Objective Steatotic liver disease is increasingly prevalent, and patients with this condition who have a poor albumin-bilirubin (ALBI) score are at a high risk of liver-related complications and all-cause mortality. We e...Objective Steatotic liver disease is increasingly prevalent, and patients with this condition who have a poor albumin-bilirubin (ALBI) score are at a high risk of liver-related complications and all-cause mortality. We evaluated the factors associated with progression to a poor ALBI score in individuals with hepatic steatosis over a 5-year follow-up in a health check-up population. Patients and Methods In this longitudinal cohort study, 5,038 individuals with hepatic steatosis at baseline and a low ALBI score (<-2.77) were followed for 5 years. Clinical and metabolic factors associated with a high ALBI score with hepatic steatosis at the end of the follow-up were analyzed using a multivariate logistic regression analysis. Results Of the 5,038 participants with hepatic steatosis and a low baseline ALBI score in 2018 with data of ALBI score in 2023, 682 (13.5%) were classified into the High group (ALBI score ≥-2.77) in 2023. A multivariate logistic regression analysis demonstrated that being overweight or obese at baseline was independently associated with a high ALBI score with hepatic steatosis at the 5-year follow-up (OR: 1.550, p<0.001). Changes in overweight or obese status from 2018 to 2023 were significantly associated with the prevalence of a high ALBI score with hepatic steatosis in 2023 (p<0.001). The prevalence was highest among participants who were overweight or obese at both time points (14.6%). Conclusion Being overweight or obese with hepatic steatosis was associated with a worse ALBI score.
Nanri K, Sakakura K, Jinnouchi H
… +10 more, Taniguchi Y, Yamamoto K, Tsukui T, Hatori M, Kasahara T, Watanabe Y, Ishibashi S, Hasegawa H, Seguchi M, Fujita H
Objective Changes in the left ventricular ejection fraction (LVEF) after an ST-segment elevation myocardial infarction (STEMI) are associated with subsequent ischemic events and mortality. This study aimed to investigate...Objective Changes in the left ventricular ejection fraction (LVEF) after an ST-segment elevation myocardial infarction (STEMI) are associated with subsequent ischemic events and mortality. This study aimed to investigate the determinants of a mid-term improvement and deterioration of LVEF in patients with STEMI. Methods We included 585 patients with STEMI who had a modified Simpson EF both at index admission and mid-term (6-12 months) follow-up. We divided the patients into the EF deterioration group (≥10% decrease in EF, n=38), the EF improvement group (≥10% increase in EF, n=127), and the unchanged EF group (<10% change in EF, n=420). Results Baseline EF was significantly associated with an EF deterioration (OR1.472 per 5.0 % increase, 95%CI:1.231-1.761, p<0.001). The hemoglobin levels were inversely associated with an EF deterioration (OR0.760 per 1.0 g/dL increase, 95%CI: 0.632-0.914, p=0.003). The peak creatine kinase levels were significantly associated with an EF deterioration (OR1.034 per 100 U/L increase, 95%CI: 1.019-1.050, p<0.001). A female sex was significantly associated with an EF improvement (OR2.118, 95%CI: 1.222-3.671, p=0.008). The pulse rate was inversely associated with an EF improvement (OR0.887 per 10 bpm increase, 95%CI: 0.791-0.995, p=0.041). Infarct-related artery with LMT-left anterior descending artery was significantly associated with an EF improvement (OR1.661, 95%CI: 1.009-2.734, p=0.046). Time interval between the Baseline EF and follow-up EF was significantly associated with an EF improvement (OR1.008, 95%CI: 1.002-1.013, p=0.006). The peak creatine kinase level (OR0.981 per 100 U/L increase, 95%CI: 0.970-0.992, p<0.001) and baseline EF (OR0.568, 95%CI: 0.500-0.645, p<0.001) was inversely associated with an EF improvement. Conclusion A higher baseline EF, lower hemoglobin levels at admission, and higher peak creatine kinase levels were associated with a mid-term deterioration of LVEF, whereas a female sex, LM-LAD as the infarct-related artery, and the time interval between baseline and follow-up EF were associated with a mid-term improvement in LVEF. Knowledge of these determinants may help to refine the post-STEMI risk stratification and therapeutic strategies.
