Two tracheal BALT lymphoma patients successfully treated with chemotherapy including rituximab

Bronchus-associated lymphoid tissue (BALT) lymphoma of the trachea, an important differential diagnosis for tracheal tumors, is a rare disease with characteristic bronchoscopic findings. In this study, we reviewed 2 cases of patients who were symptomatic at the time of diagnosis, with tumors in the trachea and left main bronchus, putting them at high risk for asphyxia. Chemotherapies including rituximab were administered, and complete remission was confirmed in both cases. Because tracheal tumors often have a pernicious course, it might be beneficial to initiate a chemotherapeutic treatment regimen instead of adopting the "wait-and-see" approach in patients with symptomatic tracheal BALT lymphoma.

Effect of lifestyle on asthma control in Japanese patients: importance of periodical exercise and raw vegetable diet

Background

The avoidance of inhaled allergens or tobacco smoke has been known to have favorable effects on asthma control. However, it remains unclear whether other lifestyle-related factors are also related to asthma control. Therefore, a comprehensive study to examine the associations between various lifestyle factors and asthma control was conducted in Japanese asthmatic patients.

Methods

The study subjects included 437 stable asthmatic patients recruited from our outpatient clinic over a one-year period. A written, informed consent was obtained from each participant. Asthma control was assessed using the asthma control test (ACT), and a structured questionnaire was administered to obtain information regarding lifestyle factors, including tobacco smoking, alcohol drinking, physical exercise, and diet. Both bivariate and multivariate analyses were conducted.

Results

The proportions of total control (ACT = 25), well controlled (ACT = 20-24), and poorly controlled (ACT < 20) were 27.5%, 48.1%, and 24.5%, respectively. The proportions of patients in the asthma treatment steps as measured by Global Initiative for Asthma 2007 in step 1, step 2, step 3, step 4, and step 5 were 5.5%, 17.4%, 7.6%, 60.2%, and 9.4%, respectively. Body mass index, direct tobacco smoking status and alcohol drinking were not associated with asthma control. On the other hand, younger age (< 65 years old), passive smoking, periodical exercise (> 3 metabolic equivalents-h/week), and raw vegetable intake (> 5 units/week) were significantly associated with good asthma control by bivariate analysis. Younger age, periodical exercise, and raw vegetable intake were significantly associated with good asthma control by multiple linear regression analysis.

Conclusions

Periodical exercise and raw vegetable intake are associated with good asthma control in Japanese patients.

The pharmacokinetics and long-term therapeutic effects of gefitinib in patients with lung adenocarcinoma harboring the epidermal growth factor receptor(EGFR)mutation

INTRODUCTION

The relationship between the pharmacokinetics and long-term antitumor activity of gefitinib in patients with epidermal growth factor receptor(EGFR)mutation-positive lung adenocarcinoma has not yet been clarified in clinical practice. The present study assessed the correlation between the pharmacokinetics and long-term therapeutic effects of gefitinib in patients with lung adenocarcinoma harboring the EGFR-activating mutation.

METHODS

Fifteen patients with lung adenocarcinoma harboring the EGFR mutation were administered 250 mg of gefitinib daily. Blood samples were collected prior to the first administration of gefitinib and after 1, 4, 6, 8, and 24 h. Plasma concentrations of gefitinib were measured via liquid chromatography mass spectrometry, and the peak plasma concentration(Cmax)and area under the plasma concentration time curve from 0 to 24 h(AUC 0-24)of gefitinib were determined. The correlations between these pharmacokinetic variables and the objective responses, including progression-free survival(PFS)and overall survival(OS), were retrospectively analyzed.

RESULTS

The Cmax of gefitinib in patients with a partial response(PR)was significantly lower than that of patients with stable disease(SD)(median Cmax: 278 vs 588 ng/mL, p<0.05 ). However, the Cmax of gefitinib did not correlate with longer PFS. Conversely, a significant negative correlation was found between the AUC 0-24 of gefitinib and longer survival(r=-0.545, p<0.05 ).

CONCLUSIONS

It may be possible that a high concentration of gefitinib is not necessary to achieve long-term therapeutic effects in patients with lung adenocarcinoma harboring the EGFR mutation.

Clinical preparedness for severe pneumonia with highly pathogenic avian influenza A (H5N1): experiences with cases in Vietnam

BACKGROUND

Avian influenza A (H5N1) in human presents a global pandemic threat, and preparedness is urgently required in high-risk countries.

METHODS

A retrospective chart review was conducted on 8 patients with H5N1 infection (aged 2-30 years; 3 fatal) who were hospitalized in Bach Mai Hospital (BMH), Vietnam, or in affiliated hospitals with consultation by physicians in BMH between 2007 and 2010. Demographic background, chest radiographs, and clinical and laboratory data were evaluated to determine the critical issues in relation to clinical outcomes. Treatment of 4 patients with acute respiratory distress syndrome (ARDS) (2 fatal) was assessed for renal replacement therapy using continuous hemodiafiltration (CHDF), polymyxin B-immobilized (PMX) hemoperfusion, or their combination.

RESULTS

Patients had direct contact with dead/sick poultry infected with H5N1 virus or lived in areas where H5N1 poultry outbreaks had been reported at the same time as their illness. Time to initiation of oseltamivir from symptom onset was 2-6 days for survivors and 7-9 days for non-survivors. All patients except one had infiltrative shadows on chest radiographs on admission. Patients with delayed treatment developed ARDS. Renal replacement therapy contributed to patient survival, with improvement of oxygenation and a dramatic decrease in serum cytokine levels if initiated earlier.

CONCLUSIONS

Understanding local H5N1 poultry outbreaks and chest radiography assist early diagnosis and initiation of antiviral treatment. Developing a network among local and tertiary care hospitals can reduce the time to initiation of treatment. CHDF and PMX hemoperfusion are possible candidates for effective treatment of ARDS with H5N1 if applied earlier.

