Tip Detection-Antegrade Dissection and Re-Entry With New Puncture Wire in CTO Intervention: Revolution Through 3D-Wiring.

Background: The authors devised the tip detection (TD) method and developed AnteOwl WR intravascular ultrasound to standardize intravascular ultrasound-based 3-dimensional wiring for intraplaque tracking in chronic total occlusion (CTO)-percutaneous coronary intervention (PCI). The TD method also allowed antegrade dissection and re-entry (ADR). Combining TD-ADR with Conquest Pro 12 Sharpened Tip (CP12ST) wire, a new ADR wire with the strongest penetration force developed to date, enabled re-entry anywhere except calcification sites. Objectives: This study investigated the efficacy and feasibility of TD-ADR by comparison of procedural outcomes with Stingray-ADR in CTO-PCI. Methods: Twenty-seven consecutive CTO cases treated by TD-ADR with CP12ST wire between August 2021 and April 2023 and 27 consecutive CTO cases treated by Stingray-ADR with Conquest 8-20 (CP20) wire between March 2018 and July 2021 were retrospectively enrolled as the TD-ADR by CP12ST wire group and Stingray-ADR by CP20 wire group, respectively, from 4 facilities that could share technical information on these procedures. Results: The success rate of the ADR procedure was significantly improved (27 of 27 cases [100%] vs 18 of 27 cases [67%], respectively; P = 0.002) and total procedural time was significantly reduced (median procedural time: 145.0 [Q1-Q3: 118.0-240.0] minutes vs 185.0 [Q1-Q3: 159.5-248.0] minutes, respectively; P = 0.028) in the TD-ADR by CP12ST wire group compared to the Stingray-ADR by CP20 wire group. There were few in-hospital major adverse cardiac and cerebrovascular events or no complications in either group. Conclusions: TD-ADR by CP12ST wire can standardize highly accurate ADR in CTO-PCI.

Effects of self-monitoring using an accelerometer on physical activity of older people with long-term care insurance in Japan: a randomized controlled trial.

PURPOSE: This study aimed to investigate the effects of a self-monitoring intervention to promote an increase in physical activity, as measured by step count, and reduce sedentary behavior in older people covered by the long-term care insurance system (LTCI) in Japan. METHODS: This was a randomized controlled trial conducted at a daycare center from October 2022 to January 2023. Fifty-two older adults with LTCI who were able to walk with or without aids were assigned to an intervention (n = 26) group and control (n = 26) group. During the 5-week follow-up period, the intervention group received education on physical activity and self-monitoring such as goal setting, self-management and feedback. The primary outcome was step count, and the secondary outcome was sedentary behavior. RESULTS: Participants who completed the study to the end of the 5-week follow-up and drop-out participants for whom outcome data were available were included in the final analysis of 57 participants, n = 24 (79.8 ± 8.8 years, male 25.5%) in the intervention group and n = 23 (82.5 ± 8.5 years, male 39.1%) in the control group. Comparisons between the two groups at baseline showed no significant differences. In the results of a two-way mixed analysis of variance (ANOVA) including 2 (group: control, intervention) × 2 (term: baseline, 5-week follow-up) factors, an interaction was observed in the number of steps, sedentary behavior, and light physical activity (p < 0.05). CONCLUSION: Self-monitoring of physical activity using an accelerometer may be effective in increasing the number of steps and light physical activity and in reducing sedentary behavior in older people with LTCI. CLINICAL TRIAL REGISTRATION: UMIN000052044, registered on 2023/08/29.

Myeloid Zfhx3 deficiency protects against hypercapnia-induced suppression of host defense against influenza A virus.