The management of ischemic heart disease has traditionally focused on obstructive epicardial coronary artery disease. However, a substantial proportion of patients with angina and objective myocardial ischemia have no si...The management of ischemic heart disease has traditionally focused on obstructive epicardial coronary artery disease. However, a substantial proportion of patients with angina and objective myocardial ischemia have no significant coronary stenosis. Vasospastic angina (VSA; also termed coronary spastic angina [CSA] ) and coronary microvascular dysfunction (CMD) are now recognized as major mechanisms underlying angina/ischemia with non-obstructive coronary arteries (ANOCA/INOCA). These evolving concepts have been progressively incorporated into the clinical practice guidelines. Japanese guidelines have played a pioneering role in establishing diagnostic criteria for VSA through coronary spasm provocation testing. More recently, international guidelines have emphasized CMD as a distinct clinical entity and recommended coronary functional assessment using both invasive and non-invasive modalities. This review summarizes the historical evolution of the guideline-based perspectives on VSA and CMD and discusses their implications for contemporary clinical practice.
Heparin-induced thrombocytopenia (HIT) is a potentially fatal complication of heparin therapy, particularly during extracorporeal mechanical support requiring anticoagulation. We report the case of a 57-year-old woman wi...Heparin-induced thrombocytopenia (HIT) is a potentially fatal complication of heparin therapy, particularly during extracorporeal mechanical support requiring anticoagulation. We report the case of a 57-year-old woman with fulminant myocarditis complicated by acute kidney injury who was transferred while receiving extracorporeal membrane oxygenation and continuous renal replacement therapy with unfractionated heparin. After transfer, a rapid platelet decline and repeated circuit occlusions raised a strong suspicion of HIT based on the 4Ts score. Heparin was replaced with nafamostat mesilate or argatroban, and HIT antibodies were detected. Both bleeding and thrombotic complications occurred during intensive care, thus reflecting the complexity of managing critically ill patients receiving multiple extracorporeal mechanical supports.
Objective This study aimed to clarify the background of non-communicable disorders, including hypertension (HTN), liver dysfunction, obesity, and hyperuricemia, which could be related to the incidence of diabetes, using...Objective This study aimed to clarify the background of non-communicable disorders, including hypertension (HTN), liver dysfunction, obesity, and hyperuricemia, which could be related to the incidence of diabetes, using a cohort of newly enrolled students (aged 18-20 years) at a university in Gifu, Japan. Methods We analyzed data collected over a 12-year period from April 2010 to March 2022 at a university in Gifu, Japan. Materials From the above dataset, we selected individuals who did not have diabetes at admission and who underwent a follow-up examination four years later at the time of their progression to a master's course (n=3,242). Results Five of these participants (0.15%) developed probable diabetes (elevated plasma glucose or HbA1c, or both) and three (0.09%) developed definite diabetes (elevated plasma glucose and HbA1c) by the time of their second visit. A logistic regression analysis of the association between preceding HTN and the risk of new-onset diabetes demonstrated a significant crude odds ratio of 53.7 for probable diabetes and 35.0 for definite diabetes. Crude odds ratios for obesity, liver dysfunction, and hyperuricemia were calculated for probable diabetes, but not for definite diabetes. Conclusion Preceding non-communicable disorders, especially HTN, are remarkable risk factors for diabetes in young adults.
Acquired lecithin-cholesterol acyltransferase (LCAT) deficiency is a rare cause of a marked reduction in high-density lipoprotein cholesterol (HDL-C). We report a 75-year-old Japanese woman with a progressive decline in...Acquired lecithin-cholesterol acyltransferase (LCAT) deficiency is a rare cause of a marked reduction in high-density lipoprotein cholesterol (HDL-C). We report a 75-year-old Japanese woman with a progressive decline in HDL-C from 64 to <2 mg/dL over five years. Laboratory tests showed a markedly decreased LCAT activity and protein levels with anti-LCAT autoantibodies, whereas a genetic analysis revealed no LCAT mutations. Lipidomic profiling demonstrated free cholesterol accumulation, the loss of HDL subclasses, and TG-rich LDL particles. No underlying autoimmune disease was identified. This case highlights the importance of a lipid subclass analysis and the recognition of acquired LCAT deficiency in patients with a marked HDL-C deficiency.
