A 65-Year-Old Man with Refractory Hemoptysis Associated with Chronic Progressive Pulmonary Aspergillosis Who Failed to Respond to Combined Endobronchial Occlusion and Bronchial Artery Embolization: A Case Report and Literature Review

BACKGROUND Hemoptysis due to airway hemorrhage is treated with hemostatic agents, bronchial artery embolization (BAE), or surgical resection. We present the case of a 65-year-old man with refractory hemoptysis associated with chronic progressive pulmonary aspergillosis (CPPA) who failed to respond to combined endobronchial occlusion (EBO) with endobronchial Watanabe spigot (EWS) and BAE. CASE REPORT A 63-year-old man was diagnosed with CPPA in the right upper lung and presented to our hospital 2 years later for hemoptysis at age 65. He developed severe hemoptysis during an outpatient visit, and was urgently admitted, intubated, and ventilated to prevent choking on blood clots. Chest computed tomography showed a large mass in the apical portion of the right lung, constituting apical pleural thickening and an encapsulated pleural effusion, and dilatation in the bronchial artery supplying the right upper lung lobe. Bronchoscopy revealed the right upper lobe B1-B3 as the bleeding source. The patient had recurrent hemoptysis that was not controlled by BAE or 6 EBO+EWS procedures, and he ultimately died of hypoxemia.In the literature review, EBO+EWS can effectively control hemoptysis in appropriate cases, without the need for BAE or surgical lung resection. It is less invasive, is associated with fewer adverse events than BAE or surgery, and can achieve temporary hemostasis for severe hemoptysis. CONCLUSIONS BAE and EBO+EWS were ineffective in controlling recurrent hemoptysis caused by CPPA in this case. However, a multidisciplinary approach such as attempting hemostasis with combined EBO+EWS and BAE may be a viable treatment option in severe cases of hemoptysis.

Artifact reduction in low and ultra-low dose chest computed tomography for patients with pacemaker: A phantom study

INTRODUCTION

Implanted pacemakers (PM) would decrease the detection of lung nodules in chest computed tomography (CT) due to the metal artifact. This study aimed to explore the computer-aided diagnosis (CAD) detectability of pulmonary nodules for the patients implanted with PMs in low- and ultra-low-dose chest CT screening.

METHODS

Four different sizes of artificial nodules were placed in an anthropomorphic chest phantom with two alternative diameters utilized. A commercially available PM was placed on the surface of the left chest wall of the phantom. The image acquisitions were performed with 120 kV and 150 kV with a dedicated selective photon shield made of tin filter (Sn150 kV) at low- and ultra-low- radiation doses (1.0 and 0.5 mGy of volume CT dose index), and reconstructed with and without Iterative Metal Artifact Reduction (iMAR, Siemens Healthineers, Erlangen, Germany). The relative artifact index (AIr) was calculated as an index of metal artifacts, and the nodule detectability was evaluated with a CAD system.

RESULTS

Sn150 kV reduced AIr in all acquisitions when comparing 120 kV and Sn150 kV. Although PM reduced the detectability of nodules, Sn150 kV showed higher detectability compared to 120 kV. The use of iMAR showed inconsistent results in nodule detectability.

CONCLUSION

Sn150 kV reduced PM-induced metal artifacts and improved nodule detectability with CAD compared to 120 kV acquisition in many conditions including low and ultra-low doses and large phantoms, but iMAR did not improve the detectability.

IMPLICATIONS FOR PRACTICE

Based on the results of the current phantom study, low and ultra-low dose with Sn150 kV acquisition reduced PM-induced metal artifacts and improved nodule detectability.

Breath Measurement Method for Synchronized Reproduction of Biological Tones in an Augmented Reality Auscultation Training System

An educational augmented reality auscultation system (EARS) is proposed to enhance the reality of auscultation training using a simulated patient. The conventional EARS cannot accurately reproduce breath sounds according to the breathing of a simulated patient because the system instructs the breathing rhythm. In this study, we propose breath measurement methods that can be integrated into the chest piece of a stethoscope. We investigate methods using the thoracic variations and frequency characteristics of breath sounds. An accelerometer, a magnetic sensor, a gyro sensor, a pressure sensor, and a microphone were selected as the sensors. For measurement with the magnetic sensor, we proposed a method by detecting the breathing waveform in terms of changes in the magnetic field accompanying the surface deformation of the stethoscope based on thoracic variations using a magnet. During breath sound measurement, the frequency spectra of the breath sounds acquired by the built-in microphone were calculated. The breathing waveforms were obtained from the difference in characteristics between the breath sounds during exhalation and inhalation. The result showed the average value of the correlation coefficient with the reference value reached 0.45, indicating the effectiveness of this method as a breath measurement method. And the evaluations suggest more accurate breathing waveforms can be obtained by selecting the measurement method according to breathing method and measurement point.

Effectiveness of Lung Ultrasound Training Utilizing a High-Fidelity Simulator

Background

The usefulness of lung ultrasound (LUS) has been demonstrated. However, it is unclear whether diagnostic techniques using LUS are accepted by all physicians. A simple simulation-based educational program may improve the LUS skills of beginners, but it has not been fully assessed.

Objective

This prospective study was conducted to assess the educational outcomes of LUS training using a high-fidelity simulator.

Methods

A simulator-based program for LUS was conducted. All clerkship students at the Department of Respirology at Chiba University Hospital participated in the program from December 2022 to April 2023. The participants watched a 30 minute teaching video on demand before a hands-on session lasting for 1 hour during the first week of the clinical clerkship. The readiness of the participants to learn LUS and the usefulness of the program were assessed using questionnaires administered before and after the program. The LUS skills were assessed using simulator-based tests during Weeks 1 and 4. Data on the accuracy and time required to answer the questions were collected during the tests.

Results

Forty clerkship students participated in this study. Thirty-three (82.5%) had received other ultrasound education; however, only two (5.0%) had experience with LUS. Based on the questionnaire responses, the participants perceived LUS as useful (preprogram: 4.6 vs. postprogram: 4.8; P = 0.010; a 5-point Likert scale was used [1: not useful to 5: useful]). The simulator-based tests showed comparable accuracies at Weeks 1 and 4 for pneumothorax (Week 1: 47.5% vs. Week 4: 52.5%; P = 0.623), pulmonary edema (Week 1: 100% vs. Week 4: 100%; P = 1.000), and pleural effusion (Week 1: 37.5% vs. Week 4: 40.0%; P = 0.800). The time required for scanning was the same for each question. In addition, the test results did not differ with prior learning, previous knowledge, or experience during clinical clerkships on LUS.

Conclusion

A short educational program consisting of on-demand learning and hands-on sessions with a high-fidelity simulator would be effective in equipping clerkship students with basic LUS skills. However, to increase its educational effectiveness to a practical degree, the program should be improved, and more opportunities for training using simulators should be provided.

Pneumonia due to Achromobacter xylosoxidans with a chronic course resembling non-tuberculous mycobacterial infection

Achromobacter xylosoxidans is a common bacterium that rarely causes pneumonia. Determining whether A. xylosoxidans is the cause of lung infection in patients suspected of having chronic infectious lung disease is challenging because it can present with colonization. We report a case of a 56-year-old immunocompetent woman suspected of having non-tuberculous mycobacteria (NTM) infection on imaging examination and monitored for 3 years. Sputum examinations revealed A. xylosoxidans several times, and it was determined to be a colonization. A. xylosoxidans was isolated from bronchial lavage fluid and aspirated sputum, but no evidence of NTM was observed. She was diagnosed with A. xylosoxidans infection and given ceftazidime for 2 weeks. Her symptoms and imaging findings improved rapidly after treatment, without recurrences. A. xylosoxidans rarely causes chronic lower respiratory tract infections similar to NTM in immunocompetent patients. A. xylosoxidans may be a target for treatment when detected in lower respiratory tract specimens.