Superiority of nebulized corticosteroids over dry powder inhalers in certain patients with cough variant asthma or cough-predominant asthma

BACKGROUND

The particle distribution might differ between nebulizer therapy and metered-dose inhaler (MDI) or dry powder inhaler (DPI) therapy because the particles repeatedly enter/re-enter the airways with the nebulizer. Inhaled corticosteroids (ICS) were administered with a nebulizer to assess the benefit of changes in the distribution of particles in patients with cough variant asthma (CVA) and cough-predominant asthma (CPA).

METHODS

Patients whose symptoms were not controlled by their current therapy were enrolled. In patients receiving high-dose ICS by MDI or DPI (ICS-MDI/DPI), steroid therapy was switched to 1,320μg/day of nebulized dexamethasone (1,600μg as dexamethasone sodium phosphate) (chronic steroid-independent group). In patients receiving systemic steroids regardless of their ICS-MDI/DPI therapy, nebulized dexamethasone was added and any concurrent ICS-MDI/DPI therapy was halted to detect a steroid-sparing effect (chronic steroid-dependent group). In patients with acute exacerbation of CVA or CPA and persistent symptoms despite systemic corticosteroids, nebulized dexamethasone was added to assess its effect (acute group).

RESULTS

Superior symptom control was achieved in 10 out of 12 steroid-independent patients, 3 out of 6 steroid-dependent patients, and all 7 acute patients.

CONCLUSIONS

Delivery of ICS via a nebulizer has advantages over ICS-MDI/DPI in some patients with CVA or CPA.

Socioeconomic factors influencing hospitalized patients with pneumonia due to influenza A(H1N1)pdm09 in Mexico

Background

In addition to clinical aspects and pathogen characteristics, people's health-related behavior and socioeconomic conditions can affect the occurrence and severity of diseases including influenza A(H1N1)pdm09.

Methodology and Principal Findings

A face-to-face interview survey was conducted in a hospital in Mexico City at the time of follow-up consultation for hospitalized patients with pneumonia due to influenza virus infection. In all, 302 subjects were enrolled and divided into two groups based on the period of hospitalization. Among them, 211 tested positive for influenza A(H1N1)pdm09 virus by real-time reverse-transcriptase-polymerase-chain-reaction during the pandemic period (Group-pdm) and 91 tested positive for influenza A virus in the post-pandemic period (Group-post). All subjects were treated with oseltamivir. Data on the demographic characteristics, socioeconomic status, living environment, and information relating to A(H1N1)pdm09, and related clinical data were compared between subjects in Group-pdm and those in Group-post. The ability of household income to pay for utilities, food, and health care services as well as housing quality in terms of construction materials and number of rooms revealed a significant difference: Group-post had lower socioeconomic status than Group-pdm. Group-post had lower availability of information regarding H1N1 influenza than Group-pdm. These results indicate that subjects in Group-post had difficulty receiving necessary information relating to influenza and were more likely to be impoverished than those in Group-pdm. Possible factors influencing time to seeking health care were number of household rooms, having received information on the necessity of quick access to health care, and house construction materials.

Conclusions

Health-care-seeking behavior, poverty level, and the distribution of information affect the occurrence and severity of pneumonia due to H1N1 virus from a socioeconomic point of view. These socioeconomic factors may explain the different patterns of morbidity and mortality for H1N1 influenza observed among different countries and regions.

[Efficacy of combination therapy with EGFR-TKI and cytotoxic drug in lung adenocarcinoma already treated with EGFR-TKI]

OBJECITVE: To assess the efficacy of combination therapy with EGFR-TKI and a cytotoxic drug in lung adenocarcinoma already being treated with EGFR-TKI.

METHODS

Eight patients with adenocarcinoma who were treated with combination therapy of EGFR-TKI and a cytotoxic drug between April 2008 and December 2010 were retrospectively evaluated for response rate, disease-control rate, progression-free survival(PFS), time-to-treatment-failure(TTF)and overall survival(OS).

RESULTS

Among the 7 patients with tumor samples available, EGFR-mutations were detected in six.The median number of prior therapy regimens received by the patients was 5.All the patients had been treated before with both gefitinib and erlotinib.Among 8 patients, six showed stable disease, including three patients intolerant because of severe hematological toxicities, and 2 with progressive disease.The disease-control rate was 75%, and median TTF, PFS, and OS were 42 days, 84 days, and 495 days, respectively.

CONCLUSION

Combination therapy with EGFR-TKI and a cytotoxic drug after the failure of EGFR-TKI may be a useful therapeutic option for selected patients.

One-step detection of the 2009 pandemic influenza A(H1N1) virus by the RT-SmartAmp assay and its clinical validation

Background

In 2009, a pandemic (pdm) influenza A(H1N1) virus infection quickly circulated globally resulting in about 18,000 deaths around the world. In Japan, infected patients accounted for 16% of the total population. The possibility of human-to-human transmission of highly pathogenic novel influenza viruses is becoming a fear for human health and society.

Methodology

To address the clinical need for rapid diagnosis, we have developed a new method, the “RT-SmartAmp assay”, to rapidly detect the 2009 pandemic influenza A(H1N1) virus from patient swab samples. The RT-SmartAmp assay comprises both reverse transcriptase (RT) and isothermal DNA amplification reactions in one step, where RNA extraction and PCR reaction are not required. We used an exciton-controlled hybridization-sensitive fluorescent primer to specifically detect the HA segment of the 2009 pdm influenza A(H1N1) virus within 40 minutes without cross-reacting with the seasonal A(H1N1), A(H3N2), or B-type (Victoria) viruses.

Results and Conclusions

We evaluated the RT-SmartAmp method in clinical research carried out in Japan during a pandemic period of October 2009 to January 2010. A total of 255 swab samples were collected from outpatients with influenza-like illness at three hospitals and eleven clinics located in the Tokyo and Chiba areas in Japan. The 2009 pdm influenza A(H1N1) virus was detected by the RT-SmartAmp assay, and the detection results were subsequently compared with data of current influenza diagnostic tests (lateral flow immuno-chromatographic tests) and viral genome sequence analysis. In conclusion, by the RT-SmartAmp assay we could detect the 2009 pdm influenza A(H1N1) virus in patients' swab samples even in early stages after the initial onset of influenza symptoms. Thus, the RT-SmartAmp assay is considered to provide a simple and practical tool to rapidly detect the 2009 pdm influenza A(H1N1) virus.