Advanced-stage Parkinson's disease (PD) and myasthenia gravis (MG) share overlapping clinical features, including dysphagia, dysarthria, fatigue, and fluctuating symptoms. When PD precedes MG, these manifestations may be...Advanced-stage Parkinson's disease (PD) and myasthenia gravis (MG) share overlapping clinical features, including dysphagia, dysarthria, fatigue, and fluctuating symptoms. When PD precedes MG, these manifestations may be misinterpreted as a progression of PD, potentially leading to an underdiagnosis of MG. Although the coexistence of PD and MG is rare, it nevertheless requires careful consideration. Furthermore, the pharmacological treatments for these two disorders differ substantially, and medications used for one condition may exacerbate the other condition. We report a patient with PD complicated by MG, in whom anticholinergic treatment with biperiden led to the exacerbation of MG-related symptoms, ultimately resulting in the diagnosis of MG.
Objectives To investigate the efficacy of switching from oral to subcutaneous methotrexate (MTX) in alleviating MTX-related intolerance symptoms in Japanese patients with rheumatoid arthritis (RA). Methods This non-rando...Objectives To investigate the efficacy of switching from oral to subcutaneous methotrexate (MTX) in alleviating MTX-related intolerance symptoms in Japanese patients with rheumatoid arthritis (RA). Methods This non-randomized, prospective, observational study included Japanese patients with RA who experienced intolerance symptoms despite combination therapy with folic acid. Patients were assigned to switch to subcutaneous MTX (switching group) or continue oral MTX (continuation group). The primary endpoint was the change in patient nausea visual analog scale (VAS) from baseline to week 13. The secondary endpoints were the change in patient fatigue VAS and the change in RA activity from baseline to week 13 before and after adjusting for patient characteristics. Results Of the 60 patients enrolled, 28 were assigned to the switching group and 32 to the continuation group. In the adjusted analysis, the switching group showed a significantly greater reduction in patient nausea VAS and a numerically greater reduction in patient fatigue VAS than that in the continuation group. Changes in the RA activity were similar between the groups. Multivariate logistic regression analyses demonstrated that switching to subcutaneous MTX significantly improved the patient-reported nausea. Conclusions Switching from oral to subcutaneous MTX reduced intolerance symptoms compared with oral MTX in Japanese patients with RA.
A woman in her late 50s with advanced lung adenocarcinoma, initially EGFR mutation-negative on single-plex testing, received cytotoxic chemotherapy and immune checkpoint inhibitors. After 1 year and 8 months, she develop...A woman in her late 50s with advanced lung adenocarcinoma, initially EGFR mutation-negative on single-plex testing, received cytotoxic chemotherapy and immune checkpoint inhibitors. After 1 year and 8 months, she developed peritoneal carcinomatosis. Third-line erlotinib led to an improvement in her performance status (PS 3 to 2 in 10 days) and a marked reduction in peritoneal carcinomatosis after 4 months, with the effect lasting for 9 months. Immunohistochemistry of the ascitic fluid revealed an EGFR L858R mutation. This case highlights the possibility of false-negative results on initial testing and suggests the potential benefit of EGFR-TKIs, even in EGFR mutation-negative cases at diagnosis.
Cerebral cortical encephalitis (CCE) represents a distinct phenotype of myelin oligodendrocyte glycoprotein (MOG) antibody-associated disease. The most frequent presentation of CCE is acute encephalitis. We describe two...Cerebral cortical encephalitis (CCE) represents a distinct phenotype of myelin oligodendrocyte glycoprotein (MOG) antibody-associated disease. The most frequent presentation of CCE is acute encephalitis. We describe two cases with diverse clinical courses that posed diagnostic challenges. The cases included a 24-year-old man with a seizure-predominant smoldering course over several months, initially diagnosed with focal epilepsy, and a 27-year-old woman with nonspecific headache and fever without any neurological deficits or seizures. Brain magnetic resonance imaging (MRI) in both cases showed cortical fluid-attenuated inversion recovery hyperintensity with adjacent subcortical hypointensity. CCE may present with diverse clinical courses, and characteristic MRI findings were pivotal for making an accurate diagnosis.