IgA Vasculitis as a Potential Complication of Fourth-Line Chemotherapy with Tegafur/Gimeracil/Oteracil (S-1) in Advanced Non-Small Cell Lung Cancer: A Case Report

BACKGROUND Immunoglobulin A (IgA) vasculitis is a systemic vasculitis that involves the small vessels. It is mainly characterized by skin symptoms such as purpura, arthritis/arthralgia, abdominal symptoms, and nephropathy, which are caused by IgA adherence to the vessel walls. Herein, we report the case of an advanced non-small cell lung cancer (NSCLC) and a purpuric skin rash of the legs that developed during fourth-line chemotherapy with tegafur/gimeracil/oteracil (S-1). CASE REPORT A 68-year-old man diagnosed with NSCLC 2 years ago was undergoing S-1 as fourth-line chemotherapy when he developed purpura and edema on the lower extremities. Biopsy renal specimens were consistent with IgA vasculitis. Considering his medical history, both IgA vasculitis induced by S-1 and a paraneoplastic syndrome were considered, although the exact cause could not be identified. Subsequently, chemotherapy was discontinued because of his deteriorating general condition, and he received optimal supportive care. The purpura spontaneously disappeared; however, his ascites and renal function deteriorated. Systemic steroids improved renal function, but the ascites did not resolve. One month after being diagnosed with IgA vasculitis, the patient died due to deterioration of his general condition. CONCLUSIONS This case emphasizes the occurrence of IgA vasculitis during lung cancer treatment and its potential impact on the disease course of lung cancer. Moreover, the possible causes of IgA vasculitis in this case were paraneoplastic syndrome or S-1 adverse effects, but further case series are needed to gain a more comprehensive understanding. Refractory, steroid-unresponsive ascites may occur as an abdominal manifestation of IgA vasculitis.

Developing Medical Education Curriculum Reform Strategies to Address the Impact of Generative AI: Qualitative Study

BACKGROUND

Generative artificial intelligence (GAI), represented by large language models, have the potential to transform health care and medical education. In particular, GAI's impact on higher education has the potential to change students' learning experience as well as faculty's teaching. However, concerns have been raised about ethical consideration and decreased reliability of the existing examinations. Furthermore, in medical education, curriculum reform is required to adapt to the revolutionary changes brought about by the integration of GAI into medical practice and research.

OBJECTIVE

This study analyzes the impact of GAI on medical education curricula and explores strategies for adaptation.

METHODS

The study was conducted in the context of faculty development at a medical school in Japan. A workshop involving faculty and students was organized, and participants were divided into groups to address two research questions: (1) How does GAI affect undergraduate medical education curricula? and (2) How should medical school curricula be reformed to address the impact of GAI? The strength, weakness, opportunity, and threat (SWOT) framework was used, and cross-SWOT matrix analysis was used to devise strategies. Further, 4 researchers conducted content analysis on the data generated during the workshop discussions.

RESULTS

The data were collected from 8 groups comprising 55 participants. Further, 5 themes about the impact of GAI on medical education curricula emerged: improvement of teaching and learning, improved access to information, inhibition of existing learning processes, problems in GAI, and changes in physicians' professionality. Positive impacts included enhanced teaching and learning efficiency and improved access to information, whereas negative impacts included concerns about reduced independent thinking and the adaptability of existing assessment methods. Further, GAI was perceived to change the nature of physicians' expertise. Three themes emerged from the cross-SWOT analysis for curriculum reform: (1) learning about GAI, (2) learning with GAI, and (3) learning aside from GAI. Participants recommended incorporating GAI literacy, ethical considerations, and compliance into the curriculum. Learning with GAI involved improving learning efficiency, supporting information gathering and dissemination, and facilitating patient involvement. Learning aside from GAI emphasized maintaining GAI-free learning processes, fostering higher cognitive domains of learning, and introducing more communication exercises.

CONCLUSIONS

This study highlights the profound impact of GAI on medical education curricula and provides insights into curriculum reform strategies. Participants recognized the need for GAI literacy, ethical education, and adaptive learning. Further, GAI was recognized as a tool that can enhance efficiency and involve patients in education. The study also suggests that medical education should focus on competencies that GAI hardly replaces, such as clinical experience and communication. Notably, involving both faculty and students in curriculum reform discussions fosters a sense of ownership and ensures broader perspectives are encompassed.

Severe Bacterial Pneumonia due to Legionella longbeachae Transmitted from Potting Soil in Japan

Pneumonia caused by Legionella longbeachae, transmitted through contaminated soil, is very rare in Japan. A 70-year-old man with severe respiratory failure was admitted to our hospital and underwent multidisciplinary procedures. Although a urinary antigen test was negative for Legionella, he was clinically diagnosed with legionellosis and administered levofloxacin. His condition subsequently improved. Thereafter, sputum culture detected L. longbeachae. Because the DNA of L. longbeachae was detected in the gardening soil, it is suspected source of infection. Therefore, it is important to suspect legionellosis based on clinical information, even if a urine antigen test is negative.

The effect of nano hydroxyapatite coating implant surfaces on gene expression and osseointegration

BACKGROUND

Hierarchical micro-nano structured topography along with surface chemistry modifications of dental implants have been suggested to positively contribute to the osseointegration process. However, the effect of such surface modifications on the molecular response as well as bone formation rate and quality are still unclear, especially in the early healing period. This study aimed to evaluate the effect of coating a double acid etched (DAE) implant surface with nano-sized (20 nm) hydroxyapatite (Nano) with respect to gene expression, histologic parameters, and nanomechanical properties when compared to DAE control at 1 and 2 weeks after implant placement in a rodent femur model.

MATERIAL AND METHODS

Expression of bone-related genes was determined by qRT-PCR (Col-I, Runx-2, Osx, Opn, Ocn, Alp). Histomorphometric evaluation of bone-to-implant contact (BIC) and bone area fraction occupancy (BAFO) within implant threads was performed using photomicrographs after histologic processing. Mechanical properties, reduced elastic modulus and hardness, were determined through nanoindentation.

RESULTS

At 1 week, the Nano group demonstrated significantly higher expression of Col-I and Ocn compared to the DAE group, indicating upregulation of osteoprogenitor and osteoblast differentiation genes. At 2 weeks, Nano surface further exhibited enhanced gene expression of Col-I and Osx in comparison to the DAE surface, suggesting an increased mineralization of the newly formed bone. Nanoindentation analysis revealed that the Nano group presented no significant difference on the ranks of reduced elastic modulus and hardness compared to DAE for both timepoints. Histomorphometric analysis yielded no significant difference in the percentage of BIC and BAFO between the Nano and DAE surfaces at 1 and 2 weeks. However, Nano implants did present a higher mean value, ~50%, of BIC compared to DAE, ~30%, after 2 weeks in vivo.

CONCLUSIONS

While no significant differences were observed in the amount and mechanical properties of newly formed bone, Nano surface positively and significantly increased the expression osteogenic genes compared to DAE surface at early healing periods.