Hypercapnia, elevation of the partial pressure of CO2 in blood and tissues, is a risk factor for mortality in patients with severe acute and chronic lung diseases. We previously showed that hypercapnia inhibits multiple macrophage and neutrophil antimicrobial functions and that elevated CO2 increases the mortality of bacterial and viral pneumonia in mice. Here, we show that normoxic hypercapnia downregulates innate immune and antiviral gene programs in alveolar macrophages (AMØs). We also show that zinc finger homeobox 3 (Zfhx3) - a mammalian ortholog of zfh2, which mediates hypercapnic immune suppression in Drosophila - is expressed in mouse and human macrophages. Deletion of Zfhx3 in the myeloid lineage blocked the suppressive effect of hypercapnia on immune gene expression in AMØs and decreased viral replication, inflammatory lung injury, and mortality in hypercapnic mice infected with influenza A virus. To our knowledge, our results establish Zfhx3 as the first known mammalian mediator of CO2 effects on immune gene expression and lay the basis for future studies to identify therapeutic targets to interrupt hypercapnic immunosuppression in patients with advanced lung disease.

Longitudinal changes in skin perfusion pressure after endovascular therapy in patients with chronic limb-threatening ischemia.

PURPOSE: The skin perfusion pressure (SPP) increases after endovascular treatment (EVT) for up to 1 month, although changes beyond 1 month remain unreported. This study aimed to investigate the changes in the SPP over time after EVT. MATERIALS AND METHODS: This was a single-center, prospective, observational study. We included patients with chronic limb-threatening ischemia who underwent EVT between January 2019 and July 2022. We evaluated the SPP after EVT monthly for up to 3 months and compared the changes in the SPP between patients with different comorbidities. Moreover, we investigated the independent predictors of recurrent foot ischemia using a multivariate analysis. RESULTS: Overall, 87 patients were included in the study. The mean preprocedural dorsal and plantar SPP was 33.9 ± 14.7 and 33.4 ± 13.1 mmHg, respectively. After the procedure, the SPP significantly increased at 1 month but decreased during months 2 and 3 (the dorsal SPP at 1, 2, and 3 months was 59.6 ± 20.3, 48.3 ± 20.9, and 39.7 ± 14.7, respectively, p < 0.01; the plantar SPP at 1, 2, and 3 months was 57.3 ± 18.2, 48.2 ± 15.6, and 40.5 ± 15.3, respectively, p < 0.01). Changes in the SPP did not differ among patients with different comorbidities. The multivariate analysis revealed that severe infrapopliteal calcification was an independent predictor of recurrent foot ischemia (odds ratio, 3.8; 95% confidence interval, 1.1-13.4; p = 0.04). CONCLUSION: The SPP after EVT significantly increased at 1 month and decreased monthly for up to 3 months. Severe infrapopliteal calcification was the sole predictor of foot ischemia recurrence. Meticulous follow-up after EVT and regular hemodynamic examinations are important.

Feasibility and impact of extra-vascular ultrasound-guided endovascular treatment for infrapopliteal artery occlusive disease.

PURPOSE: This study aimed to examine the feasibility and impact of extra-vascular ultrasound (EVUS)-guided intervention for infrapopliteal (IP) artery occlusive disease. MATERIALS AND METHODS: A retrospective analysis was performed using data collected from patients who underwent endovascular treatment (EVT) for IP artery occlusive disease between January 2018 and December 2020 at our institution. A total of 63 consecutive de novoocclusive lesions were compared according to the recanalization method utilized. Propensity score matching analysis was performed to compare the clinical outcomes of the methods utilized. The prognostic value was analyzed based on the technical success rate, distal puncture rate, radiation exposure, amount of contrast media, postprocedural skin perfusion pressure (SPP), and procedural complication rate. RESULTS: Eighteen matched pairs of patients were analyzed using propensity score-matched analysis. Radiation exposure was significantly lower in the EVUS-guided group than in the angio-guided group, with 135 and 287 mGy (p = 0.04) exposure on average, respectively. There were no significant differences between the two groups in terms of technical success rate, distal puncture rate, the amount of contrast media, postprocedural SPP, and procedural complication rate. CONCLUSION: EVUS-guided EVT for IP occlusive disease achieved a feasible technical success rate and significantly reduced radiation exposure.

Myeloid Zfhx3 Deficiency Protects Against Hypercapnia-induced Suppression of Host Defense Against Influenza A Virus.

