibiting the clearest age-related structural transitions. While limitations remain regarding sample size and classification automation, the findings support the potential of ACT-based analysis as a complementary framework for noninvasive assessment of vascular aging using PPG signals.

Elevated systolic blood pressure (SBP) increases myocardial oxygen demand, whereas low diastolic blood pressure (DBP) can impair coronary perfusion. The prognostic impact of this high-SBP/low-DBP (HSLD) profile in patients with ST-elevation myocardial infarction (STEMI) remains unknown. We analyzed 696 consecutive patients with STEMI undergoing primary percutaneous coronary intervention (PCI) from a prospective 11-center registry in Japan. Patients were categorized based on pre-procedural SBP (≥ 120 mmHg) and DBP (< 70 mmHg) into four groups: high-SBP/low-DBP (HSLD) high-SBP/high-DBP (HSHD), low-SBP/high-DBP (LSHD), and low-SBP/low-DBP (LSLD). The primary endpoint was a 1-year composite of cardiovascular death, non-fatal myocardial infarction, or stroke. Median follow-up was 369 days. The 1-year cumulative incidence of the primary endpoint was 7 (9.5%) in the HSLD group, 19 (4.2%) in the HSHD group, 2 (2.8%) in the LSHD group, and 5 (6.0%) in the LSLD group (log-rank p = 0.007). In multivariable Cox regression, the HSLD was independently associated with the primary endpoint compared to the HSHD group (hazard ratio 3.20, 95% CI 1.04-9.87; p = 0.043). The prognostic value of HSLD was consistent across major subgroups. A pre-procedural blood pressure pattern of SBP ≥ 120 mmHg combined with DBP < 70 mmHg independently predicts a higher risk of adverse cardiovascular events at 1 year in patients with STEMI. This simple measurement at admission identifies a previously unrecognized high-risk phenotype and presents a valuable opportunity for early risk stratification.

Several Ephedra Herb-containing Kampo medicines are common initial treatments for various infections; however, the ephedrine alkaloids in Ephedra Herb can cause side effects by stimulating adrenergic receptors. Accordingly, an ephedrine alkaloids-free Ephedra Herb Extract (EFE) has been developed. This study aimed to evaluate whether EFE can be used effectively and safely in patients with mild coronavirus disease 2019 (COVID-19). We randomized patients with mild COVID-19 to receive EFE equivalent to 6 g of Ephedra Herb per day or a placebo for 14 days. The primary efficacy endpoint was the non-aggravation rate up to Day 15. We allocated 41 and 40 patients to the EFE and placebo groups, respectively. All participants were included in the mITT and safety analysis populations [male ratio, mean age: 31.7%, 42.0 years (EFE); 17.5%, 43.2 years (placebo)]. The non-aggravation rate up to Day 15 for the primary endpoint was 100.0% and 94.6% in the EFE and placebo group, respectively, with no between-group difference. The number of days to the improvement in nausea symptoms was significantly shorter in the EFE group. One patient in the placebo group discontinued the trial due to a side effect. Although EFE demonstrated safety in patients with mild COVID-19, it did not show superior efficacy compared to placebo for symptoms other than nausea.

Pancreaticoduodenal artery (PDA) aneurysms are rare visceral aneurysms often associated with median arcuate ligament syndrome (MALS) due to compensatory high blood flow. Although endovascular treatment is the preferred approach, challenges such as contrast agent allergies and proximity to the superior mesenteric artery (SMA) may render such treatment unsuitable. Herein, we present a case of a 50-year-old female with a PDA aneurysm caused by MALS. Endovascular treatment was contraindicated because of contrast allergies and anatomical considerations. Laparoscopic surgery was performed to resect both the PDA aneurysm and the median arcuate ligament (MAL), marking the first reported case to use this approach. The procedure was successful, with no complications, and the patient was discharged on the fourth postoperative day. This case highlights the potential of laparoscopic surgery as a minimally invasive alternative for managing PDA aneurysms in complex clinical scenarios.

