Teikyo University Chiba Medical Center

Coronal shear fracture (CSF) of the distal humerus is rare, accounting for approximately 1% of elbow fractures; cases combined with olecranon fracture are even rarer. This study aimed to clarify the relationship between surgical methods and clinical outcomes in this uncommon injury. Between 2017 and 2025, we retrospectively reviewed 8 patients (8 elbows) with CSF associated with olecranon fracture who underwent open reduction and internal fixation in a multicenter case series and were followed for more than 6 months. Patient demographics, fracture classifications, surgical methods, postoperative complications, additional surgeries, elbow range of motion, and Mayo Elbow Performance Score at the final follow-up were analyzed descriptively. The mean age was 64 years (range, 51-79 years), and the mean follow-up was 27 months (range, 10-96 months). Dubberley classification was type 2A in 2 cases, type 3A in 2, and type 3B in 4. A posterolateral extended approach was used in 6 patients and a combined lateral-posterior approach in 2. Postoperative complications included elbow release in 2 cases and ulnar neuropathy in 2. At final follow-up, the mean Mayo Elbow Performance Score was 92.5 (range, 75-100), and the mean range of motion was -21°/121.3°. Outcomes of CSF with concomitant olecranon fracture appeared to depend on CSF severity, and complications were more frequent than in isolated CSF. Given the small sample size and observational design, these findings should be regarded as preliminary and hypothesis-generating rather than definitive evidence favoring any particular method.

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.

Glucocorticoids (GC) comprise a cornerstone in the treatment of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV); however, prolonged GC exposure leads to substantial toxicity and immune system-related complications. Hence, identifying treatment strategies that enable early GC withdrawal while maintaining disease control is of clinical importance. To investigate the proportion and characteristics of patients achieving GC-free clinical remission (GFCR) 48 weeks after treatment initiation in patients with newly diagnosed microscopic polyangiitis (MPA) or granulomatosis with polyangiitis (GPA) and examine their long-term clinical outcomes (up to week 96). We conducted a retrospective cohort study using clinical data from a multicenter, nationwide registry in Japan comprising patients with newly diagnosed MPA or GPA and at least 48 weeks of follow-up. GFCR was defined as a Birmingham Vasculitis Activity Score (BVAS) of 0 with complete GC withdrawal. Univariable and multivariable logistic regression analyses were used to identify independent predictors of GFCR at week 48, and a sensitivity analysis using a matched cohort was performed to validate robustness. A total of 728 patients were enrolled in the registry, of whom 544 were followed for ≥ 48 weeks; among them, 29 (5.3%) achieved GFCR at week 48. Use of rituximab (RTX) for induction therapy and avacopan within 48 weeks were independently associated with achieving GFCR (multivariable analysis, model 1: RTX: odds ratio [OR]: 3.9, 95% confidence interval [CI]: 1.5–10.0; avacopan: OR: 24.3, 95% CI: 5.8–101.9; both p < 0.01). Conversely, methylprednisolone pulse therapy was associated with a lower likelihood of achieving GFCR (multivariable analysis, model 1: OR: 0.08, 95% CI: 0.02–0.44; p < 0.01). Patient’s demographic and baseline disease characteristics were not predictive of GFCR. In the long-term (weeks 48 through 96), the rates of death, relapse, and serious infection were similar regardless of GFCR status at week 48. The use of RTX for induction therapy and avacopan within 48 weeks is independently associated with achieving GFCR at week 48 in patients with MPA and GPA, supporting their potential as key components of GC-sparing strategies in AAV. Prospective studies are needed to confirm these results and optimize treatment algorithms to ensure disease control and minimize GC-related toxicity.

Hepatocellular carcinoma (HCC) exhibits a striking male predominance, particularly in Hepatitis B Virus (HBV) endemic regions. While lifestyle factors and estrogen protection are traditional explanations, they fail to fully account for this disparity. This review elucidates the molecular mechanisms driving this gender gap, focusing on the interplay between the Androgen Receptor (AR), viral replication, and the suppression of NKG2D-mediated immune surveillance. We synthesized experimental and clinical findings linking AR signaling, the viral protein HBx, and the regulation of NKG2D ligands (MICA/MICB). Current evidence identifies a positive feedback loop where AR enhances HBV replication, while HBx amplifies AR activity. Crucially, this axis systematically dismantles innate immunity: AR signaling represses MICA/B transcription via miRNA networks and upregulates ADAM metalloproteases, leading to ligand shedding and the release of soluble MICA (sMICA), effectively blinding Natural Killer (NK) cells. We propose that historical failures of anti-androgen monotherapy likely stemmed from ignoring this immune modulation. Consequently, targeting the AR-NKG2D axis represents a promising strategy to sensitize tumors to immunotherapy, suggesting that future therapeutic approaches should combine AR modulation with immune checkpoint inhibitors or shedding-blockade.