Hypercapnia, elevation of the partial pressure of CO 2 in blood and tissues, is a risk factor for mortality in patients with severe acute and chronic lung diseases. We previously showed that hypercapnia inhibits multiple macrophage and neutrophil antimicrobial functions, and that elevated CO 2 increases the mortality of bacterial and viral pneumonia in mice. Here, we show that normoxic hypercapnia downregulates innate immune and antiviral gene programs in alveolar macrophages (AMØs). We also show that zinc finger homeobox 3 (Zfhx3), mammalian ortholog of zfh2, which mediates hypercapnic immune suppression in Drosophila , is expressed in mouse and human MØs. Deletion of Zfhx3 in the myeloid lineage blocked the suppressive effect of hypercapnia on immune gene expression in AMØs and decreased viral replication, inflammatory lung injury and mortality in hypercapnic mice infected with influenza A virus. Our results establish Zfhx3 as the first known mammalian mediator of CO 2 effects on immune gene expression and lay the basis for future studies to identify therapeutic targets to interrupt hypercapnic immunosuppression in patients with advanced lung diseases.

Clinical effective use of Conquest Pro 12 Sharpened Tip for chronic total occlusion intervention: A series of three case reports.

A new chronic total occlusion (CTO) guidewire, Conquest Pro 12 Sharpened Tip (CP12ST), has a stronger penetration force than the original CP12 and a deflection effect that it does not have. The CP12ST enables us to advance into hard plaque that has not ever penetrated, which might change CTO treatment as shown in three cases.

Transposition of the superficial femoral artery combined with ultrasound-guided returning-venous cannulation as a last resort for vascular access in a multi-complicated hemodialysis patient.

A superficialized artery as a blood-drawing route could be an option for vascular access (VA) in hemodialysis patients with cardiac failure, vessel damage, steal syndrome, and venous hypertension, and it could be a secondary VA option in those with repetitive vascular access troubles, routinely requiring a blood-returning venous route. The brachial artery is preferably used for superficialization due to the benefit of its appropriate diameter for cannulation, procedural ease of surgery under local anesthesia, and usable subcutaneous vein for blood-returning route in the upper limb. The superficial femoral artery (SFA) has also been reported as a candidate for arterial transposition; however, its subcutaneous transposition could have difficulties in requiring general anesthesia and securing blood-inflow-venous routes. We experienced a multi-complicated hemodialysis patient who had intractable tunneled-cuffed catheter-related bacteremia and right atrial thrombosis, low cardiac function with bilateral proximal bifurcation of the brachial artery at the axilla, and damaged cutaneous veins in the upper limb. Herein, we report a case of successful superficialization of the SFA under ultrasound-guided regional anesthesia combined with local anesthesia and intravenous sedation, which could be feasible as a blood-drawing route with ultrasound-guided ipsilateral greater saphenous vein cannulation during chronic hemodialysis. Assisted by ultrasound-guided venous cannulation in the ipsilateral lower limb, cutaneous repositioning of the SFA could be a viable and acceptable option for VA in hemodialysis patients with a multitude of complications, wherein the possibilities of VAs of arteriovenous access, arterial superficialization using vessels in the upper extremity, or artificial devices should be eliminated.

Intractable arteriovenous access-related pain relieved after a single, pain-free hemodialysis session under selective block of the sensory nerves in the upper limb: A psychosocial factorial case.