Macitentan Administration for Pulmonary Hypertension Due to β-thalassemia with Multiple Organ Failure: A Case Report

A 51-year-old Thai woman diagnosed with β-thalassemia underwent regular blood transfusion and iron-chelating therapy. However, after voluntarily discontinuing treatment, the patient developed progressive dyspnea and was diagnosed with pulmonary hypertension following right heart catheterization. Despite resuming blood transfusions, her condition did not improve. Because the patient had a history of multiple organ failure, curative treatment for β-thalassemia was not feasible, and macitentan was administered. Despite experiencing hypotension as an adverse event, her condition remained stable during macitentan treatment. Thus, macitentan may be well tolerated in patients with pulmonary hypertension caused by β-thalassemia with multiple organ dysfunction.

Role of Fibrin Monomer Complex in Coronavirus Disease 2019 for Venous Thromboembolism and the Prognosis

Objective Venous thromboembolism (VTE) is a common complication of severe coronavirus disease 2019 (COVID-19) and is associated with its prognosis. The fibrin monomer complex (FMC), a marker of thrombin generation, is reportedly useful in diagnosing acute thrombosis. To date, there has been only one report on FMC in COVID-19, and the usefulness of FMC in COVID-19 is unknown. We therefore evaluated the frequency of VTE in non-intensive-care unit COVID-19 patients in Japan and determine the clinical utility of FMC in COVID-19. Methods This was a single-center retrospective study. Laboratory test results and outcomes (thrombosis and severe progression of COVID-19) were obtained via medical record review. We assessed the relationship between FMC and VTE incidence and evaluated the association between elevated FMC levels and severe progression of COVID-19. Patients This study included 247 patients with COVID-19 who were hospitalized between December 2020 and September 2021 and had had their levels of D-dimer and FMC measured. Results Of the 247 included patients, 3 (1.2%) developed VTE. All three had elevated FMC levels on admission; however, the D-dimer level was not elevated in one case on admission. The FMC level was significantly higher in the group with severe COVID-19 progression than in the group without severe progression. A multivariate analysis showed that severe progression was associated with elevated FMC levels (odds ratio, 7.40; 95% confidence interval, 2.63-22.98; p<0.001). Conclusion FMC can be useful for diagnosing VTE in the acute phase of COVID-19. Elevated FMC was found to be associated with severity on admission and severe progression.

Diagnostic imaging of intrathoracic extramedullary haematopoiesis

Although intrathoracic extramedullary haematopoiesis (EMH) is rare, its nodular lesions should be differentiated from malignancy. 111In-bone marrow scintigraphy can be useful for the non-invasive diagnosis of intrathoracic EMH because extramedullary accumulation of 111In can be determined as EMH.

A Comparison of Clinical Presentations in Coronavirus Disease 2019 Caused by Different Omicron Variants in Japan: A Retrospective Study

Objective We evaluated the clinical differences in coronavirus disease 2019 (COVID-19) patients between the sixth wave with the Omicron BA.1/BA.2 dominant variant (from January to April 2022) and seventh wave with the Omicron BA.5 dominant variant (from July to August 2022). Methods This retrospective, single-center, observational study included COVID-19 patients admitted to our institution in the sixth wave (sixth-wave group) and the seventh wave (seventh-wave group). Inter-group comparisons of clinical presentations, the prognosis, and proportion of nosocomial infections were performed. Results A total of 190 patients were included (93 and 97 patients in the sixth- and seventh-wave groups, respectively). While there were no significant differences in severity, significantly more patients developed pneumonia caused by COVID-19 in the sixth-wave group than in the seventh-wave group. Although there was no marked difference in in-hospital deaths, more patients died from COVID-19 in the sixth-wave group than in the seventh-wave group. There were significantly more COVID-19 inpatients with nosocomial infections in the seventh-wave group than in the sixth-wave group. Pneumonia from COVID-19 was significantly more severe in the sixth-wave group than in the seventh-wave group. Conclusion COVID-19 patients in the seventh wave are at a lower risk of pneumonia than those in the sixth wave. However, even in the seventh wave, patients with underlying diseases have a risk of death because of the exacerbation of underlying diseases triggered by COVID-19.

Mixed-methods education of mechanical ventilation for residents in the era of the COVID-19 pandemic: Preliminary interventional study

INTRODUCTION

In the current era of the severe acute respiratory syndrome-coronavirus-2 epidemic, the need for respiratory care, including mechanical ventilatory (MV) management, has increased. However, there are no well-developed educational strategies for training medical personnel dealing with respiratory care in MV management.

METHODS

A novel mixed-methods hands-on seminar for learning MV management was conducted for the residents at Chiba University Hospital in March 2022. The seminar lasted approximately 2 hours. The learning goal for the residents was to develop skills and knowledge in performing basic respiratory care, including MV, during an outbreak of a respiratory infection. The seminar with a flipped classroom consisted of e-learning, including modules on respiratory physiology and MV management, hands-on training with a low-fidelity simulator (a lung simulator), and hands-on training with a high-fidelity simulator (a human patient simulator). The effectiveness of the seminar was evaluated using closed questions (scored on a five-point Likert scale: 1 [minimum] to 5 [maximum]) and multiple-choice questions (maximum score: 6) at the pre- and post-seminar evaluations.

RESULTS

Fourteen residents at Chiba University Hospital participated in the program. The questionnaire responses revealed that the participants' motivation for learning about MV was relatively high in the pre-seminar period (seven participants [50%] selected level 5 [very strong]), and it increased in the post-seminar period (all participants selected level 5) (p = 0.016). The responses to the multiple-choice questions revealed that the participants did not have enough knowledge to operate a mechanical ventilator, while the total score significantly improved from the pre- to post-seminar period (pre-seminar: 3.3 ± 1.1, post-seminar: 4.6 ± 1.0, p = 0.003).

CONCLUSIONS

The seminar implemented in this study helped increase the residents' motivation to learn about respiratory care and improved knowledge of MV management in a short time. In particular, the flipped classroom may promote the efficiency of education on MV management.

Clinical significance of lung cross-sectional area measured by computed tomography in chronic thromboembolic pulmonary hypertension: The correlation with pulmonary hemodynamics and the limitations

The percentage cross-sectional area of the lung under five (%CSA<5) is the percentage of pulmonary vessels with <5 mm2 area relative to the total lung area on computed tomography (CT). The extent that %CSA<5 is related to pulmonary hemodynamics in patients with chronic thromboembolic pulmonary hypertension (CTEPH) is unclear, as is the effect of pulmonary endarterectomy (PEA) on %CSA<5. Therefore, we aimed to evaluate the clinical significance of %CSA<5 in patients with CTEPH. We studied 98 patients (64 females, mean age 62.5 ± 11.9 years), who underwent CT with %CSA<5 measurement and right heart catheterization (RHC). Patients were classified into groups based on eligibility for PEA. We compared the %CSA<5 with pulmonary hemodynamics measured by RHC in various groups. In 38 patients who underwent PEA, the relationship between %CSA<5 and pulmonary hemodynamics was also evaluated before and after PEA. Significant correlations between %CSA<5 and pulmonary vascular resistance, and compliance, and pulmonary artery pulse pressure were observed in all patients. Pulmonary hemodynamics in the patients who underwent or were eligible for PEA showed a significant correlation with %CSA<5. Additionally, %CSA<5 was significantly lower in the postoperative than in the preoperative group. There was no correlation between changes in %CSA<5 and pulmonary hemodynamics before and after PEA. Furthermore, %CSA<5 did not correlate significantly with prognosis. %CSA<5 may reflect pulmonary hemodynamics in CTEPH with central thrombosis. Furthermore, %CSA<5 was reduced by PEA postoperatively. However, %CSA<5 is not a prognostic indicator, its clinical usefulness in CTEPH patients is limited, and further validation is required.