To investigate clinical outcomes, treatment, and survival rates of men aged ≥75 years with prostate cancer in Japan. The study used data from the Prostate Cancer Research International: Active Surveillance (PRIAS)-JAPAN, a nationwide, multicentre prospective cohort study of men with clinically localised prostate cancer managed with active surveillance (AS). The original eligibility criteria were clinical stage T1c-T2 disease, prostate-specific antigen (PSA) level ≤10 ng/mL, PSA density (PSAD) <0.20 ng/mL/mL, and Gleason Score ≤3 + 3 with two or fewer positive biopsy cores. In 2021, magnetic resonance imaging use expanded eligibility to include patients with a PSA level ≤20 ng/mL, PSAD <0.25 ng/mL/mL, and Gleason Score ≤3 + 4 with <50% of biopsy cores positive. PSA was monitored every 3-6 months, and biopsies were scheduled at 1, 4, 7, and 10 years, and every 5 years thereafter. The outcomes in those aged ≥75 years (older group) were compared with those aged <75 years (younger group). Of the 1274 eligible patients enrolled by 29 February 2024, 231 were in the older group and 1043 were in the younger group. In the older group, the median age at enrolment was 77 years. At diagnosis, patients in the older group had significantly larger prostate volumes, higher proportion of Gleason Score 3 + 4, and more T2 disease than those in the younger group. The protocol biopsy acceptance rate decreased over time (first: 82.9%, second: 63.6%, third: 42.2%, fourth: 22.4%), with no significant difference between age groups. The 10-year AS persistence rate in the older group was 8.8%. The overall survival was significantly lower in the older group than in the younger group (hazard ratio: 0.32, 95% confidence interval 0.14-0.74); however, the 10-year metastasis-free survival and cancer-specific survival rates in the older group were both 100%. In some patients aged ≥75 years an observation-focused management approach may be appropriate, in which AS is initiated as a structured monitoring phase with planned de-intensification and transition to watchful waiting, to prevent overtreatment while maintaining excellent cancer-specific outcomes.

Background:Orthopedic infections, including fracture-related infection and periprosthetic joint infection (PJI), remain difficult to eradicate because bacteria within biofilms exhibit high tolerance to systemic antibiotics. Conventional antibacterial strategies based on minimum inhibitory concentration often fail in the biofilm environment, where substantially higher antimicrobial concentrations are required. Continuous local antibiotic perfusion (CLAP) has emerged as a technique that enables sustained delivery of high local antibiotic concentrations directly to the infected site while providing continuous drainage using negative pressure wound therapy.Methods:This narrative review summarizes the principles, technical aspects, clinical indications, and reported outcomes of CLAP. A literature search of the MEDLINE database was conducted up to July 2025 using the term “continuous local antibiotic perfusion.” Clinical studies describing the use of CLAP in orthopedic infections, including case reports, case series, and retrospective studies, were reviewed. Perfusion strategies (iMAP, iSAP, iJAP, and TRAP), antibiotic regimens, safety considerations, and current limitations were analyzed.Results:CLAP enabled delivery of high local antibiotic concentrations exceeding the minimum biofilm eradication concentration while maintaining relatively low systemic exposure. Favorable outcomes for infection control, implant retention, and fracture union, were reported across various intractable infections, including fungal PJI. Complications such as transient elevations in serum antibiotic levels and renal dysfunction were reported but appeared to be infrequent. Although CLAP has shown potential utility in refractory infections, further high-quality studies with rigorous safety evaluations are required to strengthen the evidence base.Conclusion:CLAP is a promising adjunctive strategy for challenging orthopedic infections, offering targeted high-concentration antibiotic delivery with effective drainage. However, current evidence is limited to low-level studies. Prospective trials, standardized protocols, and long-term safety evaluations are needed to define its role in clinical practice.

Clinical remission in asthma has gained prominence as both a therapeutic goal and a research endpoint, although its operational definitions have varied. To harmonize Japanese practice with emerging global frameworks, the Japanese Society of Allergology (JSA) conducted a two-round modified Delphi survey to establish a consensus definition for inclusion in the 2024 Asthma Prevention and Management Guidelines (JGL 2024). In Round 1 (January 2024), 81 JGL 2024 guideline committee members representing adult and pediatric specialties were invited. Seventy-four percent agreed that clinical remission should be defined, and 50 % supported including both on- and off-treatment remission. Four core components emerged: absence of exacerbations, well-controlled symptoms, no continuous oral corticosteroid use, and optimization of pulmonary function. Round 2 refined operational thresholds for symptom control, adopting ACT ≥23 (C-ACT ≥23 for children) and ACQ ≤0.75, consistent with JGL's long-standing goal of achieving a truly symptom-free state without reliever use. Pulmonary function was defined as "optimization," encompassing normalization where achievable and stabilization when normalization is unlikely (e.g., airway remodeling), which received strong agreement. Collaboration between adult and pediatric experts affirmed clinical remission as a milestone toward off-treatment remission and potential cure, broadening its applicability across severities and age groups. This review further summarizes evidence supporting remission as an outcome of biologic therapy, its key predictors (e.g., smoking, obesity, disease duration), pediatric perspectives, and future directions. JGL 2024 formally adopts these criteria, providing a rigorous and pragmatic framework to advance patient-centered asthma care and reframe management toward disease modification and eventual cure.