Intractable arteriovenous access (AVA)-related pain can not only lead to abandonment of a well-functioning AVA, but can also cause hemodialysis (HD) patients to be unwilling to accept, interrupt, or withdraw from HD. Such pain primarily derives from nociceptive and neuropathic factors caused by mechanical stimulation of needle cannulation; however, this might be related to psychosocial factors making it difficult for patients to accept their dependency on HD. Furthermore, the pain can be complicated by the interaction of biological and psychosocial factors, which hampers appropriate pain management and treatment. However, there have been few investigations pertaining to this matter. Herein, we describe the case of an HD patient who experienced chronic refractory AVA-related pain during a 32-month period of HD sessions, which occasionally caused treatment interruption. After clinical inquiry, physical evaluation, and ultrasonographic assessment of the blood circulation and cutaneous nerves in the ipsilateral upper limb to the radiocephalic arteriovenous fistula in the anatomical snuffbox, we diagnosed the patient with primarily psychosocially driven pain in consultation with an experienced pain clinician. A single, pain-free HD session under ultrasound-guided sensory nerve blocks in the upper limb markedly relieved her pain, followed by HD sessions with subtle but acceptable pain. This report provides insights into the mechanism underlying the vicious cycle of AVA-related pain, including the psychosocial aspects that might trigger such pain, as well as into the importance of treating such pain to improve the patient's quality of life, and underscores the need for cooperation of experts engaged in HD and pain management.

Anesthetic effect of ultrasound-guided block of the musculocutaneous nerve during endovascular treatment of dysfunctional radiocephalic arteriovenous fistulas.

BACKGROUND: Delivering requisite and minimal anesthesia for endovascular treatment (EVT) of dysfunctional arteriovenous fistulas (AVFs) under the target nerve block can achieve reasonable analgesia. We evaluated the anesthetic efficacy of ultrasound (US)-guided selective block of the musculocutaneous nerve (MCN) during the EVT of runoff venous strictures in the forearm through the radiocephalic (RC)-AVF at the wrist or the anatomical snuff box and analyzed the factors inhibiting the analgesia achieved under the MCN block. METHODS: We enrolled 30 adult patients undergoing hemodialysis who had received 78 EVT sessions in an outpatient clinic mainly for long and/or multiple outflow-venous strictures in the forearm under US-guided blocks of the MCN, which provides sensory innervation to the anterolateral forearm where the cephalic vein courses. We assessed patients' pain during balloon dilations using the Wong-Baker FACES® Pain Rating Scale (WBFRS) and evaluated the factors increasing the pain (WBFRS score ⩾4), including patient characteristics, dilated strictures, additional nerve blocks, and types of balloon catheters. RESULTS: In 25 EVT sessions (32.1%) out of 78 sessions, patients complained of stronger pain (WBFRS score ⩾4), while in the other 53 sessions (67.9%), presented with no pain and slight pain (WBFRS score = 0 or 2). Univariate analysis clarified that dilation of the AVF anastomosis, presence of dilated stenosis >4 cm, and a single block of the MCN or its sensory terminal significantly triggered more pain (p < 0.05). Consequently, multivariate analysis of all the factors with p < 0.1 in the univariate analysis, including multiple dilated stenosis sites, demonstrated that dilation of the AVF anastomosis significantly caused severe pain despite the anesthesia of the MCN block (p < 0.05). CONCLUSION: US-guided selective block of the MCN could be a leading anesthetic option for EVT for multiple long stenoses of the cephalic vein draining through the RC-AVF in the wrist or anatomical snuff box.

Differences in Health-Related Quality of Life in Older People with and without Sarcopenia Covered by Long-Term Care Insurance.

Background: As a result of the increase in older people covered by long-term care insurance (LTCI), prevention of sarcopenia and maintenance and improvement of health-related quality of life (HRQOL) have become important themes. This study aimed to clarify both the differences in HRQOL in older people with and without sarcopenia covered by LTCI and the correlation between HRQOL and physical function. Methods: Participants were 101 older people with LTCI at a daycare center in Japan. We investigated clinical factors using the EuroQol five-dimension three-level questionnaire (EQ-5D-3L). Analysis was by unpaired t-test, Mann−Whitney U test, chi-square test, analysis of covariance, Pearson's correlation coefficient, and Spearman's rank correlation coefficient. Results: Compared to the no sarcopenia group (n = 40), the sarcopenia group (n = 24) had significantly lower body mass index, skeletal muscle mass index, gait speed, EQ-5D-3L, and adjusted EQ-5D-3L (p < 0.05). The EQ-5D-3L showed a significant correlation with handgrip strength in the sarcopenia group (p = 0.02) and significant correlations with gait speed and one-leg standing time (both, p = 0.01) in the no sarcopenia group. Conclusion: We clarified differences in HRQOL in older people with and without sarcopenia covered by LTCI. This information on the interrelationship between HRQOL and physical function may help maintain and improve HRQOL in these people.

