Relationship Between the Frequency and Duration of Physical Therapy and Hospitalization-associated Disability Among Geriatric Patients with Heart Failure.

OBJECTIVE: The aim of this study was to examine the relationship between the frequency and duration of physical therapy (PT) and the development of hospitalization-associated disability (HAD) in hospitalized geriatric patients with heart failure (HF). METHODS: This single-center, retrospective, observational study included hospitalized patients with HF aged 65 years or older who had received PT. Data regarding demographics, comorbidities, laboratory findings, medications, rehabilitation, and activities of daily living (ADLs) status were collected from electronic medical records. Based on the average frequency and duration of PT, patients were divided into three groups: Group 1, ≥3 days/week and ≥120 minutes/week; Group 2, ≥3 days/week and <120 minutes/week; and Group 3, <3 days/week and <120 minutes/week. Logistic regression analysis was performed to identify the association between the average frequency and duration of weekly PT and the incidence of HAD. RESULTS: In all, 105 patients (mean age, 84.8 years; proportion of women, 59%) were enrolled in the study, and 43 (41.0%) patients exhibited HAD at discharge. In the multivariate logistic regression analysis, Group 2 (odds ratio [OR], 3.66) and Group 3 (OR, 6.71) had a significantly elevated risk of developing HAD using Group 1 as the reference, even after adjusting for age, ADLs before admission, cognitive function, and severity of HF. CONCLUSION: This study showed that a lower frequency and shorter duration of PT are associated with developing HAD in hospitalized geriatric patients with HF. However, further prospective studies are required to confirm these findings.

Prediction of Neurological Outcomes in Elderly Patients With Head Trauma Using the Geriatric Trauma Outcome Score: A Retrospective Observational Study.

Introduction Head trauma in elderly people is a problem in today's aging society. Elderly people are susceptible to head trauma because of their declining physical function; this tends to be severe. Outcome prediction is important in decision-making regarding treatment strategies; however, there is no unified method for predicting neurological outcomes in elderly patients with head trauma. Methods Elderly patients with head trauma admitted to the Japan Red Cross Narita Hospital between January 2019 and August 2023 were enrolled in this single-center, retrospective observational study. A favorable neurological outcome was defined as a cerebral performance category scale of 1 or 2. Multivariate logistic regression analysis and receiver operating characteristic curve analysis were performed to investigate the association between geriatric trauma outcome scores and outcomes and to evaluate the predictive value of geriatric trauma outcome scores. The primary outcome was a favorable neurological outcome at discharge, and the secondary outcome was in-hospital mortality. Results A total of 313 elderly patients with head trauma were eligible for analysis. Multivariate logistic regression analysis revealed that the geriatric trauma outcome score was significantly associated with a favorable neurological outcome at discharge (odds ratio 0.94, P <0.0001). In the receiver operating characteristic curve analysis, the geriatric trauma outcome score had a good predictive value for favorable neurological outcomes at discharge (area under the receiver operating characteristic curve 0.83). Conclusions The geriatric trauma outcome score had good predictive value for favorable neurological outcomes at discharge in elderly patients with head trauma and has the potential to aid in decision-making regarding treatment strategies for elderly patients with head trauma.

Transverse diameter of brainstem infarction is a strong predictor of miserable outcome after mechanical thrombectomy for acute basilar artery occlusion.

Although the efficacy of mechanical thrombectomy (MT) for acute basilar artery occlusion (ABAO) has been established in two randomized controlled studies, many patients have miserable clinical outcomes after MT for ABAO. Predicting severe disability prior to the procedure might be useful in determining the appropriateness of treatment interventions. Among the ABAO cases treated at 10 hospitals between July 2014 and December 2021, 144 were included in the study, all of whom underwent MRI before treatment. A miserable outcome was defined as a modified Rankin Scale (mRS) of 5-6 at 3 months. The associations between clinical, imaging, and procedural factors and miserable outcomes were evaluated. A miserable outcome was observed in 54 cases (37.5%). Multivariate analysis identified the National Institutes of Health Stroke Scale (NIHSS), transverse diameter of brainstem infarction, and symptomatic intracerebral hemorrhage as independent factors associated with miserable outcomes, with cutoff values of NIHSS 22 and transverse diameter of brainstem infarction 15 mm. Cases with a higher preoperative severity may result in miserable postoperative outcomes. Particularly, the transverse diameter of a brainstem infarction can be easily measured and serves as a useful criterion for determining treatment indications.