Pulmonary Veno-occlusive Disease that Developed Following Hematopoietic Stem Cell Transplantation for Acute Myeloid Leukemia

We herein report a case of pulmonary veno-occlusive disease (PVOD) induced by allo-hematopoietic stem cell transplantation (HSCT) in a 48-year-old man who was diagnosed with acute myeloid leukemia. Five months after transplantation, he developed dyspnea and was diagnosed with pulmonary hypertension based on right heart catheterization. Although he received treatment with pulmonary vasodilators, diuretics, and corticosteroids, his pulmonary artery pressure did not decrease, and his pulmonary edema worsened. Based on the clinical course, hypoxemia, diffusion impairment, and computed tomography findings, the patient was diagnosed with HSCT-related PVOD. Critical attention should be paid to dyspnea after HSCT for the early diagnosis of PVOD.

Venous Stent Placement for Malignant Vena Cava Syndrome in a Patient with Liposarcoma

BACKGROUND Reports of venous stenting for inferior vena cava (IVC) syndrome (IVCS) due to sarcoma are limited, and the treatment's efficacy and safety are not clear. CASE REPORT A 36-year-old woman with myxoid liposarcoma was admitted to the Department of Respiratory Medicine for treatment of bilateral lower-leg edema and to be evaluated for acute liver dysfunction. She was 13 years old when she was diagnosed with myxoid liposarcoma. Over the next 18 years, she had 4 tumor resections and 1 round of radiation therapy. She had been on chemotherapy for 4 years and then pazopanib at the age of 35. The edema did not improve after admission despite treatment with diuretics. Computed tomography revealed a huge liposarcoma occupying the right thoracic cavity and a compressed IVC, which caused the edema. Although doxorubicin was administered as fifth-line treatment, there was no response. Since there was no additional chemotherapy regimen, her prognosis was considered to be less than 6 months. She could not be discharged to her home since she was unable to walk due to the edema; therefore, IVC stenting was performed to improve her dysmotility. After IVC stenting, the lower-leg edema improved without any adverse events, enabling her to walk and eventually return home. CONCLUSIONS In patients with IVCS caused by rare malignancies such as myxoid liposarcoma, an IVC stent can be safely implanted and can help to alleviate symptoms. IVC stenting can improve symptoms and allow for home care, resulting in improved quality of life.

The effects of simple graphical and mental visualization of lung sounds in teaching lung auscultation during clinical clerkship: A preliminary study

INTRODUCTION

The study aimed to evaluate visualization-based training's effects on lung auscultation during clinical clerkship (CC) in the Department of Respiratory Medicine on student skills and confidence.

METHODS

The study period was December 2020-November 2021. Overall, 65 students attended a lecture on lung auscultation featuring a simulator (Mr. Lung™). Among them, 35 (visualization group) received additional training wherein they were asked to mentally visualize lung sounds using a graphical visualized lung sounds diagram as an example. All students answered questions on their self-efficacy regarding lung auscultation before and after four weeks of CC. They also took a lung auscultation test with the simulator at the beginning of CC (pre-test) and on the last day of the third week (post-test) (maximum score: 25). We compared the answers in the questionnaire and the test scores between the visualization group and students who only attended the lecture (control group, n = 30). The Wilcoxon signed-rank test and analysis of covariance were used to compare the answers to the questionnaire about confidence in lung auscultation and the scores of the lung auscultation tests before and after the training.

RESULTS

Confidence in auscultation of lung sounds significantly increased in both groups (five-point Likert scale, visualization group: pre-questionnaire median 1 [Interquartile range 1] to post-questionnaire 3 [1], p<0.001; control group: 2 [1] to 3 [1], p<0.001) and was significantly higher in the visualization than in the control group. Test scores increased in both groups (visualization group: pre-test 11 [2] to post-test 15 [4], p<0.001; control group: 11 [5] to 14 [4], p<0.001). However, there were no differences between both groups' pre and post-tests scores (p = 0.623).

CONCLUSION

Visualizing lung sounds may increase medical students' confidence in their lung auscultation skills; this may reduce their resistance to lung auscultation and encourage the repeated auscultation necessary to further improve their long-term auscultation abilities.

A case of primary racemose hemangioma with endobronchial lesions demonstrating recurrent hemoptysis initially treated with bronchial arterial embolization

Primary racemose hemangioma of the bronchial artery (RHBA) is one of the causes of massive hemoptysis. A 72-year-old woman was admitted to our hospital with recurrent hemoptysis. Bronchoscopy showed an endobronchial lesion, and the angiography of the right bronchial arteries indicated RHBA. Bronchial arterial embolization (BAE) was performed to prevent hemoptysis. Although the endobronchial lesion shrank after the first BAE, the lesion re-increased and caused massive hemoptysis. A thoracoscopic right upper lobectomy was performed, and hemoptysis did not recur. Therefore, in cases of RHBA where there is recurrent hemoptysis and the endobronchial lesions that remain after BAE, additional treatments should be considered.

Chronic Expanding Haematoma Causing Stenosis of the Right Ventricular Outflow Tract and Pulmonary Hypertension

A chronic expanding haematoma (CEH) is an encapsulated mass that gradually increases in size from repeated internal bleeding and neovascularization. We herein report a 69-year-old man who was admitted with dyspnoea on exertion after undergoing thymic carcinoma resection 17 years ago. Chest computed tomography showed a heterogeneous mass in the anterior mediastinum and compression of the right ventricle, and pulmonary artery. Right cardiac catheterisation revealed pulmonary hypertension that was relieved after resection of the diagnosed CEH mass. This report highlights the mechanism underlying anterior mediastinal CEH-induced stenotic compression of the right ventricle-pulmonary artery outflow and subsequent pulmonary hypertension.

COVID-19 infection control education for medical students undergoing clinical clerkship: a mixed-method approach

BACKGROUND

Coronavirus disease (COVID-19) has induced an urgent need to train medical students not only in infection prevention control but also in the treatment of infectious diseases, including COVID-19. This study evaluates the impact of simulated clinical practice with peer role-plays and a lecture on clinical education for COVID-19.

METHODS

The sample for the study included 82 fourth- and fifth-year medical students undergoing clinical clerkship in respiratory medicine. They answered questionnaires and participated in semi-structured focus group interviews (FGIs) regarding the advantages of simulated clinical practice with peer role-plays and lectures on clinical education for COVID-19.

RESULTS

A total of 75 students participated in the COVID-19 education program between January and November 2021. The responses to the questionnaire revealed that the satisfaction level of students with COVID-19 education was high. No significant change was found among students concerning fear of COVID-19 before and after the program. The degree of burden of handling information on COVID-19 reduced significantly, while the degree with respect to the use of personal protective equipment (PPE), including appropriate wearing and removing of PPE, and care of patients with confirmed COVID-19 while taking steps to prevent infection, exhibited a decreasing trend. Nine FGIs were conducted (n = 74). The advantages of simulated clinical practice were segregated into five categories (infection prevention control, educational methods, burden on healthcare providers, self-reflection, and fear of COVID-19); and that of the lecture were segregated into four categories (information literacy, knowledge of COVID-19, educational methods, and self-reflection).

CONCLUSIONS

Simulated clinical practice with peer role-plays and the lecture pertaining to COVID-19 can prove to be efficient and safe methods for learning about COVID-19 infection and prevention control for medical students. They can reduce the burden of COVID-19 patients' care. Moreover, they can also provide an opportunity for self-reflection, realize the burden of medical care, and acquire relevant information.