Objective In cancer care, the patient burden encompasses not only physical and psychological toxicity, but also financial and time toxicity. Multiple myeloma (MM) requires ongoing therapy. However, the impact of time tox...Objective In cancer care, the patient burden encompasses not only physical and psychological toxicity, but also financial and time toxicity. Multiple myeloma (MM) requires ongoing therapy. However, the impact of time toxicity on treatment decision-making is unclear. Methods We retrospectively reviewed the medical records of the patients diagnosed with MM between April 1, 2010, and March 31, 2023, at a single center. The collected data included M-protein type, age at diagnosis, sex, Eastern Cooperative Oncology Group performance status (ECOG PS), employment status, commute time, and receipt of ixazomib, lenalidomide, and dexamethasone (IRd) therapy. Results Of the 97 identified patients, 74 with relapsed/refractory MM were included in the main analysis. The mean commute time was 74.5 min for patients who received IRd therapy and 46.3 min for those who did not. When the patients were stratified by commute time (≥65 min, Long group), 52.9% of the long group received IRd compared with 19.3% in the not-long group. In multivariable logistic regression, the longer commute time was significantly associated with IRd use (odds ratio, 4.63; 95% CI, 1.45-15.4; p = 0.009). Conclusion Our findings suggest that longer commute times may be associated with treatment selection, thus highlighting the time burden as an important factor in real-world decision-making for MM.
Malignant lymphoma in ulcerative colitis (UC) is uncommon, and diffuse large B-cell lymphoma (DLBCL) without immunosuppressive or biologic therapy is particularly rare. We report a case of an Epstein-Barr virus-negative...Malignant lymphoma in ulcerative colitis (UC) is uncommon, and diffuse large B-cell lymphoma (DLBCL) without immunosuppressive or biologic therapy is particularly rare. We report a case of an Epstein-Barr virus-negative patient with long-standing left-sided UC in remission who developed rapidly enlarging synchronous DLBCL lesions in the ascending and sigmoid colon. The diagnosis was made endoscopically and histologically, and treatment with Pola-R-CHP followed by rituximab achieved a complete remission. A literature review showed that most UC-associated lymphomas are EBV-positive DLBCL related to immunosuppression. Although malignant lymphoma is rare in patients with UC, it can occur and therefore should be considered during surveillance colonoscopy.
We report a rare case in which CD5-positive diffuse large B-cell lymphoma, not otherwise specified (DLBCL NOS), and CD5-positive intravascular large B-cell lymphoma (IVLBCL) were identified in different samples from the...We report a rare case in which CD5-positive diffuse large B-cell lymphoma, not otherwise specified (DLBCL NOS), and CD5-positive intravascular large B-cell lymphoma (IVLBCL) were identified in different samples from the same patient. A 76-year-old man presented with widespread lymphadenopathy and a prostatic mass on imaging. A prostatic biopsy revealed CD5+ DLBCL NOS. Notably, he had undergone transurethral resection of the prostate (TURP) four months prior because of urinary retention. A retrospective histological review of the TURP specimen revealed CD5-positive IVLBCL. This case suggests that DLBCL may initially manifest with an IVLBCL-like growth pattern at an extremely early stage.
True hemothorax as an initial manifestation of prostate cancer has not yet been reported. An adult male presented with acute right-sided pleural effusion. Diagnostic thoracentesis yielded hemorrhagic pleural fluid, with...True hemothorax as an initial manifestation of prostate cancer has not yet been reported. An adult male presented with acute right-sided pleural effusion. Diagnostic thoracentesis yielded hemorrhagic pleural fluid, with a pleural fluid hematocrit ≥ 50% of the peripheral blood hematocrit, confirming hemothorax. Contrast-enhanced computed tomography revealed prostate enlargement, pulmonary nodules, and pleural masses. Transbronchial biopsies of the pulmonary nodule confirmed metastatic adenocarcinoma positive for prostate-specific antigen and negative for thyroid transcription factor-1, thus establishing the diagnosis of metastatic prostate adenocarcinoma. Androgen deprivation therapy improved the hemothorax. Bloody pleural effusion warrants hematocrit measurement and evaluation for malignancy, including metastatic prostate cancer.