Contamination of sea surface water offshore the Tokai region and Tokyo Bay in Japan by small microplastics.

A nested double neuston net was prepared and used to collect samples from the surface of coastal waters around Japan to obtain information about the properties of both small microplastics (SMPs; <350 µm) and large microplastics (LMPs; >350 µm). The SMP concentrations ranged from 1000 to 5900 pieces m-3 in the open ocean and averaged approximately 3000 pieces m-3 in the inner part of Tokyo Bay. The SMP concentrations were around 20-60 times greater than the LMP concentrations. By analyzing the seawater, we obtained a microplastic size distribution that spanned 50-5000 µm. The LMPs mainly comprised packaging-related plastics, such as polyethylene (PE) and polypropylene, while the SMPs were dominated by paint-related plastics. SMPs derived from packaging materials (e.g., PE) may have gradually sank down from the sea surface when they were smaller than 600 µm.

Usefulness of Dapagliflozin for Nephrotic Syndrome Secondary to Diabetic Kidney Disease.

An 81-year-old woman with a medical history of type 2 diabetes mellitus and diabetic nephropathy was admitted with a diagnosis of multiple cerebellar infarctions. Proteinuria and leg edema were observed on the day after admission and diagnosed as nephrotic syndrome. Furosemide and spironolactone were started but showed no diuretic effect, and the renal function deteriorated. These agents were then replaced with dapagliflozin, which resulted in a positive diuretic effect and subsequent improvement of hypoalbuminemia and renal dysfunction. This case report demonstrates the utility of dapagliflozin for nephrotic syndrome to achieve a positive diuretic effect and improve hypoalbuminemia without deteriorating the renal function.

Successful Surgical and Endovascular Multidisciplinary Therapy for Mid-aortic Syndrome with Complicated Atherosclerotic Comorbidities in an Older Patient.

Mid-aortic syndrome (MAS) is a rare vascular disorder that causes refractory hypertension. A 76-year-old woman was hospitalized for acute heart failure (HF) with drug-resistant hypertension; other comorbidities included epigastric artery rupture, old myocardial infarction, an intraventricular thrombus, and a cerebral artery aneurysm. Angiography revealed severe narrowing of the descending aorta, which led to the diagnosis of MAS. Although intensive medical treatment improved her HF, optimal blood pressure (BP) could not be achieved. Percutaneous coronary intervention and surgical bypass for diseased aorta was then performed in two stages, resulting in the achievement of optimal BP and alleviation of HF.

Usefulness of Cardiac Magnetic Resonance in the Diagnosis of Löffler Endocarditis Secondary to Eosinophilic Granulomatosis with Polyangiitis.

A 40-year-old man who was diagnosed with bronchial asthma and eosinophilia was transferred to our hospital due to a worsening respiratory status. He was diagnosed with eosinophilic granulomatosis with polyangiitis (EGPA), and eosinophilic pneumoniae. Cardiac magnetic resonance (CMR) imaging indicated Löffler endocarditis. Treatment was initiated using intravenous methylprednisolone, cyclophosphamide, and heparin as anticoagulation therapy. Three months later, CMR showed the improvement of the LV myocardium. In this case, the early diagnosis of Löffler endocarditis by CMR could prevent systemic embolism and CMR was useful for assessing the curative effects of steroid and immunosuppressant therapy.

Registry of Japanese patients with atrial fibrillation focused on anticoagulant therapy in the new era: The RAFFINE registry study design and baseline characteristics.