We retrospectively examined whether anesthetic fade (AF) occurred in brain tumor surgery with direct motor field stimulation motor evoked potential (dMEP) and transcranial stimulation MEP (tcMEP), and whether it could have been avoided by compound muscle action potential (CMAP) after peripheral nerve stimulation normalization, and examined the causes of AF. In 108 muscles in 40 patients where tcMEP was performed and 24 muscles in 24 cases where dMEP was performed, and whether AF could be avoided by CMAP normalization was examined. In 108 muscles where tcMEP was performed, the relative amplitude of surgery with an operative time of 190 minutes or more was 1.07±0.88, which was significantly lower than the relative amplitude of surgery with an operative time of less than 190 minutes (1.67±2.69) (P=0.0447, Student’s t-test). The relative amplitude values under CMAP normalization were also 1.29±1.62 over 190 minutes and 1.24±1.48 under 190 minutes, indicating no significant difference (P = 0.4430).The relative amplitude of surgery with an operative time of 360 minutes or more was 0.56±0.26 in the 24 muscles where dMEP was performed, and a significant difference was observed between the relative amplitude of surgery with an operative time of less than 360 minutes (1.43±0.75) (P = 0.0045). The relative amplitude values under CMAP normalization were 0.57±0.25 over 360 minutes and 1.48±0.72 under 360 minutes, which was also significant (P = 0.0038). AF was also more intense in dMEP and could not be avoided by CMAP normalization. Although there were few cases and it required consideration of direct invasion of the pyramidal tract in brain tumor surgery, it is suggested that a decrease in the transmissibility of neuromuscular junctions is considered to be a cause of AF that and a decrease in excitability of motor field pyramidal cells may be more active at 6 hours or more.

Retrospective multicenter study. To evaluate how preoperative neck pain influences clinical outcomes following posterior decompression for cervical ossification of the posterior longitudinal ligament (OPLL). Fourteen medical institutions in Japan. We enrolled 90 patients with cervical OPLL who underwent posterior decompression and were followed for a minimum of two years. We collected demographic data, medical history, and imaging findings. Patients were divided into two groups based on preoperative neck pain presence (Pre-op. neck pain (-) and (+) groups), and their outcomes were compared. There were no significant differences in patient demographics between the Pre-op. neck pain (-) and (+) groups. Both groups showed similar distributions of ossification types and K-line positivity. Perioperative complications were comparable between the two groups. Radiographic analysis revealed no significant differences in C2-7 angles or cervical range of motion, pre- and postoperatively. Both groups demonstrated significant improvement in postoperative Japanese orthopedic association (JOA) scores, but there were no significant differences in scores or recovery rates. In the Pre-op. neck pain (-) group, factors associated with appearance of postoperative neck pain included pre- and postoperative lower JOA scores and larger C2-7 angles in neutral and extension positions. It emerges that lower pre- and postoperative JOA scores or larger C2-7 angles in neutral and extension positions predispose to postoperative neck pain even in those patients without preoperative neck pain. Therefore, this is worth discussing at the time of consenting patients for surgical decompression and fixation.

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 number of very elderly patients with acute coronary syndrome (ACS) is increasing. Therefore, owing to the need for evidence-based treatment decisions in this population, this study aimed to examine the clinical outcomes during 1year after percutaneous coronary intervention (PCI) in very elderly patients with ACS. This prospective multicenter observational study comprised 1337 patients with ACS treated with PCI, classified into the following four groups according to age: under 60, <60years; sexagenarian, ≥60 and <69years; septuagenarian, ≥70 and <80years; and very elderly, ≥80years. The primary endpoint was a composite of the first occurrence of all-cause death, nonfatal myocardial infarction, nonfatal stroke, and bleeding within 1year after PCI. We used the sexagenarian group as a reference and compared outcomes with those of the other groups. The incidence of the primary endpoint was significantly higher in the very elderly group than in the sexagenarian group (36 [12.7%] vs. 24 [6.9%], respectively; hazard ratio, 1.94; 95% confidence interval: 1.16-3.26; p = 0.012). The higher incidence of the primary endpoint was primarily driven by a higher incidence of all-cause death. When the multivariable analysis was used to adjust for patient characteristics and comorbidities, no difference was observed in the primary endpoint between the very elderly and sexagenarian groups (p = 0.96). The incidence of adverse events after PCI, particularly all-cause death, in very elderly patients with ACS was high. However, if several confounders are adjusted, comparable outcomes may be expected within 1year after PCI among this population.