Clinical Outcomes of Sotrovimab Treatment in 10 High-Risk Patients with Mild COVID-19: A Case Series

Case series

Patients:—

Final Diagnosis: COVID-19

Symptoms: Cough • fever • sore throat

Medication: —

Clinical Procedure: —

Specialty: Pulmonology

Pneumocystis pneumonia in an immunocompetent patient developing a subacute disease course with central consolidation

Pneumocystis pneumonia (PCP) typically occurs in immunocompromised individuals and rarely presents in immunocompetent individuals. A 55-year-old man was referred to our hospital with cough and anorexia that persisted for 2 months. Chest computed tomography revealed bilateral central consolidation. He was diagnosed with PCP via bronchoscopy. His symptoms and imaging findings improved with the administration of only trimethoprim and sulfamethoxazole. Although he had non-alcoholic fatty liver disease, there were no other complications that could potentially cause immunodeficiency. It should be noted that PCP in immunocompetent individuals can have a subacute disease course presenting with bilateral central consolidation.

Temporal characteristics of aspiration pneumonia in elderly inpatients: From resumption of oral intake to onset

Background

Elderly inpatients who develop fevers after resumption of oral intake are often considered to have aspiration pneumonia (AP) and be tentatively fasted. Fasting has been associated with prolonged hospital stays and decreased swallowing ability. The purpose of this study was to compare AP and other infections after resumption of oral intake in elderly inpatients and to identify the clinical characteristics.

Patients and methods

The records of patients who were admitted to a public tertiary hospital and referred for evaluation of swallowing disability were retrospectively reviewed to identify those who had developed AP, non-AP, or urinary tract infection (UTI) after resumption of oral intake. Eligible patients were enrolled consecutively in the study. The patient characteristics, physical findings, laboratory data, oral intake status at the time of onset of symptoms, and rate of discontinuation of oral intake after onset of infection were compared between the three types of infection.

Results

A total of 193 patients developed an infectious illness after resuming oral intake. Among them, 114 patients had a diagnosis of AP (n = 45), non-AP (n = 24), or UTI (n = 45). There were no significant differences in patient characteristics, physical findings or laboratory data between the group with AP and the other two groups. AP developed at a median of 6 (range 1–16) days after resumption of oral intake. The rate of discontinuation of oral intake was 91.1% in the AP group, 58.3% in the non-AP group, and 26.7% in the UTI group, respectively.

Conclusion

Infectious diseases other than AP should be considered in the differential diagnosis when nosocomial fever develops in elderly inpatients more than 17 days after resuming oral intake. Furthermore, nosocomial fever after resuming oral intake has many causes other than AP, and discontinuation of oral intake should be carefully considered.

A case of thoracic air leak syndrome with pleural parenchymal fibroelastosis after treatment for hematologic malignancy while awaiting lung transplantation: Imaging and pathological findings of rapid loss in lung volume

We report the case of a 29-year-old man who underwent umbilical cord blood transplantation for chronic myelogenous leukemia 14 years previously. He was diagnosed with secondary pleuroparenchymal fibroelastosis (sPPFE) following treatment for hematologic malignancies (sPPFE after HM-Tx) 2.5 years ago. On computed tomography, pleural thickening in the upper lobe, lung volume loss, and recurrent bilateral pneumothorax were detected. Although he waited for cadaveric lung transplantation (LTx) for 1.5 years, his respiratory failure worsened, and he died. Pathological autopsy and clinical course indicated sPPFE. After diagnosing sPPFE after HM-Tx, the timing for deciding LTx is critical, especially when pneumothorax recurs.

Sleep-related hypoventilation and hypercapnia in multiple system atrophy detected by polysomnography with transcutaneous carbon dioxide monitoring

Purpose

We aimed to evaluate sleep-related hypoventilation in multiple system atrophy (MSA) using polysomnography (PSG) with transcutaneous partial pressure of carbon dioxide (PtcCO₂) monitoring.

Methods

This prospective study included 34 patients with MSA. Motor and autonomic function, neuropsychological tests, PSG with PtcCO₂ monitoring, and pulmonary function tests were performed. Sleep-related hypoventilation disorder (SRHD) was defined according to the International Classification of Sleep Disorders, third edition.

Results

Nine (27%) of the 34 patients met the diagnostic criteria of SRHD. Twenty-nine (85%) patients had sleep-related breathing disorders based on an Apnea–Hypopnea Index of ≥ 5/h. The patients with MSA and SRHD had a higher arousal index (p = 0.017) and obstructive apnea index (p = 0.041) than those without SRHD. There was no difference in the daytime partial pressure of carbon dioxide in arterial blood or respiratory function between MSA patients with and without SRHD.

Conclusion

Sleep-related hypoventilation may occur in patients with MSA even with a normal daytime partial pressure of carbon dioxide. This can be noninvasively detected by PSG with PtcCO₂ monitoring. SRBD and sleep-related hypoventilation are common among patients with MSA, and clinicians should take this into consideration while evaluating and treating this population.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11325-022-02568-4.

Vascular involvement in chronic thromboembolic pulmonary hypertension is associated with spirometry obstructive impairment

BACKGROUND

Chronic thromboembolic pulmonary hypertension (CTEPH) is a type of pulmonary hypertension caused by persistent thromboembolism of the pulmonary arteries. In clinical practice, CTEPH patients often show obstructive ventilatory impairment, even in the absence of a smoking history. Recent reports imply a tendency for CTEPH patients to have a lower FEV_1.0; however, the mechanism underlying obstructive impairment remains unknown.

METHODS

We retrospectively analyzed CTEPH patients who underwent a pulmonary function test and respiratory impedance test to evaluate their exertional dyspnea during admission for right heart catheterization from January 2000 to December 2019. We excluded patients with a smoking history to rule out the effect of smoking on obstructive impairment.

RESULTS

A total of 135 CTEPH patients were analyzed. The median FEV_1.0/FVC was 76.0%, %FEV _1.0 had a negative correlation with the mean pulmonary artery pressure and pulmonary vascular resistance and the CT Angiogram (CTA) obstruction score. A multivariate regression analysis revealed that the CTA obstruction score was an independent factor of a lower %FEV_1.0. In the 54 patients who underwent pulmonary endarterectomy, %FEV_1.0 was improved in some cases and was not in some. Mean PAP largely decreased after PEA in the better %FEV_1.0 improved cases, suggesting that vascular involvement in CTEPH could be associated with spirometry obstructive impairment.

CONCLUSION

%FEV_1.0 had a significant correlation with the CTA obstruction score. Obstructive impairment might have an etiological relationship with vascular involvement. Further investigations could shed new light on the etiology of CTEPH.

Exacerbation of autoimmune pulmonary alveolar proteinosis that improved with lone treatment of complicating nontuberculous mycobacterial infection: A case report

Herein, we present the case of a 63-year-old man with autoimmune pulmonary alveolar proteinosis (APAP) complicated by Mycobacterium avium complex (MAC) infection. APAP was diagnosed based on serum anti-granulocyte-macrophage colony-stimulating factor antibody, bronchoalveolar lavage fluid (BALF) findings, and transbronchial lung biopsy. Nodular shadows with cavities were visible on chest CT images, and Mycobacterium intracellulare was identified by BALF culture. Rifampicin, ethambutol, and clarithromycin were administered, and 4 months later, the nodular shadows of MAC had disappeared, and APAP was remarkably improved. Thus, in cases of APAP exacerbation complicated with infections, such as MAC, control of the infections may improve APAP.