BACKGROUND: The management of atrial fibrillation (AF) has evolved with the development of direct oral anticoagulants (DOACs), but data on their clinical effectiveness and safety outside clinical trial settings are limited. METHOD: The RAFFINE registry is an observational, multicenter, prospective registry of Japanese patients with AF, designed to follow clinical events over 3 years. Patient enrollment was conducted from 2013 to 2015 at university hospitals, general hospitals, and private clinics to ensure inclusion of a broad spectrum of representative AF patients. The primary outcome events in this study will be ischemic stroke, systemic embolism, and major bleeding. RESULT: We enrolled 3901 ambulatory patients with AF from 4 university hospitals and 50 general hospitals/clinics in Japan. The mean patient age was 72.6 years and 68.5% were male. The type of AF was paroxysmal in 37.8%, persistent in 9.3%, and permanent in 51.7%. Major coexisting diseases were hypertension (72.7%), diabetes mellitus (30.3%), congestive heart failure (23.8%), history of ischemic stroke or transient ischemic attack (15.1%), and coronary artery disease (13.7%). Of the entire cohort, 44.6% were treated with warfarin and 43.0% were treated with DOACs. The prescription of DOACs exceeded that of warfarin in the general hospitals and clinics. Risk scores such as CHADS2 score, CHA2DS2-VASc score, and HAS-BLED score were higher in patients at university hospitals than in patients at general hospitals or clinics. CONCLUSION: The RAFFINE registry at baseline described the current status of anticoagulation therapy in Japan and long-term follow-up data will identify how outcomes vary between stratified groups in patients with AF in the DOAC era (UMIN Clinical Trials Registry UMIN000009617).

[Clinical Characteristics of Craniocervical Junction Arteriovenous Fistulas].

OBJECTIVE: Craniocervical junction arteriovenous fistulas(CCJ-AVFs)are extremely rare lesions that may result in both subarachnoid hemorrhage(SAH)and myelopathy. Diagnosis of CCJ-AVF is difficult and may be delayed due to variable clinical features and a spectrum of neuroradiological findings. To elucidate the clinical characteristics of CCJ-AVF, we analyzed the clinical symptoms, neuroimaging findings, and the results of surgical treatment in five patients. RESULTS: Among the five patients, four were diagnosed with dural AVFs, and the remaining patient was diagnosed with radicular AVF. Two of the five patients presented with SAH, and the rest presented with myelopathy. In both the SAH patients, the initial digital subtraction angiography(DSA)failed to reveal the AVFs, and a definitive diagnosis was made only after repeated DSAs. In two of the three myelopathy patients, the diagnosis was delayed because of nonspecific chronic neurological symptoms which resembled a thoracolumbar lesion. Four patients underwent shunt occlusion through direct surgery and demonstrated favorable outcomes. One myelopathy patient, however, demonstrated abrupt onset, associated with progressive neurological deterioration, which resulted in poor prognosis. The magnetic resonance imaging(MRI)findings, which included intramedullary high intensity on a T2 weighted image, flow void, and varix at the cervical cord, were specific for the myelopathy patients. CONCLUSION: A thorough 4-vessel DSA study, including the cervical region, is mandatory for SAH patients whose clots are predominantly in the posterior fossa, and repeated DSA must be considered in cases of unknown origin. CCJ-AVF may cause myelopathy, with symptoms such as urinary dysfunction and/or paraparesis. Screening with a cervical MRI is useful for detecting CCJ-AVF in cases of myelopathy. Emergency radical treatment must be attempted for those patients demonstrating abrupt onset associated with symptoms of progressive deterioration, such as respiratory dysfunction or bulbar palsy.

[Hemorrhagic Onset of Subependymal Giant Cell Astrocytoma Associated with Tuberous Sclerosis:A Case Report and Review of Literature].

We report on a case of subependymal giant cell astrocytoma(SEGA)in a patient with tuberous sclerosis(TSC)that presented with intratumoral hemorrhage and acute hydrocephalus. Initial treatment was external ventricular drainage to control the intracranial pressure;however, the tumor increased in size due to recurrent hemorrhage. Subsequently, the tumor was successfully removed via the transcortical-transventricular approach without neurological deterioration. Although intratumoral hemorrhage is extremely rare in patients with SEGA, subsequent acute hydrocephalus resulting from obstruction of the foramen of Monro will be fatal if prompt surgical treatment is not available. Careful and periodical radiographic examination of the central nervous system will be mandatory in patients with TSC, especially in those who have subependymal nodules(SEN)or SEGA around the foramen of Monro. Radical surgical removal should be considered before they become symptomatic.