Effect of Crack Patterns in Calcified Plaque on Lumen Area after Stenting for a Severe Calcified Coronary Artery (from the Optical Frequency Domain Imaging-Guided Percutaneous Coronary Artery Intervention for Calcified Lesion Registry).

Background: Severely calcified coronary artery stenting remains a challenge due to stent thrombosis, target vessel failure, and higher mortality. Moreover, optimal vessel preparation for calcified plaque with a crack formation pattern has not been established yet. We aimed to identify the effect of crack formation in calcified plaque in the coronary artery on the lumen area after stenting. Materials and Methods: We evaluated 50 consecutive patients undergoing drug-eluting stent implantation for severely calcified lesions by using optical frequency domain imaging (OFDI) (54 lesions); we analyzed OFDI image slices every 3 mm and evaluated the segments of 242 images in those who had the arc of calcium more than 180°. Crack formation in calcified plaque was classified into three types: type 0, no cracks; type 1, no dissection between calcified plaque and vessel wall; and type 2, any dissection between calcified plaque and vessel wall. Results: Type 2 had a significantly higher area expansion ratio between preballooning and poststenting (type 0, 196% (interquartile range (IQR), 163-244); type 1, 210% (IQR, 174-244); type 2, 237% (IQR, 203-294)). Conclusions: The dissection between calcified plaque and vessel wall was a significant factor affecting lumen area expansion after stenting.

Physical Activity and Sarcopenia in Community-Dwelling Older Adults with Long-Term Care Insurance.

The present study aimed to clarify the difference in physical activity (PA) due to sarcopenia in community-dwelling older adults with long-term care insurance (LTCI). This was a cross-sectional study that investigated data of 97 consecutive community-dwelling older Japanese adults with LTCI who underwent rehabilitation at one day care center in Japan from November 2018 to May 2019. Sarcopenia was determined according to criteria of the Asian Working Group for Sarcopenia. Unpaired t-test, Mann-Whitney U test, chi-square test and analysis of covariance were used to compare participant characteristics and clinical parameters between the older adults with and without sarcopenia. A receiver operating characteristic (ROC) curve was constructed to determine the cut-off value of PA for sarcopenia. The sarcopenia group (n = 20) had significantly lower body mass index (BMI), skeletal muscle mass index, gait speed, and PA than those in the no sarcopenia group (n = 28) (p < 0.05). After adjustment for BMI and sex, the sarcopenia group showed significantly lower PA than the no sarcopenia group. Findings showed that the cut-off value of PA indicating sarcopenia by ROC curve analysis was 1494.4 steps/day (p < 0.05); this value may aid in identifying sarcopenia in older adults with LTCI.

[Role of a Pharmacist in AST Activity and Pharmaceutical Education in a Mid-sized Japanese Community Hospital].

At small or mid-sized medical institutions, such as Japanese community hospitals, adequate infectious disease physicians (IDP) are lacking, mainly due to shortages of full-time pharmacists and IDPs who support antimicrobial stewardship team (AST) activities. With our hospital AST, we developed a multidisciplinary approach based on the interim reports of culture results or detected resistant bacteria for physicians, which are written by pharmacists and clinical laboratory technicians. At the AST conference, a pharmacist works as a chairman and reviews abstracts of cases which need to be discussed. We performed a retrospective analysis of the process and outcome of AST implementation, and introduced the use of reduction data for our hospital, obtained from Japan Surveillance for Infection Prevention and Healthcare Epidemiology (J-SIPHE). This program is important for pharmacists to promote the diagnostic process and comprehensive judgment necessary for bedside practice with infectious disease cases. We offer opportunities for pharmacy students to participate in the AST conference to learn how pharmacists consult with doctors about diagnosis and treatment. At present, the cooperation between AS and diagnostic stewardship (DS) has been emphasized, and improvements in a pharmacist's overall judgment regarding infectious disease cases are required to appropriate antimicrobial use. In addition, improving communication skills is essential for building a multidisciplinary approach. Regardless of the size of the facility, the role of pharmacists in AST should be implemented for the guidance of pharmacy students, which will help develop and secure future human resources at the facility.

