Search

Oral anticoagulant therapy for atrial fibrillation (AF) has changed dramatically. Direct oral anticoagulant (DOAC) therapy is administered by general practitioners and specialists. However, the beneficial long-term effects and safety of DOACs have not been well investigated in real-world clinical practice.The ASSAF-K (a study of the safety and efficacy of OAC therapy in the treatment of AF in Kanagawa), a prospective, multi-center, observational study, was conducted to clarify patient characteristics, status of OAC treatment, long-term outcomes, and adverse events, including cerebrovascular disease, bleeding, and death.A total of 4014 patients were enrolled (hospital: 2500 cases; clinic: 1514 cases). The number of patients in the final dataset was 3367 (mean age, 72.6 ± 10.0 years; males, 66.3 %). CHAThis multi-center registry demonstrated the long-term outcome in patients with AF treated with and without OACs and suggests that DOAC therapy is safe and beneficial in hospitals and clinics.

Objective To examine the continuation of antibody prevalence status after 12 months and background factors in antibody-positive subjects following asymptomatic infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Methods We initially determined the SARS-CoV-2 anti-nucleocapsid protein immunoglobulin G (anti-N IgG) antibody prevalence in 1,603 patients, doctors, and nurses at 65 medical institutions in Kanagawa Prefecture, Japan. We then obtained consent from 33 of the 39 subjects who tested positive and performed follow-up for 12 months. Results Follow-up for up to 12 months showed that a long-term response of the anti-N IgG antibody could be detected in 6 of the 33 participants (18.2%). The proportions with hypertension, using an angiotensin-receptor blocker, and without a drinking habit were higher among the participants with a long-term anti-N IgG antibody response for up to 12 months than among those without a long-term antibody response. Conclusions The proportion of individuals with subclinical COVID-19 who continuously had a positive result for the anti-N IgG antibody at 12 months was low.

To prevent further spread of coronavirus disease 2019 (COVID-19), the Japanese government announced a state of emergency, resulting in major stress for the population. The aim of this study was to investigate a possible association between changes in daily stress and blood pressure (BP) in Japanese patients. We retrospectively investigated 748 patients with chronic disease who were treated by the Sagamihara Physicians Association to determine changes in stress during the COVID-19 state of emergency from 7 April to 31 May 2020. During the state of emergency, office BP significantly increased from 136.5 ± 17.5/78.2 ± 12.0 to 138.6 ± 18.6/79.0 ± 12.2 (p p = 0.03, respectively). In contrast, home BP significantly decreased from 128.2 ± 10.3/75.8 ± 8.8 to 126.9 ± 10.2/75.2 ± 9.0 (p p = 0.01, respectively), and the ratio of white coat hypertension was significantly increased (p

Background In Japan, six types of sodium–glucose cotransporter inhibitors (SGLT2Is) are currently in use. Here, we evaluated differences in renal composite outcomes between SGLT2Is with or without evidence of cardio vascular outcome trials (CVOTs). Methods We retrospectively surveyed 536 Japanese patients with type 2 diabetes mellitus with chronic kidney disease who received SGLT2Is for more than 1 year. Patients were classified as having received empagliflozin, canagliflozin, or dapagliflozin (n = 270, Evidence (+) group) or as having received ipragliflozin, tofogliflozin, or luseogliflozin (n = 266, Evidence (−) group). The propensity score matching method was performed. Result On matched cohort model including 205 cases in each group, there were no significant differences in the incidence of renal composite outcomes (n = 28 [14%] in the Evidence (+) group, n = 21 [10%] in the Evidence (−) group for the matched model; p = 0.29) between groups. Cox hazard analyses in the matched cohort model showed that the risk ratio for renal composite outcomes in the Evidence (−) group was 0.73 (95% confidence interval: 0.40–1.32), which was greater than the noninferiority margin of 1.22. Conclusion Three SGLT2Is with no CVOT’s evidence did not show noninferiority compared with other SGLT2Is with evidences.

Aims/Introduction Large‐scale clinical trials have reported that, in patients with type 2 diabetes mellitus, sodium–glucose cotransporter 2 (SGLT2) inhibitor treatment affords favorable renal outcomes; the underlying mechanisms, however, remain unclear. Thus, this study investigated how SGLT2 inhibitor‐induced changes in the mean arterial pressure (MAP; denoted as ΔMAP) are associated with renal outcomes in type 2 diabetes mellitus patients with chronic kidney disease (CKD). Materials and Methods We retrospectively assessed the data of 624 Japanese type 2 diabetes mellitus patients with CKD who had been using SGLT2 inhibitors for >1 year. For propensity score matching (1:1 nearest neighbor match, with caliper value = 0.053, no replacement), patients were categorized into two groups based on the ΔMAP (>−4 mmHg [n = 329] and ≤−4.0 mmHg [n = 295]). Composite albuminuria progression or a ≥15% annual reduction in the estimated glomerular filtration rate was regarded as the end‐point. Results Per group, 173 propensity‐matched patients were compared. Patients with ΔMAP ≤−4 mmHg had a significantly lower incidence of composite renal outcomes than those with ΔMAP ≥−4 mmHg (5.8% [n = 10] vs 15.6% [n = 27], P = 0.003). Although the between‐group differences in the estimated glomerular filtration rates were non‐significant, patients with a ΔMAP ≤−4 mmHg had significantly larger reductions in the logarithmic urine albumin‐to‐creatinine ratio (P = 0.005). Conclusions The degree of blood pressure reduction after SGLT2 inhibitor treatment influenced renal composite outcomes in Japanese type 2 diabetes mellitus patients with CKD, confirming the importance of blood pressure management in type 2 diabetes mellitus patients with CKD, even when they are under SGLT2 inhibitor treatment., From the results of the propensity score matching method, the incidence of renal composite outcome was significantly lower in patients with changes in the mean arterial pressure ≤−4 mmHg than in those with changes in the mean arterial pressure >−4 mmHg (n = 10 [5.8%] and n = 27 [15.6%], respectively, P = 0.003). The reduction in mean arterial pressure after sodium–glucose cotransporter 2 inhibitor treatment influenced the renal composite outcome in Japanese patients with type 2 diabetes mellitus and chronic kidney disease.