Interventricular septal curvature as an additional echocardiographic parameter for evaluating chronic thromboembolic pulmonary hypertension: a single-center retrospective study

BACKGROUND

Noninvasive estimation of the actual systolic pulmonary artery pressure measured via right-sided heart catheterization (sPAP_RHC) is vital for the management of pulmonary hypertension, including chronic thromboembolic pulmonary hypertension (CTEPH). Evaluation related to the interventricular septum (IVS) is generally performed with only visual assessment and has been rarely assessed quantitatively in the field of echocardiography. Thus, this study aimed to investigate the utility of echocardiographic IVS curvature to estimate sPAP_RHC in patients with CTEPH.

METHODS

Medical records of 72 patients with CTEPH were studied retrospectively. We estimated sPAP_RHC using echocardiographic IVS curvature (esPAP_curv) and left ventricular eccentricity index (esPAP_LVEI), and compared their ability to predict sPAP_RHC with estimated sPAP_RHC using tricuspid regurgitant pressure gradient (esPAP_TRPG).

RESULTS

IVS curvature and LVEI were significantly correlated with sPAP_RHC (r = - 0.52 and r = 0.49, respectively). Moreover, the IVS curvature was effective in estimating the sPAP_RHC of patients with trivial tricuspid regurgitation (r = - 0.56) and in determining patients with sPAP_RHC ≥ 70 mmHg with higher sensitivity (77.0%) compared to those with esPAP_TRPG and esPAP_LVEI.

CONCLUSION

Our results indicate that the echocardiographic IVS curvature could be a useful additional tool for estimating sPAP_RHC in CTEPH patients for whom accurate estimation of sPAP_RHC using tricuspid regurgitant pressure gradient is challenging.

Six Cases of Hemoptysis with Angiogenesis from Non-Bronchial Systemic Arteries

BACKGROUND Although bronchial arteries are the most common cause of hemoptysis, other systemic arteries can cause hemoptysis and are potential pitfalls for successful embolization. CASE REPORT We present 6 cases of hemoptysis showing vascularization from systemic arteries other than bronchial arteries that presented to our department between 2013 and 2020. Chronic inflammatory diseases such as tuberculosis and pulmonary aspergillosis were the underlying diseases in 4 of the 6 cases. In all 6 cases, the lesions were close to the pleura. The abnormal non-bronchial systemic arteries were the internal thoracic artery in 4 cases, intercostal artery in 2 cases, lateral thoracic artery in 2 cases, and the subclavian, thyrocervical, and inferior phrenic arteries in 1 case each, all of which formed a shunt with the pulmonary artery. Additionally, depending on the location of the lesion, the non-bronchial systemic arteries near the lesion proliferated into the lung parenchyma through the adherent pleura. CONCLUSIONS When lesions are in contact with the pleura, various non-bronchial systemic arteries near the lesion can develop in the pulmonary parenchyma via the adherent pleura, which can cause hemoptysis. In patients with hemoptysis, it may be useful to evaluate chest contrast-enhanced computed tomography and angiography, while always accounting for the potential involvement of non-bronchial systemic arteries to ensure a safer and more reliable treatment.

Possibility of deterioration of respiratory status when steroids precede antiviral drugs in patients with COVID-19 pneumonia: A retrospective study

Introduction

Coronavirus disease (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2. Although most patients with COVID-19 develop asymptomatic or mild disease, some patients develop severe disease. The effectiveness of various therapeutic agents, including antiviral drugs, steroids, and anti-inflammatories for COVID-19, have been being confirmed. The effect of administering steroids in early disease is unclear. This study therefore aimed to evaluate the effectiveness and risk of exacerbation of steroids administered preceding antiviral drugs in patients with COVID-19 pneumonia.

Methods

This retrospective, single-center, observational study included consecutive patients with COVID-19 between March 2020 and March 2021. Patients were divided into a steroids-first group and antiviral-drugs-first group. Mortality, duration of hospitalization, incidence rate and duration of intensive care unit (ICU) admission, intubation, and extracorporeal membrane oxygenation (ECMO) induction of the two groups were compared.

Results

A total of 258 patients were admitted during the study period. After excluding patients who received symptomatic treatment only, who were taking immunosuppressive drugs, or who were administered antiviral drugs only, 68 patients were included in the analysis, 16 in the steroids-first group and 52 in the antiviral-drugs-first group. The rate of intubation, ICU admission and ECMO induction were significantly higher in the steroids-first group than in the antiviral-drugs-first group (81.3% vs. 33.3, p<0.001, 75.0% vs. 29.4%, p = 0.001, and 31.3% vs. 7.8%, p = 0.017, respectively). Furthermore, patients who received steroids within ten days after starting antiviral drugs had significantly lower rates of ICU admission, intubation, and ECMO induction. (81.3% vs. 42.9% p = 0.011, 75.0% vs. 37.1% p = 0.012, and 31.3% vs. 8.6% p = 0.039, respectively).

Conclusions

Administering steroids prior to antiviral drugs soon after symptom onset can aggravate disease severity. When administration of steroids is considered soon after symptom onset, it may be safer to initiate antiviral drugs first.

Yellow nail syndrome with massive chylothorax after esophagectomy: A case report

Yellow nail syndrome (YNS) is a rare condition characterized by the triad of yellow nails, lymphedema, and respiratory manifestations. Diuretics and thoracic drainage are often not effective in YNS, and the most effective treatments are pleurodesis and decortication/pleurectomy. A 66-year-old man was admitted to our hospital for YNS after esophagectomy with gastric tube reconstruction for esophageal cancer. The patient presented with yellow nails and lymphedema. Chest X-rays and computed tomography showed massive pleural effusions and ascites that were both chylous. The patient was considered to have YNS that became apparent after surgery. He recovered with diuretics and a low-fat diet without pleurodesis and decortication/pleurectomy. Thoracic surgery can exacerbate the functional impairment of lymphatic drainage in patients with asymptomatic and undiagnosed YNS, and can lead to further development of YNS-related clinical symptoms. Despite relatively massive chylothorax following thoracic surgery, chylothorax related to YNS could be successfully controlled with conservative treatment without pleurodesis and decortication/pleurectomy.

Voriconazole treatment of pulmonary mycosis caused by Chrysosporium zonatum after treatment for pulmonary tuberculosis

Chrysosporium zonatum is a soil-dwelling fungus that rarely causes pulmonary infections, and a small number of cases have been reported to date. A 74-year-old man, who had previously been treated for tuberculosis, presented with symptoms of low-grade fever, anorexia, cough, and bloody sputum. Chest computed tomography (CT) showed a thick-walled cavitary lesion in the right upper lobe, in which there was a suspected mycotic mass. Initially, the patient was suspected to have chronic aspergillosis due to positive serum anti-Aspergillus antibodies. However, bronchoscopic culture revealed the growth of C. zonatum. Symptoms and imaging findings improved with administration of voriconazole for 18 months. Infection by C. zonatum is very rare and is difficult to differentiate from aspergillosis by clinical features. Clinicians should be aware of the possibility of coinfection with C. zonatum and Aspergillus sp. Voriconazole may be an effective treatment option.

Bronchiolitis obliterans after stem cell transplantation for hematologic malignancies rescued by lung transplantation: A report of two cases

Bronchiolitis obliterans syndrome (BOS) occurring after hematopoietic stem cell transplantation (HSCT) for hematologic malignancies is a progressive and refractory disease, and lung transplantation (LTx) seems to be the only promising treatment. We report two cases of BOS after HSCT, which showed distinct clinical courses and were successfully treated with LTx. The respiratory symptoms and function of the two patients progressively deteriorated to a critical level during the waiting period. In one patient, recurrent and intractable pneumothoraxes consistent with thoracic air-leak syndrome (TALS) occurred, which were associated with pleuroparenchymal fibroelastosis. TALS could accelerate clinical deterioration, thus permitting a shorter waiting period for LTx.