Expansion in calcific lesions and overall clinical outcomes following bioresorbable scaffold implantation optimized with intravascular ultrasound.

OBJECTIVES: This study aimed to investigate clinical outcomes following bioresorbable scaffold (BRS) optimized with intravascular ultrasound (IVUS), and furthermore expansion of BRS in calcific lesions. BACKGROUND: Although IVUS use has contributed to improved clinical outcomes with metallic stent implantation, it is unclear if this is also true with regards to BRS, especially in calcified lesions. METHODS: Between May 2012 and April 2015, 291 lesions in 198 patients were treated with BRS with IVUS use. We evaluated overall clinical outcomes at 1-year and investigated the expansion and eccentricity index of BRS amongst quadrants categorized by calcium arc (CA) every 90-degrees. RESULTS: The rates of major adverse cardiac events were 5.4% (at 6 months) and 10.7% (at 12 months). TLR was observed in 3.1% at 6-month and 7.5% at 12-month follow up. Although there was a significant difference among quadrants regarding to eccentricity of calcium (0°â‰¦CA < 90°: 0.82 ± 0.09, 90°â‰¦CA < 180°: 0.75 ± 0.12, 180°â‰¦CA < 270°: 0.78 ± 0.11, and 270°â‰¦CA≦360°: 0.79 ± 0.09, ANOVA P = 0.002), the BRS expansion index [minimal scaffold area (MSA) divided by BRS area expanded at a nominal pressure] was comparable between quadrants. CONCLUSIONS: The use of IVUS to optimize BRS implantation results in favorable clinical outcomes even for complex lesions. Although eccentric calcium distribution resulted in asymmetric expansion of BRS, the final MSA was comparable irrespective of calcium distribution. © 2016 Wiley Periodicals, Inc.

Clinical outcomes of a real-world cohort following bioresorbable vascular scaffold implantation utilising an optimised implantation strategy.

AIMS: It has become apparent that, in comparison to metallic stents, bioresorbable vascular scaffolds (BVS) require specific implantation techniques. The aim of this study was to investigate outcomes following BVS implantation using a dedicated strategy for optimal deployment. METHODS AND RESULTS: Four hundred consecutive lesions (264 patients) treated with the Absorb BVS were analysed. All procedures were performed based on the following principles: 1) aggressive lesion preparation; 2) high-pressure post-dilation; and 3) a low threshold for intravascular imaging. The majority of target lesions (74.8%) were type B2 or C lesions. Predilation (97.3%) and post-dilation (99.8%) were performed in almost all cases. The mean post-dilation pressure was 21±5 atm, and the total scaffold length per patient was 53.2±32.5 mm. Intravascular imaging was performed in the majority of cases (85.8%) and, when utilised after post-dilatation, a further intervention was required in 24.5% of lesions. The cumulative target lesion failure rates were 7.9% at one year and 11.6% at two years. Definite/probable scaffold thrombosis occurred in three patients (1.2% at one and two years). CONCLUSIONS: Clinical outcomes following implantation of current-generation BVS, in a real-world population with a high prevalence of complex lesions, were acceptable when utilising our optimised implantation strategy.

Clinical Outcomes After Implantation of Overlapping Bioresorbable Scaffolds vs New Generation Everolimus Eluting Stents.

INTRODUCTION AND OBJECTIVES: There is limited evidence on procedural and clinical outcomes in patients treated with overlapping bioresorbable scaffolds vs overlapping everolimus-eluting stents. We evaluated the outcomes of propensity-matched patients treated with overlapping scaffolds vs everolimus-eluting stents. METHODS: After propensity matching, 70 consecutive stable angina patients treated with overlapping bioresorbable scaffolds and 70 patients treated with overlapping new generation everolimus stents were included in this study. The primary outcome was the 1-year rate of major adverse cardiovascular events, defined as the composite of all-cause mortality, nonprocedural myocardial infarction, and target-vessel revascularization. RESULTS: Patients in the 2 groups had similar age (scaffold vs stent: 64.5 ± 10.3 vs 66 ± 9.7 years; P=.381), sex, diabetes, previous cardiovascular history, and SYNTAX score (scaffold vs stent: 18.6 ± 9.2 vs 19.4 ± 10.4; P=.635). Postprocedural acute gain was significantly lower in patients treated with scaffolds (1.82±0.66 vs 2.03±0.68mm; P=.033). At 1-year follow up, the estimated major adverse cardiovascular event rate was not significantly different between the 2 groups (scaffold vs stent: 14.5% vs 14.6%; Plog-rank=.661). Similarly, no significant differences were seen in 1-year rates of target vessel (scaffold vs stent: 14.5% vs 10%; Plog-rank=.816) or target lesion revascularization (scaffold vs stent: 9.7% vs 8.3%; Plog-rank=.815). CONCLUSIONS: Treating long lesions with overlapping scaffolds is feasible with acceptable 1-year outcomes.