In 2019, the Japanese Society of Hypertension guidelines for the management of hypertension (JSH) were revised. We previously reported the awareness of JSH among general practitioners in 2014, and in the current study, the same questionnaire was administered to determine their awareness of JSH 2019, and their responses were compared. We also sought to identify effective strategies to raise awareness of hypertension. The questionnaires included the same 12 questions as in 2014 and were mailed to members of two professional organizations from October to November 2019. Responses from 256 general practitioners in 2019 and 209 in 2014 were compared using the propensity score matching method to align the responders’ backgrounds. Component analysis was performed to classify responders into appropriate clusters. The matched cohort of all 202 responders was analyzed. In both 2014 and 2019, >80% of responders instructed patients to perform home blood pressure monitoring (JSH 2014: 81.7% and JSH 2019: 84.6% in the matched cohort), and >70% instructed patients with hypertension to restrict their salt intake (JSH 2014: 79.7% and JSH 2019: 74.7% in the matched cohort). Regarding the clinical blood pressure measurement method, more responders answered “one time outside the consulting room” in the JSH 2019 group (p = 0.042). Fewer general practitioners responded that differential diagnosis for primary aldosteronism was performed in the JSH 2019 group (p = 0.032); however, the frequency of checking the aldosterone-renin ratio increased in the JSH 2019 group (p = 0.055). We confirmed the change in general practitioners’ awareness of hypertension management. The categorized clusters may be useful for the development of effective strategies for higher-quality hypertension management in clinical practice.

Aim: Sodium–glucose cotransporter 2 inhibitors (SGLT2is) provide renal protection in patients with type 2 diabetes mellitus (T2DM). The aim of this study was to elucidate the renal effects of long-...

Reduction in blood pressure (BP) contributes to the cardiovascular and renal protective effects of sodium-glucose co-transporter 2 inhibitors (SGLT-2is) and glucagon-like peptide 1 receptor agonists (GLP-1Ras). However, there has been no direct comparison in terms of BP-lowering efficacies. We compared the rates of achieving a target BP with SGLT-2i and GLP-1Ra treatments administered to Japanese patients with type 2 diabetes mellitus (T2DM). This retrospective study included 384 SGLT-2i- and 160 GLP-1Ra-treated patients with a BP > 130/80 mmHg before treatment. Inverse probability weighting methods using propensity scores were applied in this study. The integrated odds ratios (OR) for BP control rates were calculated and clinical changes were analyzed using a generalized linear model. SGLT-2i treatment resulted in significantly higher BP control rates than the GLP1Ra treatment (integrated OR = 2.09 [1.80, 2.43]). Compared with GLP-1Ra, SGLT-2i treatment determined significantly larger decreases in diastolic BP, mean arterial pressure, and body weight (-3.8 mmHg, P = 0.006; -4.1 mmHg, P = 0.01; and -1.5 kg, P = 0.008, respectively) and increased annual estimated glomerular filtration rate (eGFR; 1.5 mL/min/1.73 m2/year, P = 0.04). In T2DM patients with poorly controlled BP, compared with GLP-1Ra, SGLT-2i treatment significantly improved BP management along with increasing eGFR.

In 2019, the Japan Physicians Association conducted a second nationwide survey on the management of chronic kidney disease (CKD) among the Japanese general practitioners (GPs). We aimed to clarify the changes in the state of CKD medical care by GPs since the 2013 survey. The 2013 and 2019 surveys included 2214 and 601 GPs, respectively, who voluntarily participated. The two surveys were compared, using propensity score matching to balance the background of the responded GPs. For the medical care of CKD, the frequency of urine or blood examination, use of estimated glomerular filtration rate (eGFR) value for CKD management, and continuous use of renin-angiotensin system inhibitors for their reno-protective effects were significantly higher in 2019 than in 2013 (all: p < 0.001). The medical cooperation in CKD management, the utilization of the clinical path for CKD management and the measurement of the eGFR during the medical health checkup were significantly increased in 2019, compared to those in 2013. More GPs felt dissatisfied with the components of CKD treatment by nephrologists (p < 0.001). The two surveys confirmed improvements in the level of medical care for CKD and a strengthening in cooperation. However, the dissatisfaction with the consultation with nephrologists did not necessarily improve.