A case of yellow nail syndrome with dramatically improved nail discoloration by oral clarithromycin

An 80-year-old woman was admitted to our hospital with pneumonia and exacerbation of sinobronchial syndrome (SBS). She presented with yellow discoloration of the nail beds of all fingers and toes, and her nails were recognized as growing slowly. Chest X-ray revealed bronchiectasis in the bilateral lower lobe and bilateral pleural effusion. We diagnosed her as having yellow nail syndrome (YNS), based on the triad of yellow nails, lymphedema, and lung disease. After treatment with antibiotics [ampicillin/sulbactam and clarithromycin (CAM)] for pneumonia and SBS, her general condition improved, and the yellow nails disappeared in some fingers. When she was previously treated with 200 mg CAM for SBS, her yellow nails had not shown improvement. This time, her yellow nails improved after treatment with 400 mg CAM. The literature reports vitamin E, zinc, and topical corticosteroid plus active vitamin D3 to be effective in the treatment of yellow nails. Two studies have reported treatment for YNS using CAM, though they found a lack of efficacy. Thus, the present case is the first to report improved yellow nails using CAM alone. We conclude that not only SBS and lung disease but also YNS were improved by treatment with 400 mg CAM.

Usefulness of linezolid in the treatment of hospital-acquired pneumonia caused by MRSA: a prospective observational study

Clinical results for linezolid (LZD) treatment of hospital-acquired pneumonia (HAP) caused by methicillin-resistant Staphylococcus aureus (MRSA), particularly microbiologically evaluable or severe cases, are limited in Japan. A prospective observational study was conducted in order to assess the usefulness of LZD in Japanese patients with MRSA pneumonia. The study tracked fifteen participants treated with LZD for pneumonia who met the criteria of the HAP guidelines and were confirmed to have pneumonia caused by MRSA. Of these, six were severe and 13 had received antibiotic treatment before treatment with LZD. Of the 13 participants assessed for their clinical responses, seven were rated as cures, three were rated as failures, and three were indeterminate. The overall cure rate (cure/cure + failure) was 70.0% (7/10), and the cure rate by severity was 33.3% (1/3) for severe cases and 85.5% (6/7) for moderate cases. The one severe case with a clinical response rating of cure had failed to respond to vancomycin. Among the seven participants with a clinical response rating of cure, the microbiological response was eradication in three, presumed eradication in three, and indeterminate in one. Three serious adverse events occurred in two of the 15 participants, but none were considered to be causally related to LZD. The results suggest that LZD has high potential for severe and multidrug-resistant cases. A higher cure rate was achieved in moderate cases. In cases of pneumonia that are most likely MRSA infections with poor prognosis, it was suggested to be important for patient outcome to implement the most effective therapy before the patient's condition becomes serious.

Impact of educational intervention concerning awareness and behaviors relating to avian influenza (H5N1) in a high-risk population in Vietnam

BACKGROUND

Early initiation of treatment is essential for treatment of avian influenza A/H5N1 viral infection in humans, as the disease can lead to rapid development of severe pneumonia which can result in death. Contact with infected poultry is known to be a significant risk factor for contraction of H5N1 infection. However, handling and encountering poultry are a part of most peoples' daily lives, especially in rural communities in Vietnam where epidemic outbreaks among poultry have been continuously reported. Enhancing proper knowledge relating to H5N1 and to the importance of early initiation of treatment are crucial. The aim of this study was to develop an effective educational program to enhance awareness of H5N1 and motivate people to access to health care earlier when H5N1 infection is suspected or likely.

METHODOLOGY AND PRINCIPAL FINDINGS

A study was conducted in two agricultural communities (intervention and control groups) in the Ninh Binh province in Vietnam, where epidemic outbreaks of avian influenza have recently occurred in birds. A unique educational intervention was developed and provided to the intervention group, and no intervention was provided to the control group. A knowledge, attitude and practice (KAP) survey was conducted in both groups with a face-to-face interview by trained local healthcare workers at time points before and after the educational intervention. KAP scores were compared between the different time points and between the groups. How educational intervention influenced awareness relating to H5N1 and accessibility of healthcare in the population was analyzed. The study indicated an increased awareness of H5N1 and increased reliance on local health care workers.

CONCLUSIONS

The novel educational program which was developed for this study impacted awareness of H5N1, and resulted in more people seeking early access to healthcare, and also resulted in earlier medical intervention for patients with H5N1 avian influenza infection in Vietnam.

Reducing occurrence and severity of pneumonia due to pandemic H1N1 2009 by early oseltamivir administration: a retrospective study in Mexico

Background

Anti-viral treatment has been used to treat severe or progressive illness due to pandemic H1N1 2009. A main cause of severe illness in pandemic H1N1 2009 is viral pneumonia; however, it is unclear how effective antiviral treatment is against pneumonia when administered >48 hours after symptom onset. Therefore, we aimed to determine how time from symptom onset to antiviral administration affected the effectiveness of antiviral treatment against pneumonia due to pandemic (H1N1) 2009.

Methods/Principal Findings

A retrospective medical chart review of 442 patients was conducted in a hospital in Mexico. Subjects had tested positive for pandemic H1N1 2009 virus by real-time reverse-transcriptase-polymerase-chain-reaction and were administered oseltamivir. Median time from symptom onset to oseltamivir administration was 5.0 days (range, 0–43). 442 subjects, 71 (16.1%) had severe pneumonia which required mechanical ventilation, 191 (43.2%) had mild to moderate pneumonia, and 180 (40%) did not have pneumonia. Subjects were divided into four groups based on time to oseltamivir administration: ≤2, 3–7, 8–14, and >14 days. Severity of respiratory features was associated with time to treatment, and multivariate analysis indicated that time to oseltamivir administration was associated with severity of respiratory features. A proportional odds model indicated that 50% probability for occurrence of pneumonia of any severity and that of severe pneumonia in patients who would develop pneumonia reached at approximately 3.4 and 21 days, respectively, after symptom onset. Patients with a shorter time to oseltamivir administration were discharged earlier from the hospital.