Idiopathic multicentric Castleman disease with TAFRO syndrome (iMCD-TAFRO) rarely involves the lungs. We report the case of a 50-year-old man with persistent gastrointestinal symptoms who was found to have bilateral grou...Idiopathic multicentric Castleman disease with TAFRO syndrome (iMCD-TAFRO) rarely involves the lungs. We report the case of a 50-year-old man with persistent gastrointestinal symptoms who was found to have bilateral ground-glass opacities on chest CT. Despite prominent imaging abnormalities, a bronchoscopic lung biopsy revealed no inflammatory changes in the lungs. Bone marrow and lymph node biopsies confirmed the diagnosis of iMCD-TAFRO. Treatment with tocilizumab and corticosteroids resulted in clinical remission for 3 years. Pulmonary manifestations likely reflect secondary fluid retention rather than primary lung disease. This illustrates the importance of performing comprehensive tissue evaluations beyond a lung biopsy when systemic symptoms are accompanied by pulmonary findings.
Delayed inflammatory complications after the coil embolization of intracranial aneurysms appearing years after angiographic cure are rare. We describe a patient who underwent coil embolization for a ruptured internal car...Delayed inflammatory complications after the coil embolization of intracranial aneurysms appearing years after angiographic cure are rare. We describe a patient who underwent coil embolization for a ruptured internal carotid-posterior communicating artery aneurysm at 61 years of age and developed recurrent transient neurological symptoms seven years later. A cerebrospinal fluid analysis revealed marked neutrophilic pleocytosis and hypoglycorrhachia, strongly suggesting infectious meningitis. However, extensive tests for infection and autoimmune reactions were negative. Magnetic resonance imaging revealed perianeurysmal vasogenic edema with intra-aneurysmal enhancement. Corticosteroid therapy resulted in a rapid clinical and radiological resolution of the symptoms. This case highlights a rare delayed inflammatory complication that mimics infectious meningitis.
Hirose K, Matsumoto Y, Ohashi K
… +17 more, Tokunaga M, Kubota N, Terajima Y, Matsumoto K, Watanabe M, Nakadoi T, Nawachi S, Hayashi K, Miyawaki Y, Watanabe H, Katsuyama E, Katsuyama T, Takano-Narazaki M, Sada KE, Nasu Y, Nishida K, Wada J
Osteoporosis is a major complication of rheumatoid arthritis (RA), caused by glucocorticoid use and chronic inflammation, leading to an increased fracture risk. We report a rare case of bilateral insufficiency calcaneal...Osteoporosis is a major complication of rheumatoid arthritis (RA), caused by glucocorticoid use and chronic inflammation, leading to an increased fracture risk. We report a rare case of bilateral insufficiency calcaneal fractures presenting with talalgia and swelling in a patient with RA who was initially misdiagnosed as having a disease relapse and treated with escalated biological disease-modifying antirheumatic drugs. Subsequent foot magnetic resonance imaging (MRI) revealed bone marrow edema and bilateral fracture lines in the posterior calcaneus without synovitis. This case highlights that talalgia in patients with RA may reflect insufficiency fractures rather than disease relapse, and appropriate imaging evaluation is therefore important for an early and accurate diagnosis.
IgG4-related disease (IgG4-RD) is characterized primarily by elevated serum IgG4 levels and it can affect multiple organs. We herein present a case of IgG4-RD affecting the kidneys, right submandibular gland, lungs, medi...IgG4-related disease (IgG4-RD) is characterized primarily by elevated serum IgG4 levels and it can affect multiple organs. We herein present a case of IgG4-RD affecting the kidneys, right submandibular gland, lungs, mediastinal lymph nodes, and retroperitoneum, despite normal serum IgG4 levels. In this case, a histopathological examination of the kidneys and submandibular glands revealed marked lymphoplasmacytic infiltration and a relatively small number of IgG4-positive plasma cells. The patient was diagnosed with IgG4-RD and showed a favorable response to corticosteroid therapy. This case highlights the importance of a histopathological evaluation for diagnosing IgG4-RD, particularly in patients with normal serum IgG4 levels.