Background and Aim: Direct comparison between sodium glucose cotransporter 2 inhibitor (SGLT2i) and glucagon-like peptide 1 receptor agonist (GLP1Ra) —that have shown a renal protective effect in previous large-scale clinical trials—has not been evaluated thoroughly. The aim of this study is to clarify the difference between the renal protective effect of SGLT2i and GLP1Ra treatment, depending on the decreased mean arterial pressure (MAP) . Methods: We conducted different retrospective surveys for patients treated with SGLT2i and GLP1Ra, continuously administered over a period of more than 1 year. This study included 541 SGLT2i-treated patients without the concomitant use of GLP1Ra and 265 GLP1Ra-treated patients without the concomitant use of SGLT2i. We constructed two cohort models based on the change in MAP after treatment (ΔMAP) . The comparisons between SGLT2i and GLP1Ra were performed with a generalized linear model, including inverse probability weights using the propensity score. Results: In the ΔMAP Conclusion: The decrease in blood pressure was related to the more favorable influence on renal function in SGLT2i-treated patients than in GLP1Ra-treated patients. Disclosure K.Kobayashi: None. M.Toyoda: None. N.Hatori: None. K.Tamura: None.

Objectives We investigated relationships between subclinical COVID-19 (coronavirus disease 2019) and background factors. Methods We determined SARS-CoV-2 antibody (IgG) prevalence in 1603 patients, doctors, and nurses in 65 medical institutions in Kanagawa Prefecture, Japan and investigated their background factors. Antibodies (IgG) against SARS-CoV-2 were analyzed by Immunochromatographic test. Results The 39 subjects (2.4%) were found to be IgG antibody-positive: 29 in the patient group (2.9%), 10 in the doctor/nurse group (2.0%), and 0 in the control group. After adjustment for age, sex, and the antibody prevalence in the control group, antibody prevalence was 2.7% in the patient group and 2.1% in the doctor/nurse group. There was no significant difference between the antibody-positive subjects and the antibody-negative subjects in any background factors investigated including overseas travel, contact with overseas travelers, presence/absence of infected individuals in the living area, use of trains 5 times a week or more, BCG vaccination, and use of ACE inhibitor and ARB. Conclusions Antibody prevalence in the present survey at medical institution is higher than that in Tokyo and in Osaka measured by the government suggesting that subclinical infections are occurring more frequently than expected. No background factor that influenced antibody-positive status due to subclinical infection was identified.

Aims/Introduction Sodium–glucose cotransporter 2 inhibitors (SGLT2i) improve renal outcome in patients with type 2 diabetes mellitus, but the mechanism is not fully understood. The aim of this retrospective study was to assess the association of achieved blood pressure with renal outcomes in Japanese type 2 diabetes mellitus patients with chronic kidney disease. Materials and Methods We assessed 624 Japanese type 2 diabetes mellitus patients with chronic kidney disease taking SGLT2i for >1 year. The patients were classified as those with post‐treatment mean arterial pressure (MAP) of ≥92 mmHg (n = 344) and those with MAP of, Incidence of renal composite outcome and changes in logarithmic value of the albumin‐to‐creatinine ratio and estimated glomerular filtration rate.

Objective To examine the continuation of antibody prevalence and background factors in antibody-positive subjects after asymptomatic infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Methods A study was carried out to investigate the SARS-CoV-2 antibody (IgG) prevalence. SARS-CoV-2 antibodies (IgG) were measured and analyzed with immunochromatographic tests. Patients Among 1603 subjects, comprising patients, physicians, and nurses at 65 medical institutes in Kanagawa, Japan, 39 antibody-positive subjects received follow-up for 6 months. Results Of the 33 subjects who consented to the follow-up (23 patients and 10 medical professionals), continued positivity of IgG antibodies was confirmed in 11 of 32 cases (34.4%) after 2 months, 8 of 33 (24.2%) after 4 months, and 8 of 33 (24.2%) after 6 months. A significant difference was found in the sleeping time, drinking habits, hypertension, and use of angiotensin-receptor blockers on comparing subject background characteristics among three groups: patients with antibody production that continued for six months after the first detection of positivity, patients in whom antibody production stopped at four months, and patients in whom antibody production stopped at two months. Conclusions The continuation rate of IgG antibody prevalence was 24.2% at 6 months after the first detection of antibody positivity in cases with asymptomatic coronavirus disease 2019 (COVID-19) infections. This percentage is low compared with the antibody continuation rate in patients who have recovered from symptomatic COVID-19 infection.

In 2019, a nationwide questionnaire survey on the management of chronic kidney disease (CKD) was circulated to general practitioners (GPs) throughout Japan by The Japan Physicians Association. The aim was to assess the current state of CKD medical care in the country and evaluate the utilization of CKD-specific guidelines in the treatment by GPs. The voluntary survey targeted all members of Japan Physicians Association, a nationwide organization consisting primarily of 15,000 GPs in clinics throughout the country. GPs were divided into groups: 171 GPs using and 414 GPs not using the guidelines. Comparisons between the groups' responses were made using propensity score matching and component cluster analysis. Overall responses revealed that the estimated glomerular filtration rate's utilization rate was high (95.1%). However, evidence-practice gaps in urine protein quantification and anemia remedy were prominent. There were significantly favorable answers in terms of CKD management in the user group compared with those in the non-user group, except for the questions about a urine check at the first visit, stopping the use of renin-angiotensin system inhibitors, and the target blood pressure for elderly CKD patients. The differences suggest that utilization of the CKD guidelines has improved CKD management practices by GPs. Further promotion of CKD guidelines utilization (28% in this survey) is considered valid for CKD medical education.