Conclusions

Earlier initiation of oseltamivir administration after symptom onset significantly reduced occurrence and severity of pneumonia and shortened hospitalization due to pandemic H1N1 2009. Even when administered >48 hours after symptom onset, oseltamivir showed considerable potential for reducing pneumonia. Application of these results would benefit patients affected by future influenza pandemics.

Mutation analysis of 2009 pandemic influenza A(H1N1) viruses collected in Japan during the peak phase of the pandemic

BACKGROUND

Pandemic influenza A(H1N1) virus infection quickly circulated worldwide in 2009. In Japan, the first case was reported in May 2009, one month after its outbreak in Mexico. Thereafter, A(H1N1) infection spread widely throughout the country. It is of great importance to profile and understand the situation regarding viral mutations and their circulation in Japan to accumulate a knowledge base and to prepare clinical response platforms before a second pandemic (pdm) wave emerges.

METHODOLOGY

A total of 253 swab samples were collected from patients with influenza-like illness in the Osaka, Tokyo, and Chiba areas both in May 2009 and between October 2009 and January 2010. We analyzed partial sequences of the hemagglutinin (HA) and neuraminidase (NA) genes of the 2009 pdm influenza virus in the collected clinical samples. By phylogenetic analysis, we identified major variants of the 2009 pdm influenza virus and critical mutations associated with severe cases, including drug-resistance mutations.

RESULTS AND CONCLUSIONS

Our sequence analysis has revealed that both HA-S220T and NA-N248D are major non-synonymous mutations that clearly discriminate the 2009 pdm influenza viruses identified in the very early phase (May 2009) from those found in the peak phase (October 2009 to January 2010) in Japan. By phylogenetic analysis, we found 14 micro-clades within the viruses collected during the peak phase. Among them, 12 were new micro-clades, while two were previously reported. Oseltamivir resistance-related mutations, i.e., NA-H275Y and NA-N295S, were also detected in sporadic cases in Osaka and Tokyo.

[A case of acute exacerbation of interstitial pneumonia complicated with dermatomyositis during treatment for lung cancer, and literature review]

A 72-year-old man was referred to our hospital with complaints of cough, facial rash, proximal muscle pain and weakness. Chest computed tomography (CT) revealed a nodule in the right S6, interstitial pneumonia in bilateral lower lobes and mediastinal lymph node swelling. A biopsy specimen of the nodule revealed non-small cell lung carcinoma. Gottron's sign was noted on his hands, and elevated skeletal muscle enzymes were recognized. Based on clinical and histopathological examinations, the patient was given a diagnosis of dermatomyositis. He was treated with chemotherapy (carboplatin/paclitaxel) for lung cancer and his dermatomyositis was treated with steroids (1 mg/kg of prednisolone) for prolonged muscle pain and cough. Although both therapies were successful, he died of respiratory failure due to acute exacerbation of interstitial pneumonia. In the present case, we found that decreasing tumor size might be related to the activity level of skin and muscle symptoms, not interstitial pneumonia. A combination of 3 diseases is thought to be very rare, and we discussed the intercorrelation among lung cancer, dermatomyositis and interstitial pneumonia with a review of the literature.

Dioxins in ascites and serum of women with endometriosis: a pilot study

BACKGROUND

Animal studies and laboratory experiments have demonstrated that exposure to dioxins may be involved in the pathophysiology of endometriosis. However, recent epidemiological investigations have shown conflicting results. Although peritoneal fluid is a specific microenvironment playing a pivotal role in the development of endometriosis, to our knowledge, there is no published study evaluating the concentrations of dioxins in serum and peritoneal fluid simultaneously. The present study explores the possible correlation between the local peritoneal fluid levels of dioxins and concurrent endometriosis.

METHODS

There were 17 infertile women enrolled in the present study. After the diagnostic laparoscopic examination, the women were divided into two groups: endometriosis (n = 10) and controls (n = 7). We measured 29 dioxins simultaneously in serum and peritoneal fluid samples: 7 polychlorinated dibenzo-p-dioxins (PCDDs), 10 polychlorinated dibenzofurans (PCDFs), and 12 polychlorinated biphenyls (dioxin-like PCBs). A dioxin toxic equivalency (TEQ) system was utilized to calculate the dioxin concentration in each sample.

RESULTS

Serum concentrations of itemized components of 29 dioxins were similar in the endometriosis patients compared with the controls. Higher concentrations of PCDFs and dioxin-like PCBs were observed in peritoneal fluid than in serum, whereas the reverse was shown for PCDDs. Statistical analysis showed that higher levels of dioxin TEQ (PCDDs and PCDFs) in peritoneal fluid were significantly associated with an increased risk of endometriosis (OR: 2.5; 95% CI: 1.17-5.34; P = 0.035).

CONCLUSIONS

This is the first report suggesting that higher concentrations of dioxins (PCDDs and PCDFs) in peritoneal fluid are linked to endometriosis. More detail and epidemiological research is warranted to further explore this link.

[Trends in and challenges for highly pathogenic avian influenza A (H5N1)]

A new pandemic influenza A (H1N1) virus had emerged and rapidly spread throughout the world. The clinical pathological observations associated with severe cases of pandemic (H1N1) 2009 are similar to that of high pathogenic avian influenza (H5N1). In order to find the most effective treatment methods for this pandemic influenza (H1N1), we describe our experiences, investigations and collaboration studies of avian influenza (H5N1) in Vietnam in association of our cooperative study of pandemic (H1N1) 2009 in Mexico. Effective treatment methods for critical illness due to influenza will be discussed from medical, regional and global points of view, which may be applied for the treatment of any type of influenza virus.