Clinical outcomes following "off-label" versus "established" indications of bioresorbable scaffolds for the treatment of coronary artery disease in a real-world population.

AIMS: Our aim was to investigate one-year outcomes in patients treated with bioresorbable scaffolds (BRS) for "off-label" versus currently "established" indications. METHODS AND RESULTS: Consecutive patients treated with BRS between May 2012 and September 2014 in two centres were retrospectively recruited. Patients who met inclusion criteria as defined by the ABSORB III study were allocated to the established indication group (ESTG; 21 patients with 35 lesions) and the remaining patients to the off-label group (OFLG; 168 patients with 225 lesions). Target vessel failure (TVF) and ischaemia-driven target lesion revascularisation (id-TLR) at one year were evaluated in both groups. Patients in the OFLG had a higher prevalence of diabetes mellitus and longer lesion length. Predilatation, post-dilatation and intracoronary imaging were conducted in the majority of patients. At one-year follow-up, TVF (0% vs. 7.8%, p=0.32) and id-TLR (0% vs. 4.5%, p=0.31) occurred only in the OFLG with no adverse events in the ESTG. Definite stent thrombosis occurred in two OFLG patients (1.3%). CONCLUSIONS: In a real-world setting, the majority (88.9%) of patients were treated with BRS for off-label indications. Off-label use of BRS appears to be associated with an acceptable occurrence of outcomes considering the greater complexity of this patient group.

The use of a scoring balloon for optimal lesion preparation prior to bioresorbable scaffold implantation: a comparison with conventional balloon predilatation.

AIMS: Meticulous lesion preparation prior to bioresorbable vascular scaffold (BVS) implantation has been strongly recommended. The aim of this study was to investigate if there was a benefit associated with scoring balloon use in lesion preparation in comparison to conventional balloons prior to implantation of a BVS. METHODS AND RESULTS: Of the lesions treated with BVS between May 2012 and July 2014, 155 lesions in the conventional balloon group and 29 lesions in the scoring balloon group were included. Procedures without predilatation and those which utilised cutting balloon or rotational atherectomy devices were excluded. Complex (B2/C lesion: 76.1% vs. 93.1%; p=0.028), restenotic (5.2% vs. 17.2%; p=0.036) and calcified (36.1% vs. 79.3%; p<0.001) lesions were more common in the scoring balloon group. Compared to the conventional balloon group, the scoring balloon group demonstrated better procedural IVUS outcomes with regard to both expansion index (defined as scaffold lumen area divided by final post-dilatation balloon cross-sectional area, 0.71 vs. 0.86; p<0.001) and eccentricity index (defined as minimal scaffold diameter divided by maximal scaffold diameter, 0.78 vs. 0.84; p<0.001). The occurrence of ischaemia-driven target lesion revascularisation at one year was similar (6.1% vs. 7.1%; p=0.87). CONCLUSIONS: Lesion preparation for complex lesions using a scoring balloon appeared to facilitate optimal sizing and radially concentric expansion of BVS.

Hybrid strategy with a bioresorbable scaffold and a drug-coated balloon for diffuse coronary artery disease: the "no more metallic cages" multicentre pilot experience.