The decrease in blood pressure is thought to play an important role for the renoprotective effects of sodium-glucose cotransporter 2 inhibitors in patients with diabetes mellitus. However, their influence on blood pressure at home has not been well studied. The aim of this study is to clarify how long-term use of sodium-glucose cotransporter 2 inhibitors influence on blood pressure both at the office and at home, and the kidney function. We retrospectively analyzed 102 patients with type 2 diabetes mellitus and chronic kidney disease to whom sodium-glucose cotransporter 2 inhibitors were administered for more than 1 year, and whose blood pressure were monitored both at the office and at home. The blood pressure at the office and at home significantly decreased, and there was a significant positive correlation between both blood pressure values. Controlled, white-coat, and sustained hypertension were observed in 9.8%, 14.7%, and 55.9% of the patients at the beginning of the treatment, which changed to 16.7%, 15.7%, and 48.0% at the time of the survey, however, the ratio of masked hypertension was not changed (19.6%). The cutoff value of mean arterial pressure at home after treatment for the improvement of urine albumin to creatinine ratio was 92.0 mm Hg, with 54.1% of sensitivity and 60.0% of specificity. Sodium-glucose cotransporter 2 inhibitors can be useful for the strict management of blood pressures both at the office and at home. The decrease in blood pressure at home by this treatment might be related to the improvement of diabetic nephropathy.

Background and Aim: Some large clinical trials using SGLT2 inhibitor revealed the superiority in the renal outcome in patients with type 2 diabetes mellitus (T2DM) patients. We already reported that SGLT2 inhibitor improved urinary albumin-creatinine ratio at baseline (ACR) in Japanese T2DM patients with CKD and revealed some factors that influence to the renoprotective effects of SGLT2 inhibitor. The aim of this study is to clarify how the concomitant insulin treatment with SGLT2 inhibitor influence the renal composite outcome. Research Design and Methods: We retrospectively assessed 624 patients with Japanese T2DM patients with CKD who underwent SGLT2 inhibitor treatment for more than 1 year. We set the renal composite endpoint that was the progression of the stage of albuminuria or the decrease in eGFR by ≥15% per year. For comparative analyses, we performed the cohort model of patients with or without insulin treatment that was used propensity score (PS) matching methods. The PS matching was using the following algorithm: 1:1 nearest neighbor match with a ±0.04 caliper and no replacement. Further, all patients were stratified into quintiles based on the corresponding PS and included in the analyses. Results: The comparison of 149 PS-matched patients in each group were performed. The incidence of renal composite outcome was significantly higher in patients with insulin treatment than without it (n=23[15.4%] and n=10[6.7%], respectively, p=0.033). The results from the analysis depending on the quintiles of all patients by the Mantel-Haenszel method, there was a significant difference between the two groups (p=0.021) and the odds ratio for the renal composite outcome was 2.09 (95%CI,1.15, 3.80, p=0.016) in patients with insulin treatment. Conclusion: The concomitant insulin treatment with SGLT2 inhibitor influenced the renal composite outcome in Japanese T2DM patients with CKD. Disclosure K. Kobayashi: None. M. Toyoda: None. H. Sakai: None. K. Tamura: Research Support; Self; AstraZeneca K.K., Ono Pharmaceutical Co., Ltd. Speaker’s Bureau; Self; AstraZeneca K.K., Ono Pharmaceutical Co., Ltd. N. Hatori: None.

This study aimed to clarify the differences in how sodium glucose co-transporter 2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP1Ra) influence kidney function in Japanese patients with type 2 diabetes mellitus (T2DM).We retrospectively built two databases of patients with T2DM who visited the clinics of members of Kanagawa Physicians Association. We defined the renal composite outcome as either progression of albuminuria status and/or 15% deterioration in estimated glomerular filtration rate (eGFR) per year. We used propensity score matching to compare patient outcomes after SGLT2i and GLP1Ra treatments.The incidence of renal composite outcomes was significantly lower in SGLT2i-treated patients than in GLP1Ra-treated patients (n = 15[11%] and n = 27[20%], respectively, P = 0.001). Annual eGFR changes (mL/min/1.73 mRenal composite outcome incidence was lower in SGLT2i-treated patients than in GLP1Ra-treated patients.

Decrease in blood pressure contributes to the reno-protective effects of sodium-glucose cotransporter 2 inhibitors; however, its relationship with home monitoring of blood pressure is unclear. We retrospectively analyzed 101 visiting members of the Kanagawa Physicians Association with type 2 diabetes mellitus and chronic kidney disease who were taking sodium-glucose cotransporter 2 inhibitors and who monitored blood pressure at home for a median treatment period of

The aim of this study was to assess the renal effects of the glucose-lowering SGLT2 inhibitors in Japanese type 2 diabetes mellitus patients with chronic kidney disease.The Kanagawa Physicians Association maintains a registry of patients who visit their 31 clinics. Clinical data of type 2 diabetes mellitus patients with chronic kidney disease, who were prescribed SGLT2 inhibitors in addition to other treatments, were collected and analysed.SGLT2i was associated with a fall in HbAThis study confirmed that the beneficial renal effects of SGLT2 inhibitor in Japanese type 2 diabetes mellitus patients with chronic kidney disease, similar to those reported in large-scale clinical trials conducted in Western countries.

