Coronary CT angiography (CCTA) has become widely used as a tool that enables the noninvasive evaluation of coronary artery stenosis and plaque. Evidence of the accuracy of CCTA for the diagnosis of angina has been established and its incremental value combined with the coronary artery calcium score obtained by plain CT has been proven. Regarding evaluation of plaques, while there have been reports that CCTA is useful for detecting vulnerable plaques associated with a high incidence of acute coronary syndrome, problems remain in relation to subjective and quantitative evaluation. In addition, although coronary atherosclerosis is often detected clinically in asymptomatic high-risk patients, evidence has not yet been obtained that CCTA can be used for risk assessment in asymptomatic patients. Although severe coronary artery calcification was a major problem that interfered with assessment of the severity of stenosis, the recent development of subtraction CCTA imaging has overcome this problem in some cases. As for radiation exposure, this has been reduced considerably by new developments in equipment and imaging protocols, as well as advances of reconstruction techniques. Thanks to remarkable advances in CT scanners and the development of new imaging and analysis techniques, CCTA is expected to become even more useful for the diagnosis of coronary artery disease and re-stratifying risk in many patients, and its applications will expand further in the future.
Catheter intervention is constantly evolving and has developed with increasing patient needs because it is less invasive than cardiovascular surgery. Catheter intervention can be used for various fields such as coronary artery disease (CAD), peripheral arterial disease (PAD), and structural heart disease (SHD) through the development of a variety of devices and techniques for each specific disease. Thus, catheter intervention has become the first choice in many fields because of its proven efficacy and safety. Although every patient may not be suitable, catheter-based treatment should be chosen for the best strategy based on the medical condition of the individual patient and their long-term prognosis.
Asymptomatic abdominal aortic aneurysm (AAA) is a common and potentially life-threatening condition. It should be repaired before its rupture, because ruptured AAA is nearly uniformly fatal. Elective repair is the most effective management for rupture prevention. Two methods of aneurysm repair are currently available, open surgery and endovascular aneurysm repair (EVAR). Open surgery is capable of treating various complexities of aneurysms, but EVAR is preferred in many cases due to its minimal invasiveness. Although it is not indicated for all patients, various advancements in endovascular treatment strategies allow for active treatment with EVAR in our department. This review article describes these advancements in EVAR.
Recently, the incidence of atherosclerotic diseases, including coronary artery disease, ischemic stroke, aortic aneurysm, and peripheral artery disease, has increased in Japan. Atherosclerotic diseases develop as a result of various environmental and lifestyle factors such as an imbalance of dietary habits, low physical activity, active/passive smoking, and heavy alcohol consumption. These life style choices are the primary causes of increased blood pressure, glucose intolerance, and dyslipidemia, resulting in the initiation and progression of atherosclerosis. Therefore, the essential approaches for preventing atherosclerotic diseases should be based on the principle of lifestyle management for maintaining adequate food balance, increasing physical activity, stopping active/passive smoking, and avoiding excessive alcohol consumption. In this review, we will discuss the important points of lifestyle modification for preventing atherosclerotic diseases. In addition, we will also propose an “ultimate” practice for achieving health and longevity.
Juntendo University Hospital’s Infection Hotline system provides year-round phone consultation service for inquiries from each hospital department. The most common incoming call is, as expected, “We have a patient with a fever! ” However, at present there are many physicians who say “We have not done a blood culture,” and “As a stop-gap, we started the patient on an antibiotic as of yesterday.” In fact, reaching a diagnosis of a nosocomial fever without having performed the first work-up for a fever (i.e., two sets of blood culture, chest X-rays taken in two directions, and general urinalysis and smear culture) is like reaching a diagnosis of myocardial infarction without performing an ECG. The root of these problems is a lack of awareness of the importance of the initial response to febrile patients. Ill-considered administration of an antibiotic can result in delayed (perhaps indefinitely) diagnosis of a patient with infectious endocarditis. In fact, since the causative organism of infectious endocarditis is unknown, in most cases there has been earlier administration of an antibiotic. We carried out a collaborative retrospective clinical study at 17 hospitals affiliated with the Japanese Society of Hospital General Medicine to investigate the diagnostic methods used for causative diseases of fevers of unknown origin (FUO). We found that, even for patients with classical FUO, blood cultures were not performed in 13.2% of the patients with FUO. To exclude bacteremia, it is necessary to perform two sets of blood culture using blood drawn when the patient has not been administered an antibiotic for at least 48 h. When a catheter-related blood infection is suspected, simultaneous culture of the catheter tip and blood should be submitted. In our hospital, the rate of collection of two sets of blood culture and the rate of submission of only catheter culture are reported for each department. The problems with blood inflammatory markers (e.g., WBCs, CRP, ESR, etc.) are that they do not identify the site of inflammation and the assay data do not always match the severity. For inflammation at sites remote from blood, such as meningitis, abscess, etc., the CRP does not always increase. The blood procalcitonin value has been reported to have high specificity for bacterial infections, but evaluations of its clinical usefulness have not shown consistent results. Especially in patients with classical FUO, procalcitonin values were not found to correlate with the causative diseases. Inflammatory markers cannot be relied upon to exclude bacterial infections.