AIMS: Our aim was to assess the feasibility and results of a hybrid approach with a bioresorbable scaffold (BRS) plus a drug-coated balloon (DCB) for the treatment of diffuse coronary artery disease (CAD). METHODS AND RESULTS: A retrospective analysis was performed on consecutive patients with diffuse de novo or in-stent restenosis treated with BRS implantation (larger proximal segment) and DCB inflation (smaller distal segment or bifurcation side branch). Endpoints were procedural success, then ischaemia-driven target lesion revascularisation (ID-TLR) and BRS/DCB segment thrombosis rates at follow-up. A total of 42 consecutive patients were treated with the hybrid strategy. Mean patient age was 62±1.02 years, while 12 (28.6%) patients were diabetics. Mean BRS and DCB length were 28.0±5.1 mm and 25.8±8.8 mm, respectively. Procedural success was obtained in all patients, but three (7.3%) patients required bail-out scaffolding for DCB-related dissection. At a median follow-up of 12 months (IQR: 6-18), there were no cases of cardiac death, target vessel myocardial infarction, or BRS/DCB segment thrombosis. ID-TLR occurred in two (4.7%) BRS-treated segments. CONCLUSIONS: Our data in consecutive patients with diffuse CAD suggest that a hybrid strategy using BRS and DCB in different segments of the diseased vessel is feasible and associated with encouraging clinical outcomes.

Comparison of Clinical and Angiographic Outcomes After Bare Metal Stents and Drug-Eluting Stents Following Rotational Atherectomy.

Few studies have investigated the clinical outcomes of rotational atherectomy (RA) prior to and during the drugeluting stent (DES) era. The goal of this study was to assess the long-term outcome after RA followed by DES and bare metal stent (BMS) implantation in complex calcified coronary lesions and to compare the outcomes among various DESs.This was a single center retrospective observational study. Consecutive 406 patients who underwent elective RA followed by BMS or DES implantation at our institution from 2001 to 2011 were included. This study compared the long-term outcomes after treatment with RA among BMS and 3 different DESs (sirolimus-eluting stent, paclitaxel-eluting stent, and everolimus-eluting stent) implantation.The mean follow-up period was 4.6 years. Patients with DES were older and exhibited more vessel disease, longer lesion length, and smaller vessel size. Patients with BMS had a significantly higher rate of target lesion revascularization, restenosis, and larger late lumen loss than those with DES. Composite events including mortality, ACS, and target vessel revascularization were significantly higher in the BMS-RA group than in the DES-RA group. After adjustment, BMS remained an independent predictor of MACE and ACS plus death in patients treated with RA. However, there were no significant differences in late lumen loss, restenosis rate, and MACE among the 3 DES.The combination of DES-RA has a favorable effect in both the angiographic and clinical outcomes compared with BMS-RA. However, no significant differences in late loss and events rates were observed among the 3 DES groups.

Increased cystatin C levels as a risk factor of cardiovascular events in patients with preserved estimated glomerular filtration rate after elective percutaneous coronary intervention with drug-eluting stents.

Chronic kidney disease (CKD) is an important risk factor for coronary artery disease (CAD) and cardiovascular events. Cystatin C (CysC) has been proposed as a sensitive marker for CKD. However, the predictive value of CysC for cardiovascular events in CAD patients with preserved estimated glomerular filtration rate (eGFR) is unclear. We enrolled 277 consecutive patients undergoing elective percutaneous coronary intervention with sirolimus-eluting stents (SES). Patients with an eGFR ≤60 ml/min/1.73 m(2) were excluded. Serum CysC levels were measured immediately before SES implantation. Major adverse cardiac and cerebrovascular events (MACCE) were defined as cardiovascular death, acute coronary syndrome, stroke, and hospitalization because of congestive heart failure. After a median follow-up of 63 months, 29 patients had MACCE. The subjects were divided into 2 groups based on median serum CysC levels and eGFR (0.637 mg/L and 72.43 ml/min/1.73 m(2), respectively). Kaplan-Meier curves showed that the high CysC group had a significantly higher occurrence of MACCE than the low CysC group (p = 0.006), although a low level of eGFR was not significantly associated with an increased risk for occurrence of MACCE. Multivariate analysis revealed that serum CysC levels were an independent predictor of MACCE [hazards ratio: 1.30 per 0.1 mg/L (1.01-1.63), p = 0.038]. These data suggested that serum CysC level is an independent predictor of MACCE, even in patients with preserved eGFR after elective SES implantation.