To evaluate the Japanese Society of Hypertension Guidelines for the Management of Hypertension 2014 (JSH2014) among Japanese general practitioners (GPs), we used a questionnaire survey with 209 GPs from the Kanagawa Physicians Society. Overall, 93.6% of GPs felt that the contents of the JSH2014 were useful. Based on the results showing that 81.8% of GPs instructed the measurement of blood pressure (BP) in the early morning at home to most patients, GP's acceptance of home BP methods and their penetration among patients with hypertension were considerably high. Regarding the number of home BP measurements, percentages for "one time," "two times," "three times," and "as many times as the patient decides," were 20.2%, 44.9%, 12.2%, and 22.9%, respectively; as such, no consensus was reached. Overall, 80.6% of GPs instructed most patients on sodium restriction; however, the content and method of restriction varied. Furthermore, 14.7% collected spot urine to assess salt intake. Many GPs respected the JSH2014 and faithfully adopted the guidelines during medical care. However, GPs did not necessarily agree with all guidelines. GPs sometimes selected the appropriate method for the individual patients and careful observations of how the guidelines affect actual clinical practice may lead to better medical care.

Background Atrial fibrillation (AF) is one of the most prevalent cardiac arrhythmias associated with substantially increased risks of ischemic stroke and thromboembolism. Oral anticoagulants (OACs) are the cornerstone of AF management and effectively prevent AF-related stroke. As new non-vitamin K antagonist OACs (NOACs) have become available, the landscape of stroke prevention in AF has changed. However, there are considerable gaps between daily clinical practice and current guideline-based recommendations for anticoagulant therapy in Japan. Consequently, little is known about the real-world setting and the current use of NOACs, especially by practitioners in Japan. Methods We conducted a prospective, observational study in 3847 patients with AF who were enrolled in clinics and hospitals located in Kanagawa Prefecture from September 2013 through March 2015. The participating centers included practitioners (small clinics), medium-sized hospitals, and university hospitals. The primary endpoints were epidemiologic characteristics, status of treatment with anticoagulants and antiplatelet agents, outcomes, and adverse events, including cerebrovascular disease, bleeding, and death. Results The mean CHADS2 score was 1.81±1.27, the mean CHADS2-Vasc score was 3.02±1.58, and the mean HAS-BLED score was 2.23±1.06, respectively. The usage rate of warfarin was 44.2% overall, and the usage rate of NOACs was 33.5%. Conclusions The results of the study are expected to serve as the basis for providing clinical practice guidance to healthcare institutions in Japan, with the ultimate goals of better characterizing the appropriate use of OACs and providing clinical decision support to physicians to facilitate the design of appropriate therapeutic strategies and the selection of anticoagulants for the management of AF.

Background: In some large-scale clinical trials, the administration of sodium glucose co-transporter 2 inhibitors (SGLT2i) in patients with type 2 diabetes mellitus (T2DM) has revealed pronounced and consistently beneficial renal outcome. However, it is unclear whether long term SGLT2i administration led to similar results in Japanese T2DM patients. Objective: To elucidate the renal effects of long term SGLT2i administration in Japanese T2DM patients with chronic kidney disease (CKD). Method: Data from T2DM patients with CKD who were visiting members of Kanagawa Physicians Association and being administered SGLT2i for more than 1 year were used. Result: We analyzed 753 patients. Six SGLT2i types were used with median administration period of 33.0 months. The mean albumin-to-creatinine ratio (ACR) significantly decreased from 36.0 to 27.5 (mg/gCr, p Conclusion: This study confirmed that the improvement of ACR was also observed in the real world; however, eGFR gradually decreased after long term SGLT2i administration. The relationship between background factors should be further discussed in future. Disclosure K. Kobayashi: None. M. Toyoda: Speaker's Bureau; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Daiichi Sankyo Company, Limited, Eli Lilly and Company, Kyowa Hakko Kirin Co., Ltd., Medtronic Japan Co., Ltd., Mitsubishi Tanabe Pharma Corporation, Novo Nordisk Inc., Sanofi, Sumitomo Dainippon Pharma Co., Ltd., Takeda Pharmaceutical Company Limited. N. Hatori: None. H. Sakai: None. T. Furuki: None. K. Tamura: Advisory Panel; Self; AstraZeneca. Research Support; Self; AstraZeneca, Ono Pharmaceutical Co., Ltd. Speaker's Bureau; Self; AstraZeneca, Ono Pharmaceutical Co., Ltd. M. Miyakawa: None.