Mapping of susceptibility locus for endometriosis within the HLA region using microsatellite markers in Japanese women

Endometriosis is a female disorder characterized by the presence of uterine endometrial tissue in ectopic loci. Previous studies reported a higher prevalence of particular human leukocyte antigen (HLA) in endometriosis. In order to confirm the association between endometriosis and the HLA region, 15 polymorphic microsatellite markers distributed in the HLA class II to class III region were subjected to association analysis by polymerase chain reaction (PCR)-based DNA typing of 89 patients and 136 healthy controls. Statistical analysis of the allelic frequency at each microsatellite locus showed that there were no statistically significant differences in the allele frequency distributions between the cases and controls. This finding suggests that the etiology of endometriosis does not involve the HLA class II genomic region and a portion of class III genomic region in the Japanese population.

[Household transmission of pneumococcal pneumonia associated with pandemic influenza (H1N1) 2009]

We report 2 cases of household transmission of pneumococcal pneumonia in isolation, associated with pandemic influenza (H1N1) 2009. A Chinese-American family consisting of a 47-year-old woman and her 16- and 9-year-old sons came to Japan at the beginning of July 2009. The day after their arrival, the woman noticed a high fever in the eldest son. The following day, the other family members also developed high fevers. Real-time reverse transcription polymerase chain reaction (RRT-PCR) analysis confirmed pandemic influenza A (H1N1) 2009 infection in all family members. After diagnosis, all patients were given oseltamivir at another hospital. Subsequently, they were admitted to our hospital and placed in isolation in accordance with the Japanese Infectious Disease Law. At the time of admission, all family members were in a stable condition. However, on the day after admission, the mother complained of a productive cough. Upon further investigation, a CT scan showed a consolidation shadow in the right middle lung lobe. After isolating Streptococcus pneumoniae from her sputum culture, we diagnosed bacterial pneumonia due to S. pneumoniae. In addition, both of her sons also developed fever and cough, and sputum obtained from her elder son indicated S. pneumoniae infection. All 3 were treated with ampicillin and their symptoms improved over a period of a few days. Although the role of Streptococcus pneumoniae in cases of novel influenza A (H1N1) remains unclear, these bacteria may have been responsible for many complications during past pandemic and non-pandemic influenza cases. Use of the 23-valent pneumococcal polysaccharide vaccine should be considered as a potential way to prevent pneumococcal pneumonia during future influenza pandemics.

[Three cases of pulmonary aspergilloma treated by cavernostomy and simultaneous removal of fungus balls]

We report 3 cases of pulmonary aspergilloma treated by cavernostomy and simultaneous removal of fungus balls to eliminate their symptoms. They presented with hemoptysis and prolonged fever with cavitary lesions in their lungs. It was difficult to perform pulmonary resection for them, because of their high age, low respiratory function, and poornutrition. Treatment with anti-fungal agents, obtained no marked effects and thier symptoms were unchanged. Therefore we carried out cavernostomy and simultaneous removal of fungus balls for symptom management. After the surgical treatment, not only did their symptoms improve, but also we were able to maintain good symptom control for a long time. The burden of the surgery on the patients was light and no complications ensued. We strongly believe that cavernostomy and removal of the fungus ball is one of the useful treatment strategies for the patients with pulmonary aspergilloma who are high risks for pulmonary resection and/or who are poorly controlled with anti-fungal chemotherapy.

[Case of repeated hemoptysis successfully treated with bronchial artery embolization with N-butyl cyanoacrylate]

We report a case of repeated hemoptysis successfully treated with bronchial artery embolization (BAE) with N-butyl cyanoacrylate (NBCA). A 75-year-old woman with non-tuberculous mycobacteriosis and pulmonary aspergillosis was admitted with recurrent hemoptysis despite repeated BAE. Considering the ineffectiveness of BAE with Spongel or polyvinyl alcohol, BAE with NBCA was selected. Immediate cessation of hemoptysis was obtained and it has not been seen for 2 years. Although NBCA is the most widely used liquid embolic material to treat brain aneurysm, arteriovenous malformations or gastric varices, there are only a few cases are reported in the treatment of hemoptysis. It seems to be a possible useful treatment for patients with repeated hemoptysis.

[A patient with Mycobacterium avium lung disease presenting with rapid, progressive and multiple cavity formation, who had been treated rheumatoid arthritis with disease modifying anti-rheumatic drugs (DMARDs)]

An 80-year-old woman presented with rapid, progressive and multiple cavitary lesions in both lungs. Rheumatoid arthritis had been diagnosed and been treated with prednisolone (5 mg/day) and bucillamine since 1996. Due to worsening of arthralgia, methotrexate (6 mg/week) and leflunomide (10 mg/day) had been added to the medication since 2003. In April 2005, her chest radiography revealed multiple cavities and nodules predominantly in both upper lung fields, although she complained of no respiratory symptoms. No pathogenic organisms were found, and the cavitary and nodular shadows were increased rapidly within the next 2 months. Therefore, the patient was referred to our hospital in July 2005. Repeat microbiologic findings of sputum were negative for bacteria and fungi, except for Mycobacterium avium (M. avium). She was given a diagnosis of M. avium lung disease, and it seemed to be associated with her compromised status caused by disease modifying anti-rheumatic drugs (DMARDs). She was then successfully treated with combined chemotherapy employed clarithromycin, rifampicin, ethambutol and streptomycin. So far, rapid and progressive deterioration of non-tuberculous mycobacterial lung disease accompanied with an intake of DMARDs had not been reported in Japan. An increase of M. avium complex lung disease in the elderly is now becoming a problem among respiratory physicians. This case highlights the fact that patients who are scheduled to be given DMARDs, particularly elderly case, should be considered to be at an elevated risk of developing non-tuberculous mycobacterial (NTM) lung disease, and the risk of NTM infection should be excluded before prescribing drugs.