Long-term (beyond 5 years) clinical impact of Xience everolimus-eluting stent implantation.

OBJECTS: We aim at examining the long-term clinical outcome after Xience everolimus-eluting stent (X-EES) implantation. BACKGROUND: Long-term clinical outcomes beyond 5 years after X-EES implantation remain unclear. METHODS: This retrospective study has collected data from 1184 consecutive patients, corresponding to 1463 lesions, who were treated with X-EES alone in the Nagoya Heart Center between January 2010 and December 2013. The primary endpoint was the 10-year cumulative incidence of target lesion failure (TLF), defined as cardiac death, target vessel myocardial infarction (MI), and clinically indicated target lesion revascularization (TLR). Definite/probable stent thrombosis (ST) was evaluated as a secondary outcome. RESULTS: At 10 years, the cumulative incidence of TLF was recorded to be 12.4%, whereas that of cardiac death, target vessel MI, and clinically indicated TLR was at 4.4%, 4.1%, and 7.8%, respectively. The cumulative rate of definite/probable ST was observed to remain low (0.3% at 30 days; 0.3% at 1 year; 0.6% at 5 years; and 1.1% at 10 years). In the multivariate analysis, the risk factors of TLF were insulin-treated diabetes (hazard ratio (HR), 1.93; 95% confidence interval (CI), 1.13-3.29; P = .02), left ventricular dysfunction (HR, 2.28; 95% CI, 1.43-3.62; P < .01), hemodialysis (HR, 2.22; 95% CI, 1.39-3.56; P < .01), prior percutaneous coronary intervention (HR, 1.68; 95% CI, 1.18-2.41; P < .01), peripheral vascular disease (HR, 1.70; 95% CI, 1.07-2.69; P < .01), severe calcification (HR, 2.08; 95% CI, 1.36-3.09; P < .01), and in-stent restenosis (HR, 2.93; 95% CI, 1.64-4.89; P < .01). CONCLUSIONS: The incidence rates of the long-term adverse effects after X-EES implantation, such as late TLR and ST, were determined to be low in this study; however, they increased over time until 10 years after stent implantation.

Prevalence and Related Factors of Sarcopenia in Community-dwelling Elderly with Long-term Care Insurance.

BACKGROUND AND OBJECTIVE: The purpose of this investigation was to examine the prevalence, related factors, and cut-off value of body mass index for sarcopenia in community-dwelling elderly covered by long-term care insurance. METHODS: Design was a cross-sectional study, in which113 consecutive community-dwelling elderly with long-term care insurance who underwent rehabilitation at a daycare center in Japan from January 2016 to January 2018, those who were aged ≥65 years old and could walk were included. Those in whom skeletal muscle mass index could not be measured were excluded. The determination of sarcopenia was made according to the criteria of the Asian Working Group for Sarcopenia. We analyzed the data with the unpaired t-test, χ2 test, logistic regression analysis, and receiver operating characteristic curves. RESULTS: The 99 elderly meeting the criteria were included and divided into the sarcopenia group (n=36) and no sarcopenia group (n=63). The prevalence was 36.4%. The sarcopenia group was significantly older and had lower body mass index, skeletal muscle mass index, and grip strength than the group without sarcopenia (p <0.05). Age and body mass index were extracted as significant sarcopenia- related factors (p <0.05). The cut-off value of body mass index for sarcopenia was 22.6 kg/m2. CONCLUSION: The prevalence of sarcopenia in the elderly in the long-term care insurance region was 36.4%, and age and body mass index were extracted as sarcopenia-related factors. The cut-off value of body mass index for sarcopenia was 22.6 kg/m2.