Aim. The renoprotective effect of sodium-glucose cotransporter 2 inhibitors is thought to be due, at least in part, to a decrease in blood pressure. The aim of this study was to determine the renal effects of these inhibitors in low blood pressure patients and the dependence of such effect on blood pressure management status. Methods. The subjects of this retrospective study were 740 patients with type 2 diabetes mellitus and chronic kidney disease who had been managed at the clinical facilities of the Kanagawa Physicians Association. Data on blood pressure management status and urinary albumin-creatinine ratio were analyzed before and after treatment. Results. Changes in the logarithmic value of urinary albumin-creatinine ratio in 327 patients with blood pressure<130/80 mmHg at the initiation of treatment and in 413 patients with BP above 130/80 mmHg were −0.13±1.05 and −0.24±0.97, respectively. However, there was no significant difference between the two groups by analysis of covariance models after adjustment of the logarithmic value of urinary albumin-creatinine ratio at initiation of treatment. Changes in the logarithmic value of urinary albumin-creatinine ratio in patients with mean blood pressure of n=537) and those with ≥102 mmHg (n=203) at the time of the survey were −0.25±1.02 and −0.03±0.97, respectively, and the difference was significant in analysis of covariance models even after adjustment for the logarithmic value of urinary albumin-creatinine ratio at initiation of treatment (p<0.001). Conclusion. Our results confirmed that blood pressure management status after treatment with SGLT2 inhibitors influences the extent of change in urinary albumin-creatinine ratio. Stricter blood pressure management is needed to allow the renoprotective effects of sodium-glucose cotransporter 2 inhibitors.

Anticoagulant therapy for atrial fibrillation (Af) has been dramatically changed in the era of therapy with direct oral anticoagulants (DOACs). The real-world status of patients with Af treated with warfarin or DOACs or without anti-coagulants is not clarified. Furthermore, the beneficial three-year

Aim In Japan, six sodium-glucose co-transporter 2 inhibitors have been approved for use, and some agents are associated with a significant decrease in cardiovascular events. In this study, the effects of tofogliflozin and empagliflozin were compared. Methods Patients with type 2 diabetes mellitus who were administered tofogliflozin (n = 10) and empagliflozin (n = 12) were extracted. The clinical parameters and 24-h accumulated urine samples before and after 48 weeks were analyzed with generalized linear mixed model. Results Both groups showed significant differences in the following parameters: body weight (p Conclusions The present results indicate that empagliflozin and tofogliflozin influence certain clinical parameters similarly; however, empagliflozin significantly increased the hematocrit than tofogliflozin. Differences in the effects of tofogliflozin and empagliflozin might influence cardiovascular events.

We performed a cross-sectional survey to investigate actual clinical practice concerning blood-pressure control among patients with hypertension in Kanagawa. The guidelines of the Japanese Society of Hypertension (JSH) for the management of patients with hypertension were revised in 2014. From October 1 to November 30, 2014, questionnaires on the care of patients with hypertension were sent via post to members of the Kanagawa Physicians Association in Kanagawa Prefecture, Japan. -Data on 1,105 patients (mean age: 68.4±12.3 years, 537 men and 568 women) were obtained. The overall mean systolic blood pressure (BP) of these patients was 128.7±12.1 mmHg for home monitoring and 132.9±12.6 mmHg for office monitoring; diastolic BP was 75.7±9.7 for home monitoring and 77.0±9.7 mmHg for office monitoring. According to the JSH 2014 guidelines, the target BP was achieved by 68.1% of all subjects; 89.2% of late-phase elderly patients (75 years or older); 69.1% of young, middle-aged, and early-phase elderly patients (younger than 75 years except in patients with diabetes mellitus [DM] or chronic kidney disease [CKD] with proteinuria); 9.3% of patients with DM except late-phase elderly patients; and 11.9% of CKD patients with proteinuria except DM. Cross-sectional analysis showed that the factors significantly associated with an increased likelihood of achieving the target BP were as follows: 1) good medication compliance even for a small number of antihypertensive agents at small amount of doses in patients 75 years and older; 2) good medication compliance in patients in younger than 75 years; 3) an older age, a larger proportion in the female-to-male ratio and a lower body mass index in patients with DM except late-phase elderly patients; and 4) usage of a large number of antihypertensive agents in CKD patients with proteinuria. Further follow-up surveys are necessary to investigate changes in clinical practice following the introduction of the revised guidelines.

We performed a cross-sectional survey to investigate actual clinical practices regarding blood-pressure control in patients with hypertension. From October 16 to 31, 2008, postal questionnaires regarding the care of patients with hypertension were sent to members of the Kanagawa Physicians Association in Kanagawa, Japan. Data of 675 patients (mean age: 70.1 ± 10.6 years, 301 men and 374 women) were returned. The overall mean systolic blood pressure (BP) in these patients was 134.6 ± 10.6 mm Hg, and diastolic BP was 76.2 ± 8.3 mm Hg. According to the 2009 guidelines of the Japanese Society of Hypertension for the management of patients with hypertension, the target office BP was achieved by 53.9% of all subjects; 29.7% of patients with diabetes mellitus, chronic kidney disease, or a history of myocardial infarction; 72.0% of elderly patients; 23.6% of nonelderly patients (younger than 65 years); and 75.4% of patients with cerebrovascular disease. Cross-sectional analysis showed that factors significantly associated with an increased likelihood of achieving the target office BP were: 1) usage of a larger number of antihypertensive agents in nonelderly patienys and in patients with diabetes mellitus, chronic kidney disease, or a history of myocardial infarction and: 2) usage of a smaller number of antihypertensive agents in elderly patients and patients with cerebrovascular disease. Further follow-up surveys are necessary to provide a full assessment.