Drug Fever Due to Favipiravir Administration for the Treatment of a COVID-19 Patient

A 55-year-old Japanese man was hospitalized with the novel coronavirus disease 2019 (COVID-19). On the 14th day after the start of favipiravir administration, the patient developed a fever with a temperature of 38.1°C. His pulse rate also became elevated to 128 bpm, so relative bradycardia was not suspected. Since he was in good overall health and no concomitant symptoms and signs were apparent, we considered it to be drug fever due to favipiravir. After the completion of favipiravir treatment, the patient's temperature normalized within 24 hours. We herein report this case of drug fever caused by favipiravir.

Haemoptysis due to an atypical right bronchial artery branching from the left subclavian artery evaluated by four-dimensional CT and bronchial arteriography

Haemoptysis can be a life-threatening condition, and bronchial artery embolisation (BAE) is the most effective treatment. A 19-year-old man who had been followed up for neutrophil migration failure and bronchiectasis since birth was admitted to our department with repeated haemoptysis. Contrast-enhanced CT revealed hyperplasia and tortuosity of the bronchial artery; however, it could not reveal the origin and running by the axial views. Three-dimensional (3D) and four-dimensional (4D) CT revealed branching of the right bronchial artery from the left subclavian artery and a bronchial artery–pulmonary artery shunt. Bronchial angiography confirmed these findings. Based on these findings, BAE was successfully performed. 3D and 4D CT can be useful for determining the cause of haemoptysis. Furthermore, evaluating the anatomy of bronchial arteries prior to BAE may be useful for performing safer procedures.

Alternative approaches for clinical clerkship during the COVID-19 pandemic: online simulated clinical practice for inpatients and outpatients-A mixed method

BACKGROUND

The COVID-19 pandemic has created a need for educational materials and methods that can replace clinical clerkships (CCs) for online simulated clinical practice (online-sCP). This study evaluates the impact of using simulated electronic health records (sEHR) for inpatients, and electronic problem-based learning (e-PBL) and online virtual medical interviews (online-VMI) for outpatients, for an online-sCP using a learning management system (LMS) and online meeting system facilitated by a supervising physician.

METHODS

The sEHR was reviewed by medical students and subsequently discussed with a supervising physician using an online meeting system. In the e-PBL, medical students reviewed the simulated patients and discussed on the LMS. For the online-VMI, a faculty member acted as an outpatient and a student acted as the doctor. Small groups of students discussed the clinical reasoning process using the online meeting system. A mixed-method design was implemented. Medical students self-assessed their clinical competence before and after the online-sCP. They answered questionnaires and participated in semi-structured focus group interviews (FGIs) regarding the advantages and disadvantages of the practice.

RESULTS

Forty-three students completed the online-sCP during May and June 2020. All students indicated significant improvement in all aspects of self-evaluation of clinical performance after the online-sCP. Students using sEHR reported significant improvement in writing daily medical records and medical summaries. Students using e-PBL and online-VMI reported significant improvement in medical interviews and counseling. Students also indicated CCs as more useful for learning associated with medical interviews, physical examinations, and humanistic qualities like professionalism than the online-sCP. Eight FGIs were conducted (n = 42). The advantages of online-sCP were segregated into five categories (learning environment, efficiency, accessibility, self-paced learning, and interactivity); meanwhile, the disadvantages of online-sCP were classified into seven categories (clinical practice experience, learning environment, interactivity, motivation, memory retention, accessibility, and extraneous cognitive load).

CONCLUSIONS

Online-sCP with sEHR, e-PBL, and online-VMI could be useful in learning some of the clinical skills acquired through CC. These methods can be implemented with limited preparation and resources.

Heritable pulmonary arterial hypertension complicated by multiple pulmonary arteriovenous malformations

Heritable pulmonary arterial hypertension (HPAH) is a type of familial pulmonary arterial hypertension, while pulmonary arteriovenous malformations (PAVMs) are abnormal communications between pulmonary arteries and veins that occur frequently in patients with hereditary hemorrhagic telangiectasia (HHT). A 21-year-old woman on continuing medication for HPAH was hospitalized. She had been diagnosed with HPAH at age 4 years and had been receiving epoprostenol infusion from age of 9 years. Although lung perfusion scintigraphy showed a shunt fraction of 18.9% at age of 19 years, the cause of the shunt was unclear. At the time of the present hospitalization, enhanced computed tomography (CT) of the chest and four-dimensional reconstructed images revealed multiple abnormal communications between the peripheral pulmonary arteries and veins. Furthermore, right heart catheterization revealed an elevated mean pulmonary arterial pressure. Wedged angiography of the pulmonary artery of the right lower lobe revealed several PAVMs. Multiple PAVMs and suspected HHT with HPAH was diagnosed. The possibility of PAVMs should be considered even in patients with HPAH. Moreover, evaluation of the shunt fraction by lung perfusion scintigraphy and morphological examination of PAVM by contrast-enhanced CT may facilitate PAVM detection in patients with HPAH.

The extent of enlarged bronchial arteries is not correlated with the development of reperfusion pulmonary edema after pulmonary endarterectomy in patients with chronic thromboembolic pulmonary hypertension

This study investigated whether dilated bronchial arteries are associated with reperfusion pulmonary edema in patients with chronic thromboembolic pulmonary hypertension. Results showed that the extent of enlarged bronchial arteries was not associated with the development of reperfusion pulmonary edema, whereas the residual pulmonary hypertension had a significant association.

Adult cases of late-onset congenital central hypoventilation syndrome and paired-like homeobox 2B-mutation carriers: an additional case report and pooled analysis

STUDY OBJECTIVES

Congenital central hypoventilation syndrome (CCHS) is caused by the paired-like homeobox 2B (PHOX2B) mutation and predominantly diagnosed during the neonatal period. Although late-onset CCHS and PHOX2B mutation carriers have been reported, the features of these disease states in adults remain uncertain. This study aimed to identify the characteristics of adult-onset CCHS and PHOX2B-mutation carriers in adult.

METHODS

We mainly searched the PubMed/Medline and Cochrane Databases and classified our target patients into 2 groups: group A, symptomatically diagnosed with late-onset CCHS in adulthood; group B, adult PHOX2B-mutation carriers. Then, clinical characteristics, including the onset, treatment, long-term course, and pattern of the PHOX2B mutation in both groups were analyzed. Additionally, a new adult-case of late-onset CCHS was added to the analysis.

RESULTS

Group A was comprised of 12 patients. The onset triggers of illness included a history of respiratory compromise following general anesthesia and respiratory tract infections. All patients in group A had 20/25 polyalanine repeat mutations and required some chronic ventilatory support at least during sleep, including portable positive pressure ventilator via tracheostomy or noninvasive positive pressure ventilation. In these patients with ventilatory support during sleep, sudden death or poor prognosis was not reported. Group B was comprised of 33 adults from 24 families with PHOX2B mutations. Nine patients in group B were confirmed with the diagnosis of CCHS. Although polyalanine repeat mutations 20/25 represented the most common gene mutation, diverse mutations, including mosaicism, were observed. Hypoventilation of several cases in group B were underdiagnosed by overnight polysomnography without monitoring for CO₂.