Effect of famotidine and lansoprazole on serum phosphorus levels in hemodialysis patients on calcium carbonate therapy

AIMS

Histamine H2 receptor antagonists (HRA) or proton pump inhibitors (PPI) are frequently administered to patients on hemodialysis, because their intestinal mucosa is fragile. Although three studies have indicated that concomitant HRA administration causes a decrease in the binding of phosphate by calcium carbonate, the HRA doses tested in these studies were 2-4 times higher than the recommended dose for hemodialysis patients. In addition, it remains unclear whether PPI therapy affects serum phosphate levels in hemodialysis patients taking calcium carbonate. Accordingly, the aim of this study was to evaluate the influence of lansoprazole and the recommended dose of famotidine on serum phosphate and calcium levels in hemodialysis patients.

METHODS

The study included 115 hemodialysis patients who were taking calcium carbonate and who were also treated with either famotidine (10 mg/day) or lansoprazole (30 mg/day). Changes of the mean serum phosphate and calcium levels over 2 months before and after the start of famotidine or lansoprazole therapy were compared. The same parameters were also compared when famotidine was switched to lansoprazole.

RESULTS

The mean serum phosphate level increased significantly after administration of either famotidine or lansoprazole (by 6.6 +/- 21.9% or 13.0 +/- 26.3%, p = 0.032 and p = 0.029, respectively). The mean serum calcium level was unchanged after administration of famotidine, but showed a significant decrease after administration of lansoprazole (by 3.44 +/- 7.73%, p = 0.013). Therefore, the calcium x phosphorus product was significantly increased by administration of famotidine, but not by administration of lansoprazole (6.68 +/- 23.37% and 8.73 +/- 27.41%, p = 0.046 and p = 0.251, respectively). When famotidine was switched to lansoprazole, the serum phosophate level did not change, but serum calcium decreased significantly by 3.8 +/- 13.0% (p = 0.0006).

CONCLUSION

Not only administration of 20 mg/ day of famotidine as previously reported, but also 10 mg/day of this drug (the recommended dose for hemodialysis patients) caused a significant increase of serum phosphate in patients taking calcium carbonate. PPIs have been reported to show no effect on the serum phosphate level, but 30 mg/day of lansoprazole also caused a significant increase of serum phosphate in patients taking calcium carbonate.

FDG-PET/CT finding of high uptake in pulmonary alveolar microlithiasis

Pulmonary alveolar microlithiasis (PAM) is a rare lung disease characterized by progressive intra-alveolar calcification. We present a case of PAM with abnormal accumulation of 18F-fluorodeoxyglucose (FDG) in both lungs. A 55-year-old man was referred to our hospital for progressive dyspnea. He had been diagnosed with PAM 25 years earlier by transbronchial lung biopsy. High-resolution computed tomography revealed multiple dense calcifications with little aerated lung. Combined positron emission tomography and computed tomography using 18F-FDG (FDG-PET/CT) showed the abnormal accumulation of FDG in both lungs with a maximal standardized uptake value of 7.3. High FDG uptake was observed mainly in the lung regions showing sparing calcification. The patient died of respiratory failure a month later and an autopsy revealed no significant inflammatory changes in either lung. We suspect that the markedly enhanced pulmonary FDG uptake may have some relation to the pathophysiology of PAM.

Identification and detection of Pseudomonas plecoglossicida isolates with PCR primers targeting the gyrB region

Pseudomonas plecoglossicida is the agent of bacterial haemorrhagic ascites (BHA) in freshwater fish farming in Japan. To develop a rapid identification and detection method for P. plecoglossicida, a PCR amplification technique targeting the chromosomal DNA region coding the B subunit of the DNA gyrase (gyrB) was used. The nucleotide sequences of gyrB were determined in nine isolates of P. plecoglossicida and two other Pseudomonas species. On the basis of these determined sequences and the gyrB sequences of other Pseudomonas species or fish pathogenic bacteria deposited in international nucleotide sequence databases (GenBank/EMBL/DDBJ), PCR primers PL-G1F, PL-G1R, PL-G2F and PL-G2R were designed for specific amplification of the partial gyrB of P. plecoglossicida. The specificity of these primers in amplifying the gyrB of P. plecoglossicida was verified using selected strains of related bacterial species. The nested PCR technique was used to detect P. plecoglossicida from kidney and intestine of ayu. Primer pair PL-G1F and PL-G1R was used for the external PCR, and primer pair PL-G2F and PL-G2R for the internal PCR. Of 10 ayu juveniles, expected size PCR products were observed from intestine and kidney samples in one and two specimens, respectively. The PCR technique with primers based on the gyrB sequence is thus useful for the diagnosis of BHA.

Molecular typing by pulsed-field gel electrophoresis of Flavobacterium psychrophilum isolates derived from Japanese fish

Sixty-four isolates of Flavobacterium psychrophilum from ayu, Plecoglossus altivelis altivelis (Temminck & Schlegel), and other fish (n=16) in Japan and the type strain (NCIMB 1947(T)) were typed using pulsed-field gel electrophoresis (PFGE) with endonuclease BlnI and XhoI. These isolates were classified into 20 clusters and 42 genotypes by PFGE analysis. The most predominant cluster of isolates from ayu was cluster XII (n=20), followed by clusters XVII, XVI, XX, XI, IX, X, XIII and XV; the remaining 17 isolates from other fish were divided into clusters I, II, III, IV, V, VI, VII, VIII, XIV, XVIII and XIX. The PFGE genotype of isolates from ayu clearly differed from those of other fish. The isolates from ayu in Gunma Prefecture belonged to clusters XII, XVI, XVII and XX, and the strains of three of these clusters (XII, XVII and XX) were isolated from ayu in 15 of 19 prefectures. PFGE typing enabled more accurate classification of isolates into clusters than previously achieved by analysing the restriction fragment length polymorphism of PCR products. These results suggest that F. psychrophilum isolated from ayu and other fish are genetically different and strains with several PFGE types have spread within Japan.