The coronary venous system is an alternate route for drug delivery to the acutely ischemic myocardium when the coronary arterial blood flow is impeded. This study was designed to determine the effect of retrograde infusion of lipid microsphere containing prostaglandin E1 (lipo-PGE1), which is believed to prevent rapid destruction of PGE1, on myocardial infarct size after acute myocardial ischemia and reperfusion. Twenty-one open-chest porcine models were subjected to 45 minutes of left anterior descending coronary artery (LAD) occlusion followed by 4 hours of reperfusion. Group A (n=7), the control group, was given, into the great cardiac vein, 4 ml of vehicle dissolved in 36 ml of saline for 5 minutes starting before the onset of reperfusion. In group B (n=7), 20 µg/4ml of lipo-PGE1 was administered into the great cardiac vein in the same manner as in group A. Group C (n=7) was treated the same as group B, but lipo-PGE1 was injected into the inferior vena caval vein. Infarct size, expressed as a percentage of area at risk, was significantly smaller in group B (56.1±12.6%) than groups A (79.4±11.4%) and C (83.0±11.1%) (p

We studied the protective effects of intrathecally administered lidocaine against ischemic spinal cord injury during surgery. Seven patients (mean age 63.7 years, male∶female=6∶1) with descending thoracic aortic aneurysms underwent reconstructive surgery. Following intrathecal lidocaine administration (10 ml), the operation was performed under femorofemoral bypass with an oxygenator. The aorta was cross-clamped at the distal end of the descending thoracic aorta and the proximal end of the lesions. The cross-clamping time was 47.1±23.3 minutes (mean ± SD). The operative procedure was total replacement of the descending thoracic aorta in five cases and patch closure in two. There were no operative deaths but paraparesis developed in two cases of total replacement. Neurological deficit was transient and disappeared in one case. In the other case, with 88 minutes of normothermic aortic cross-clamping, paraparesis gradually improved but was persistent after 7 months of follow-up. Graft anastomosis at the distal aortic arch was time consuming in this case and presumably caused prolonged spinal cord ischemia. Intrathecal administration of lidocaine was likely to reduce ischemic spinal cord injury and increase tolerance of the spinal cord to ischemia caused by prolonged aortic cross-clamping. This method was considered to provide a useful assistance to expand the safety limit of spinal cord ischemia in surgical reconstruction of the descending thoracic aorta requiring aortic occlusion. Tissue protective effects of intrathecal lidocaine administration may be further augmented by combining with deep hypothermia.

Between April, 1981, and May, 1991, 40 patients underwent extra-anatomical bypass surgery for 49 lesions. Thirty-six men and 4 women with a mean age of 68 years (range 48–81) presented with symptoms of aortoiliac occlusive diseases caused by atherosclerosis. Patients were followed up for 44 months (range 1 to 121 months) after surgery. The operative mortality rate was 2.5% (1/40) and there were 4 late deaths. Hypertension, cardiac disease (history of ischemic heart disease and abnormal ECG), cerebrovascular disturbance, and diabetes mellitus were common concomitant preoperative diseases. Forty-nine percent of the limbs (24/49) were classified as Fontaine’s class II, 32.7% (16/49) as class III, and the remaining 18.4% (9/49) as class IV. Surgical procedures were axillofemoral bypasses on 53.1% of the lesions (26/49) and femorofemoral bypasses on the other 46.9% (23/49). Graft materials consisted of expanded polytetrafluoroethylene (EPTFE) (31/49), Dacron (13/49), and modified human umbilical veins (5/49). The ten-year cumulative patency rate was 95% in the femorofemoral bypass group and 88% in the axillofemoral bypass group. The anticoagulant (coumarin derivatives) was given at the first postoperative day, and it was continued as long as possible. No complications were recognized regarding this therapy. The value of the thrombo test was maintained between 20% and 40% during the follow-up period. The extra-anatomical bypass grafting was considered to be a beneficial alternative surgery to anatomical bypass in elderly and high-risk patients. Postoperative anticoagulant therapy may contribute to the patency of grafts.

Objective: The atrial conduction properties associated with cardiac disease are speculated as the background of postoperative atrial fibrillation (POAF). We examined the atrial conduction patterns and conduction properties during sinus rhythm (SR) in patients that had undergone cardiac operations and evaluated the incidence of POAF in all patients. Methods: Fifty-two patients with stable SR who underwent cardiac surgery, with a diagnosis of valvular disease in 25, ischemic heart disease in 24, and others in 3, were enrolled in this study. The epicardial recordings were made using a mapping system with 60 unipolar electrodes placed on the right atrium (RA) intraoperatively. The activation patternsof theRAwere assessed, and the longitudinal, transverseand obliqueconductionvelocity andmax anisotropic ratiowere also examined. Results: Sinus activation was initiated from various sites (single origin at the high-lateral RA in 40, mid-lateral RA in 4, low-lateral RA in 2, and multiple origins in 6 patients) and it demonstrated anisotropic conduction (1.8 0.6) with the longitudinal conduction being more rapid than transverse and oblique conduction. Fifteen patients demonstrated non-uniform activation patterns such as, a localized conduction delay in seven, functional conduction block in two and mosaic-activation pattern associated with multiple origins in six. A total of 21 patients (44%) developed POAF. A conduction delay and mosaic activation pattern was found significantly more often in patients with POAF than in patients who remained in sinus rhythm. Multivariate analysis revealed that non-uniform activation pattern (odds ratio = 8.71; 95% confidence interval [CI] = 1.74—43.67; p = 0.008) and TR (odds ratio = 4.95; 95% CI = 1.14—21.37; p = 0.032) were independently associated with the development of POAF. Although all patients had converted to SR at the time of discharge, the administration of antiarrhythmic drugs caused sinus bradycardia in two patients who demonstrated a mosaic activation pattern in RA. Conclusions: Cardiac surgery patients exhibited a variety of sinus activation patterns, which also provided an arrhythmogenic substrate for POAF. A better understanding of the sinus activation using an intraoperative mapping system may provide benefit in the clinical management of POAF.