CONCLUSION

Alveolar hypoventilation with unknown origin can be caused by the PHOX2B mutation even in adult cases. Both the identification of the PHOX2B mutation and the incorporation of capnography in polysomnography are important for adult cases with unexplained alveolar hypoventilation or asymptomatic mutation carriers.

Characteristics of Japanese elderly patients with pulmonary arterial hypertension

Previous nationwide Japanese data suggested that pulmonary arterial hypertension (PAH) predominantly affects young women. However, the number of elderly patients diagnosed with PAH has been increasing in western countries. There have been no reports on elderly PAH patients in Asian countries. This study aimed to investigate the clinical characteristics of elderly PAH patients in a Japanese cohort. Idiopathic/heritable PAH (I/H-PAH) was included in the national research project on intractable diseases. The patients were required to submit a clinical research form completed by their attending physicians. We analyzed the characteristics of Japanese I/H-PAH using the newly registered forms in 2013 (Study 1, n = 148). Also, we did a retrospective, observational cohort study at Chiba University Hospital (Study 2, n = 42). We compared the characteristics of elderly PAH patients (≥65 years old) with younger patients (<65) in both studies. Study 1 revealed a predominance of males (51% male), better hemodynamics and poorer exercise capacity in the elderly group (n = 72), compared with the younger group (n = 76) in study 1. In Study 2, elderly patients showed a male predominance (63% male), a higher ratio of smokers, a lower % carbon monoxide diffusing capacity, and poorer exercise tolerance. Elderly patients in Study 2 showed less improvement in hemodynamics with therapy. There was no significant difference in disease-specific survival between elderly and younger patients. Japanese elderly patients with I/H-PAH showed poorer exercise capacity and impaired gas exchange, but better pulmonary hemodynamics than younger patients.

Spondylodiscitis and spinal epidural abscess related to long-term placement of an airway stent for malignant central airway obstruction

A 70‐year‐old male was referred to our hospital with lower limb muscle weakness and numbness of the left hand. The patient had previously been diagnosed seven years ago with lung cancer accompanied by central airway obstruction and had received chemoradiotherapy following placement of a metallic stent. Computed tomography (CT) scan revealed an osteolytic lesion which was adjacent to the fractured stent. T2‐weighted magnetic resonance imaging (MRI) demonstrated high signal intensity in the disc space. The patient was diagnosed with spondylodiscitis and spinal epidural abscess related to the airway stent. Despite hemilaminectomy, laminectomy and long‐term antibiotic therapy, the infection was uncontrolled. Moreover, osteolytic destruction and kyphotic deformity progressed. Removal of the airway stent was necessary; however, it was impossible because bronchial resection was required and the risk of mediastinal injury was considered to be high. The patient subsequently received palliative care. Long‐term airway stenting can cause spondylodiscitis and spinal epidural abscess. Indications for the placement of metallic stents for malignant central airway obstruction should be carefully evaluated after considering the difficulty in removal and the long‐term risk of severe complications.

Key points

Significant findings of the study

Long‐term placement and fracture of the airway stent can cause spondylodiscitis and spinal epidural abscess.

What this study adds

The indication of placement of a metallic stent for malignant central airway obstruction should be considered with caution, especially if long‐term survival can be expected.

Clinical characteristics and risk factors of drug-induced lung injury by ALK tyrosine kinase inhibitors: A single center retrospective analysis

BACKGROUND

If anaplastic lymphoma kinase (ALK) gene rearrangement in lung cancer is identified, ALK-tyrosine kinase inhibitors (ALK-TKIs) can be an effective treatment. However, the details of drug-induced lung injury (DILI) caused by ALK-TKI, which can be a serious side effect of ALK-TKIs, remains unclear. This study aimed to investigate the clinical features and the onset risk factors of DILI by ALK-TKIs in clinical practice.

METHODS

The clinical features of 56 consecutive patients who received crizotinib, alectinib, and/or ceritinib at our hospital from 2012 to 2018 were retrospectively examined. Among these, patients diagnosed with DILI due to ALK-TKIs were evaluated in terms of clinical features and parameters. Each clinical parameter before the administration of ALK-TKIs was compared between the DILI onset group and the non-onset group.

RESULTS

A total of seven cases were diagnosed with DILI due to ALK-TKIs; no DILI-related deaths were observed. Chest computed tomography (CT) scan findings identified six patients with the organizing pneumonia (OP) pattern and one with the hypersensitivity pneumonia pattern. The onset of DILI was significantly different in patients age ≥ 64 years and with a creatinine clearance <80 mL/minute.

CONCLUSIONS

Extra caution for DILI due to ALK-TKIs may be needed when recommending ALK-TKIs for patients over 64 years of age, or with decreased renal function. CT images of the majority of patients with DILI by ALK-TKIs show an OP pattern.

KEY POINTS

Significant findings of the study: Extra caution is needed when recommending ALK-TKIs for patients over 64 years of age or those with decreased renal function. Computed tomography images of the majority of patients with DILI by ALK-TKIs show an OP pattern.

WHAT THIS STUDY ADDS

The same or a different ALK-TKI may be considered as a treatment option after the onset of DILI, based on careful judgment.

Effects of pulmonary endarterectomy on pulmonary hemodynamics in chronic thromboembolic pulmonary hypertension, evaluated by interventricular septum curvature

The interventricular septum curvature, measured in images of electrocardiogram-gated 320-slice multidetector computed tomography, is reportedly useful and less invasive than right heart catheterization, as it could provide clues regarding pulmonary arterial pressure in patients with chronic thromboembolic pulmonary hypertension. Although pulmonary endarterectomy is an efficient treatment for chronic thromboembolic pulmonary hypertension, the interventricular septum curvature in patients who have received pulmonary endarterectomy has not been evaluated. We evaluated whether the interventricular septum curvature on electrocardiogram-gated 320-slice multidetector computed tomography can predict pulmonary hemodynamics in chronic thromboembolic pulmonary hypertension even after pulmonary endarterectomy. We studied 40 patients with chronic thromboembolic pulmonary hypertension (60.5 ± 9.7 years; 30 females), who underwent pulmonary endarterectomy at Chiba University Hospital between December 2010 and July 2018. To measure the interventricular septum curvature, we prepared left ventricular short-axis tomographic images from 4D images of electrocardiogram-gated 320-slice multidetector computed tomography. We calculated the radius of interventricular septum and determined the interventricular septum curvature in both the systolic and diastolic phases. We compared the interventricular septum curvature with pulmonary hemodynamics measured by right heart catheterization before and after pulmonary endarterectomy. After pulmonary endarterectomy, the correlations of the interventricular septum curvature with mean pulmonary arterial pressure, systolic pulmonary arterial pressure, and pulmonary vascular resistance disappeared, although the interventricular septum curvature was correlated with these pulmonary hemodynamic parameters before pulmonary endarterectomy. Changes in systolic interventricular septum curvature revealed significant correlations with changes in mean pulmonary arterial pressure, systolic pulmonary arterial pressure and pulmonary vascular resistance. Diastolic interventricular septum curvature also showed significant correlations with preoperative pulmonary hemodynamics, but not with postoperative pulmonary hemodynamics. Changes in the interventricular septum curvature after pulmonary endarterectomy could estimate the efficacy of pulmonary endarterectomy, although the interventricular septum curvature after pulmonary endarterectomy showed no significant correlations with pulmonary hemodynamics. Additionally, our findings confirmed that the interventricular septum curvature before pulmonary endarterectomy could be used to evaluate the severity of disease.