PCR-RFLP genotypes associated with quinolone resistance in isolates of Flavobacterium psychrophilum

A novel genotyping method for epizootiological studies of bacterial cold-water disease caused by Flavobacterium psychrophilum and associated with quinolone resistance was developed. Polymerase chain reaction followed by restriction fragment length polymorphism (PCR-RFLP) was performed on 244 F. psychrophilum isolates from various fish species. PCR was performed with primer pair GYRA-FP1F and GYRA-FP1R amplifying the A subunit of the DNA gyrase (GyrA) gene, which contained the quinolone resistance determining region. Digestion of PCR products with the restriction enzyme Mph1103I showed two genotypes, QR and QS. The difference between these genotypes was amino acid substitutions at position 83 of GyrA (Escherichia coli numbering). The genotype QR indicated an alanine residue at this position associated with quinolone resistance in F. psychrophilum isolates. Of the 244 isolates tested in this study, the number of QR genotype isolates was 153 (62.7%). In isolates from ayu (n=177), 146 (82.5%) were genotype QR. With combination of this technique and previously reported PCR-RFLP genotyping, eight genotypes were observed in F. psychrophilum isolates. Using this genotyping system, the relationships between genotype and host fish species, or locality of isolation, were analysed and are discussed.

[Effects of new discharge criteria incorporating DOTS on treatment outcome of patients with smear-positive tuberculosis]

BACKGROUND

Some problems remain in the treatment of tuberculosis (TB) in Japan, with a higher prevalence of TB, low percentages of completed therapy and cases given DOTS, and longer admission period compared to the United States. We defined our own new criteria for discharge as sputum smear negativity instead of culture negativity, modified according to CDC criteria with shortened admission periods. However, the effects on treatment outcome have not been evaluated.

OBJECTIVES

The aim of this study was to ensure the effectiveness of the new criteria, including DOTS undertaken after discharge.

PATIENTS/METHODS

Group I comprised 459 cases hospitalized between January 2000 and December 2002 that were discharged under the old criteria, while Group II comprised 259 cases hospitalized between January 2003 and April 2004 that were discharged under the new criteria. We tried to undertake DOTS in cooperation with local health centers. The main outcome measures were admission period, treatment completion and relapse rates at 1 year after the completion of treatment.

RESULTS

The new criteria enabled median admission period to be shortened from 84 days to 69 days, although patients in Group II were older and displayed more severe tuberculosis lesions compared to Group I. DOTS coverage rate increased significantly from 5.9% to 40.5%, and treatment completion rate, percentage of lost cases and relapse rate for completed cases at 1 year changed from 83.0% to 86.6%, 6.3% to 3.9%, and 2.5% to 2.5%, respectively. No significant differences in these 3 rates were noted between Groups I and II.

CONCLUSION

The new criteria incorporating DOTS enabled shortened admission period without any adverse effect on treatment outcomes.

Mutations in the SLC34A2 gene are associated with pulmonary alveolar microlithiasis

RATIONALE

Pulmonary alveolar microlithiasis is an autosomal recessive disorder in which microliths are formed in the alveolar space.

OBJECTIVES

To identify the responsible gene that causes pulmonary alveolar microlithiasis.

METHODS

By means of a genomewide single-nucleotide polymorphism analysis using DNA from three patients, we have narrowed the region in which the candidate gene is located. From this region, we have identified a gene that has mutations in all patients with pulmonary alveolar microlithiasis.

MEASUREMENTS AND MAIN RESULTS

We identified a candidate gene, SLC34A2, that encodes a type IIb sodium phosphate cotransporter and that is mutated in six of six patients investigated. SLC34A2 is specifically expressed in type II alveolar cells, and the mutations abolished the normal gene function.

CONCLUSION

Mutations in the SLC34A2 gene that abolish normal gene function cause pulmonary alveolar microlithiasis.

[Case of cavitary coccidioidomycosis with fungus balls in the apices of both lungs]

Pulmonary cavitary coccidioidomycosis with a fungus ball was observed in a immunocompetent case. A 32-year-old Japanese man visited Arizona to play golf. After 1 month he consulted a local hospital complaining of a prolonged cough and hematopysis. The laboratory examination revealed eosinophillia and chest radiograph showed 2 cavitary lesions, surrounded by small nodules in the apices of both lungs. Pulmonary tuberculosis was suspected and treated with 4 antituberculosis drugs for 3 months. However, the cavities enlarged and he was admitted to our hospital for further examination and treatment. Transbronchial lung biopsy was performed and serologically, bacteriologically and histologically a diagnosis of chronic coccidioidmycosis was made. It is very rare for fungus ball formation and coexistence of spherules and hyphae of Coccidioides immitis to be seen. Fluconazole was temporarily effective, causing cavities to shrink and eosinophilia to decrease, however Amphotericin B needed to be used later. Eosinophilia was closely related to the severity of the disease gravity.

A phase I/II trial of irinotecan-cisplatin combined with an anti-late-diarrhoeal programme to evaluate the safety and antitumour response of this combination therapy in patients with advanced non-small-cell lung cancer

We conducted a phase I/II study in patients with advanced non-small-cell lung cancer (NSCLC) to increase the therapeutic index of the cisplatin–irinotecan combination by institution of an anti-late-diarrhoeal program (ADP). A total of 77 chemotherapy-naive patients with advanced NSCLC were enrolled. The cisplatin dose was fixed at 60 mg m⁻² (Day 1). Irinotecan was escalated in 5 mg m⁻² increments, starting from 60 mg m⁻² (Days 1 and 8). ADP consisted of oral sodium bicarbonate, magnesium oxide, basic water, and ursodeoxycholic acid, and was administered orally for 4 days with each dose of irinotecan. In the phase I portion, irinotecan pharmacokinetics was also examined. After the recommended dose of irinotecan with ADP was determined, a phase II study was conducted to evaluate the response. Maximum tolerated dose was reached at an irinotecan dose of 80 mg m⁻² (Grade 4 diarrhoea and neutropenia). Pharmacokinetic studies show that the maximum concentration and the area under the curve of both irinotecan and SN38 (active metabolite of irinotecan) tend to increase in the dose-dependent manner of irinotecan. The phase II portion of the study included 48 patients, who were treated with 75 mg m⁻² of irinotecan. Grade 3/4 toxicities included neutropenia in 65%, leucopenia in 33%, and late diarrhoea in 6% of the patients. During this treatment, PS did not change in 65% of patients. At the end of the chemotherapy, PS did not decline in 90% of patients. In the phase II portion, a response occurred in 63% (95% confidential interval (CI), 47–76%) of patients. Median time to progression was 19 weeks (95% CI, 15–22 weeks), and median survival was 52 weeks (95% CI, 39–64 weeks). This regimen of irinotecan and cisplatin with ADP resulted in promising efficacy with acceptable toxicity for patients with advanced NSCLC. This regimen is a candidate for the experimental arm towards future phase III studies.