Purpose: Endoscopic endocrine neck surgery is desirable from a cosmetic viewpoint. We compared the effectiveness of our new technique with that of conventional surgery in a clinical study. Methods: We performed our original endoscopic method of video-assisted neck surgery (VANS) on 130 patients: 126 with thyroid tumors and 4 with parathyroid tumors. The percentage of patients who underwent VANS among all those who underwent neck surgery and the procedure involved were analyzed. Operating time and blood loss were compared between the first 40 patients and last 39, and all factors were statistically analyzed in the most recent 20 patients who underwent the VANS method and the most recent 20 who underwent conventional surgery. Results: More than 60% of benign thyroid tumors and 5.3% of malignant thyroid tumors were operated on by the VANS method. Nearly total lobectomy was the most common procedure (57.7%), followed by total lobectomy (26.1%), for benign tumors. Malignancy was defined as papillary carcinoma less than 1 cm in diameter. Total lobectomy with lymph node clearance was performed for all malignant tumors. There was less bleeding when the VANS method (P < 0.001) was used than when conventional surgery was performed, and the operating time has been reduced with experience. Conclusion: The VANS method is feasible, practical, and safe, and has great cosmetic benefits.

A 65-year-old man was admitted to the National Defense Medical College Hospital for acute anterolateral myocardial infarction and cardiogenic shock. Emergency coronary angiography demonstrated occlusion of the proximal left anterior descending artery. Primary percutaneous transluminal coronary angioplasty (PTCA) was successfully performed with the support of intra-aortic balloon pumping (IABP) and medical treatment to stabilize the patient's blood pressure. On the second hospital day, the patient suffered cardiac tamponade. Pericardiocentesis showed bloody fluid and revealed that an oozing-type of left ventricular rupture had occurred after the myocardial infarction. Cardiogenic shock persisted after successful removal of the pericardial effusion. Although the heparinization required during percutaneous cardiopulmonary support (PCPS) can increase pericardial effusion, PCPS was initiated to correct the systemic hypoperfusion; a surgical team was on standby in case massive pericardial effusion resulted, but fortunately that did not occur, and cardiac function recovered. The patient was weaned successfully from PCPS and IABP and has remained in a satisfactory condition for over 1 year. PCPS contributed to the patient's recovery from cardiac shock and may have decreased the effusion from the oozing-type rupture by reducing ventricular wall tension.

We performed cross-sectional surveys to investigate changes in clinical practices regarding blood-pressure control in patients with hypertension from 2008 through 2011. Questionnaires regarding the care of patients with hypertension were mailed to members of the Kanagawa Physicians Association in Kanagawa Prefecture, Japan. Data were obtained on 675 patients in 2008, 332 in 2009, and 1,076 in 2011. The mean systolic blood pressure (BP) was significantly lower in 2011 than in 2008 (132.2±11.9 mm Hg versus 134.6±10.6 mm Hg). The office-measured target BP, according to the 2009 guidelines of the Japanese Society of Hypertension for the management of patients with hypertension, was achieved in 53.9% of patients in 2008, 55.1% in 2009, and 57.1% in 2011. In nonelderly patients (younger than 65 years), the achievement rate was significantly greater in 2011 (41.2%) than in 2008 (23.6%). This analysis showed that the factor most significantly associated with a decrease in office-measured BP was treatment with a larger number and higher doses of antihypertensive agents. To investigate changes in clinical practices according to the guidelines, further follow-up surveys are necessary.

We analyzed the risk factors predisposing elderly patients to develop postoperative respiratory complications (PRCs) and investigated the possibility of predicting the postoperative pulmonary function and PRC rate. The postoperative pulmonary functions were predicted according to a simplified system, which we developed using plain chest roentgenograms from patients with primary lung cancer. Both univariate and multivariate analyses of PRCs were performed in 39 elderly patients with lung cancer from July 1982 to March 1991 (the early period). Based on the results obtained, the permissible extent of lung resection to achieve a predicted postoperative % forced expiratory volume in 1 s (ppo%FEV1.0) and a predicted postoperative % vital capacity (ppo%VC) of more than 55% was selected as the basic criteria for undergoing such an operation after April 1991 (the recent period). A ppo%FEV1.0 and/or ppo%VC of 55% or less was the most significant risk factor for developing PRCs. The PRC rate decreased from 33.3% to 9.8% (P = 0.0251) and the operative mortality rate decreased from 10.3% to 0%. The survival rates for stage I, II. and III cases were not significantly different between the early and recent periods. Decisions made on the operability and the permissible extent of lung resection based on our system using plain chest roentgenograms therefore appeared to reduce the PRC rate and operative mortality rate in elderly patients.