We describe the case of a 32-year-old man with C-reactive protein (CRP) elevation of unknown origin who was transferred to Juntendo University Hospital on suspicion of systemic viral infection. Whole-body computed tomography (CT) showed enlargement of the para-aortic, common iliac and axillary lymph nodes. Laboratory data showed elevated levels of immunoglobulin (Ig)G4. Axillary lymph node biopsy was performed to investigate suspected IgG4-related disease, revealing marked infiltration of IgG4-positive plasma cells. Various imaging modalities and laboratory tests have recently become available. However, most neoplastic diseases need invasive testing such as biopsy to reach a definitive diagnosis. Clinicians should not hesitate to obtain pathological specimens to definitively diagnose patients with suspected neoplastic disease.
Objective: Previous studies investigating the link between nicotine and energy expenditure (EE) have shown a 6-10% increase in EE after nicotine intake using gum or spray, which increase blood level acutely. However, the effects of transdermal nicotine patches, which increase nicotine blood levels gradually, are still unknown. Thus, we studied the effects of nicotine patches on EE using human calorimeter. Design: EE was measured over a 10-hour period with a human calorimeter using a crossover design to assess whether transdermal nicotine patches increase EE. Subjects were 8 adult, male non-smokers. Interventions: All subjects followed the same schedule for measurement: enter the human calorimeter at 6:45 PM, sleep from 11:00 PM to 6:00 AM, and rest on a chair from 6:00 AM to 7:00 AM. EE and Respiratory quotient (RQ) were calculated from measurements from the human calorimeter. Results: There were no significant differences in EE during the sleeping period between experimental and control conditions (Nicotine: 1.08±0.08 kcal/min, Control: 1.06±0.08 kcal/min; p=0.161). EE while sitting at rest 10 h after nicotine patch application was significantly increased by 0.07 kcal/min (5.8%) in the nicotine condition compared to the control condition (Nicotine: 1.22±0.10 kcal/min, Control: 1.15±0.12 kcal/min; p=0.035). Conclusion: Results from this study indicate that EE may increase after transdermal nicotine patch exposure when blood nicotine levels have reached an estimated maximum.
Objective: We aimed to reveal the declining status of autopsy rate in Japanese university hospitals during the last 34-year period, to draw attention to the importance of autopsy. Methods: Autopsy related data from 1979 to 2012 in all Japanese university hospitals were collected and analyzed on annual basis under categories of Juntendo University Hospital, Japanese university hospitals, public university hospitals and private university hospitals separately. Trends of changes in autopsy rate from 1979 to 2012 were plotted and compared between the groups. Results: The autopsy rate in Juntendo University Hospital was maintained at the levels of 50-60% until 1986, then started to decline steadily and reached to 9.7% in 2012. Regression coefficient of the autopsy rate during the 34-year period was -0.0173. The mean autopsy rate of all university hospitals in Japan was maintained at 45% until 1983, then started declining steadily and reached to 6.8% in 2012. Of these hospitals, the mean autopsy rate in public hospitals was still kept at 45% in 1985 but continued declining to 9.3% in 2012, while in private hospitals it reached to 45% in 1983 and kept declining to only 5.6% in 2012. Conclusion: The steady decline of the autopsy rate in university hospitals in Japan began early 1980’; this trend still continues, and the autopsy rate declined to 6.8% in 2012. We should work to prevent the decline of autopsy rate furthermore in Japanese university hospitals.
Objective: Report on the activity of a medical relief team from Shizuoka Hospital during the 2016 Kumamoto earthquake. Design: Narrative report Results: Two staff members from our department were assigned to the Aso Disaster Recovery Organization (ADRO) at Aso Medical Center. Their main activities included summarizing reports from the medical teams at refugee stations, managing the needs and supplies of medical requests, assigning missions to the medical relief teams, inputting data on the chronology of the ADRO into the Emergency Medical Information System, taking minutes on the daily evening meeting, and reporting these activities to the headquarters of medical relief at the Kumamoto Prefectural Office. Conclusion: The staff members learned the importance and difficulty of managing a medical administrative supervisory section temporarily established during a natural disaster.