Detection and identification of Flavobacterium psychrophilum from gill washings and benthic diatoms by PCR-based sequencing analysis

A nested polymerase chain reaction (PCR) amplification technique was used to detect Flavobacterium psychrophilum from washings of fish gill surfaces and benthic diatoms as environmental samples. Gill washing samples were prepared from kawamutsu, Zacco temminckii (Temminck & Schlegel) and oikawa, Z. platypus (Temminck & Schlegel). Benthic diatom samples were collected from stone surfaces. All samples were collected from rivers in Wakayama Prefecture, Japan from November 2003 to January 2004. Following simple DNA extraction using a chelating resin, nested PCR techniques targeting 16S-rDNA and gyrB regions were performed, and PCR products were cloned and sequenced. With nested PCR amplification for the 16S-rDNA gene, ambiguous PCR products were detected from two of six samples, and by cloning and sequencing analysis were found not to be DNA fragments amplified from F. psychrophilum. Using nested PCR for the gyrB gene, however, five of six samples were clearly positive for F. psychrophilum in agarose gel electrophoresis, and were found to be identical with nucleotide sequences of F. psychrophilumgyrB deposited in DNA databases by sequencing analysis. Results indicate that nested PCR for the gyrB region is a useful technique to detect low levels of F. psychrophilum from environmental samples contaminated with many other organisms.

Relief of suffering and regard for personhood: nurses' ethical concerns in Japan and the USA

The ethical concerns of Japanese nurses are compared with those of previously described nurses from the USA. Patient comfort was a primary concern of nurses from both countries. Participants described an ethical imperative to provide adequate pain medication for patients and prevent unnecessary and uncomfortable invasive tests and procedures, especially at the end of life as the focus changed from 'cure' to 'care'. The notion of regard for personhood varied, based on the communication styles and definition of the self inherent in the different cultures of the nurses. A common meaning centred around knowing patients as persons, listening to their needs and preferences, supporting their everyday choices through advocacy, and maintaining their dignity. Despite background cultural differences, there are common ethical concerns between nurses in Japan and the USA. This article invites readers to reflect on everyday nursing practices that exemplify ethical expertise, and the significance of this expertise in uncovering and articulating nursing ethics across cultures.

Interactions between clarithromycin and digoxin in patients with end-stage renal disease

OBJECTIVE

To report a significant increase in the serum levels of digoxin associated with the use of clarithromycin in six patients undergoing renal replacement therapy.

CASE SUMMARY

All six patients were males with end-stage renal disease and in need of renal replacement therapy. Four patients were anuric. The mean age was 78.8 +/- 5.8 (66-83) years. All patients except one, who was treated by hemofiltration, were treated by hemodialysis. All patients except one, who had been treated with metildigoxin (0.35 mg/week), were also taking digoxin (0.375 mg/week). Clarithromycin was administered at a dose of 200-400 mg/day for the treatment of bronchitis in all patients. The concomitant administration of clarithromycin increased serum digoxin levels from 1.8-4.0-fold in all cases. In two of six cases, a high probability of digoxin intoxication and suspicion of digoxin intoxication was evident. In three of six cases, serum digoxin levels increased within 12 days after the co-administration of clarithromycin, while in the other three cases, serum digoxin levels were increased 53-190 days after the administration of clarithromycin.

CONCLUSION

The simultaneous administration of clarithromycin caused an increase in digoxin levels in six patients undergoing renal replacement therapy. The increase in the serum digoxin can be attributed to the inhibition of P-glycoprotein in the intestine and/or bile capillary rather than the kidney by clarithromycin since renal function was dramatically impaired, and four of the patients were anuric. The issue of why serum digoxin levels were increased so late in three patients undergoing renal replacement is unclear. However, this interaction seemed to be clinically significant even in ESRD patients, whose renal function was highly impaired. The simultaneous use of digoxin and clarithromycin should be avoided even in patients undergoing renal replacement therapy whose renal function is impaired, since digoxin levels may increase unexpectedly.

Cancer incidence in children and young adults did not increase relative to parental exposure to atomic bombs

We have examined whether parental exposure to atomic bomb radiation has led to increased cancer risks among the offspring. We studied 40 487 subjects born from May 1946 through December 1984 who were cancer-free in January 1958. One or both parents were in Hiroshima or Nagasaki at the time of the bombing and for childbirth. Using population-based tumor registry data we analyzed cancer incidence data from 1958 to 1997 by Cox regression models, and we examined the effects of both paternal and maternal irradiation with adjustment for city, sex, birth year, and migration. During follow-up, 575 solid tumor cases and 68 hematopoietic tumor cases were diagnosed. Median age at diagnosis was 39.7 years. Median doses were 143 millisierverts for 15 992 exposed (5+ millisierverts or unknown dose) fathers and 133 millisierverts for 10 066 exposed mothers. Cancer incidence was no higher for subjects with exposed parents than for the reference subjects (0–4 millisierverts), nor did the incidence rates increase with increasing dose. For 3568 subjects with two exposed parents, the adjusted risk ratio for all cancer was 0.97 (95% confidence interval 0.70–1.36). Because of the small number of cases, however, we cannot exclude an increase in cancer incidence at this time.