Invalidity of JRS atypical pneumonia prediction score in Omicron variant of COVID-19 pneumonia

BACKGROUND

We evaluated whether the Japanese Respiratory Society (JRS) atypical pneumonia prediction score can be adapted for the diagnosis of COVID-19 pneumonia due to Omicron BA.1, BA.2, and BA.5 subvariants.

METHODS

We enrolled a total of 547 patients with community-acquired COVID-19 pneumonia. Of the COVID-19 pneumonia patients, 198 cases were the Omicron BA.1 subvariant, 127 cases were the Omicron BA.2 subvariant, and 222 cases were the Omicron BA.5 subvariant. Patients with extremely severe pneumonia were excluded and finally 524 patients were analyzed.

RESULTS

Rates of conformity for the six predictors were identical among the three Omicron groups, and high rates of conformity were observed in the following predictors: adventitious sounds; etiological agent; and a peripheral WBC count. The sensitivities of the diagnosis of atypical pneumonia in patients with COVID-19 pneumonia based on four or more predictors were 49.0% in the BA.1 subvariant group, 58.1% in the BA.2 subvariant group, and 51.0% in the BA.5 subvariant group. The diagnostic sensitivities for Omicron BA.1, BA.2, and BA.5 subvariant groups were 96.6%, 100%, and 96.4% for non-elderly (aged <60 years) patients and 28.4%, 29.7%, and 34.2% for elderly (aged ≥60 years) patients, respectively.

CONCLUSIONS

In Omicron variant of COVID-19, the JRS atypical pneumonia prediction score is a useful tool for distinguishing between COVID-19 pneumonia and bacterial pneumonia only in patients aged <60 years.

Prevalence and causes of chronic cough in Japan

BACKGROUND

Chronic cough is one of the most common symptoms of respiratory diseases and can adversely affect patients' quality of life and interfere with social activities, resulting in a significant social burden. A survey is required to elucidate the frequency and treatment effect of chronic cough. However, clinical studies that cover all of Japan have not yet been conducted.

METHODS

Patients who presented with a cough that lasted longer than 8 weeks and visited the respiratory clinics or hospitals affiliated with the Japan Cough Society during the 2-year study period were registered.

RESULTS

A total of 379 patients were enrolled, and those who did not meet the definition of chronic cough were excluded. A total of 334 patients were analyzed: 201 patients had a single cause, and 113 patients had two or more causes. The main causative diseases were cough variant asthma in 92 patients, sinobronchial syndrome (SBS) in 36 patients, atopic cough in 31 patients, and gastroesophageal reflux (GER)-associated cough in 10 patients. The time required to treat undiagnosed patients and those with SBS was significantly longer and the treatment success rate for GER-associated cough was considerably poor.

CONCLUSIONS

We confirmed that the main causes of chronic cough were cough variant asthma, SBS, atopic cough, and their complications. We also showed that complicated GER-associated cough was more likely to become refractory. This is the first nationwide study in Japan of the causes and treatment effects of chronic cough.

Is the JRS atypical pneumonia prediction score useful in detecting COVID-19 pneumonia under nursing or healthcare settings?

BACKGROUND

SARS-CoV-2 causes frequent outbreaks in elderly care facilities that meet the criteria for nursing and healthcare-associated pneumonia (NHCAP). We evaluated whether the Japanese Respiratory Society (JRS) atypical pneumonia prediction score could be adapted to the diagnosis of nursing and healthcare acquired COVID-19 (NHA-COVID-19) with pneumonia.

METHODS

We analyzed 516 pneumonia patients with NHA-COVID-19 and compared them with 1505 pneumonia patients with community-associated COVID-19 (CA-COVID-19). NHA-COVID-19 patients were divided into six groups; 80 cases had the ancestral strain, 76 cases had the Alfa variant, 30 cases had the Delta variant, 120 cases had the Omicron subvariant BA.1, 53 cases had the Omicron subvariant BA.2, and 157 cases had the Omicron subvariant BA.5.

RESULTS

The sensitivities of the diagnosis of atypical pneumonia in patients with NHA-COVID-19 based on four or more predictors were 22.8 % in the ancestral strain group, 32.0 % in the Alfa variant group, 34.5 % in the Delta variant group, 23.1 % in the BA.1 subvariant group, 32.7 % in the BA.2 subvariant group, and 30.4 % in the BA.5 subvariant group. The diagnostic sensitivity for the presumptive diagnosis of atypical pneumonia was significantly lower for NHA-COVID-19 than for CA-COVID-19 (28.2 % vs 64.1 %, p < 0.0001).

CONCLUSIONS

Our present study demonstrated that the JRS atypical pneumonia prediction score is not a useful tool in elderly patients even if there is a lot of atypical pneumonia in the NHCAP group. The caution is necessary that JRS atypical pneumonia prediction score was not fully applied to prediction for NHA-COVID-19 pneumonia.

Nursing and healthcare-associated pneumonia due to SARS-CoV-2 Omicron variant

BACKGROUND

There were many differences in the clinical characteristics between nursing and healthcare-associated pneumonia (NHCAP) and community-acquired pneumonia (CAP) due to the SARS-CoV-2 ancestral strain, Alpha variant and Delta variant. With the replacement of the Delta variant by the Omicron variant, the Omicron variant showed decreased infectivity to lung and was less pathogenic. We investigated the clinical differences between NHCAP and CAP due to the Omicron variant.

METHODS

We analyzed 516 NHCAP and 547 CAP patients with COVID-19 pneumonia. Of 516 patients with COVID-19 NHCAP, 330 cases were the Omicron variant (120 cases were BA.1, 53 cases were BA.2, and 157 cases were BA.5 subvariants) and 186 cases were non-Omicron variants.

RESULTS

The median age, frequency of comorbid illness, rates of intensive care unit (ICU) stay, and mortality rate were significantly higher in Omicron patients with NHCAP than in those with CAP. Rates of ICU stay and in-hospital mortality were significantly higher in NHCAP patients with non-Omicron variants compared with those in the Omicron variant group. No clinical differences were observed in patients with NHCAP among the Omicron BA.1, BA.2, and BA.5 subvariant groups.

CONCLUSIONS

The present study supported that the NHCAP category is necessary not only for bacterial pneumonia but also viral pneumonia. It is necessary to consider prevention and treatment strategies depending on the presence or absence of applicable criteria for NHCAP.

Efficacy of Gefapixant, a P2X3 Antagonist, for Refractory Atopic Cough

Cough, a frequent symptom encountered in clinical practice, often has a considerable impact on patients' lives. There is an urgent need to investigate more potent antitussive treatments for chronic refractory cough, particularly atopic cough, which is a major cause of chronic refractory cough in Japan. Previous studies have shown that eosinophilic tracheobronchitis with hypersensitivity to sensory nerve C-fibers is the pathophysiology of atopic cough. Gefapixant is a first-in-class P2X3 antagonist that has recently become available for clinical use in patients with refractory coughs. A 64-year-old female non-smoker presented to our hospital with a complaint of chronic intractable cough due to atopic cough. Addition of gefapixant (90 mg/day) to her previous treatment improved her distressing cough, despite the partial efficacy of many other drugs. The findings of this case demonstrate that P2X3 inhibition is a viable therapeutic option for patients with chronic refractory cough caused by atopic cough. This case report offers valuable information regarding currently available treatment options for refractory chronic refractory cough caused by atopic cough. There remains an urgent need to clarify the disease entities presenting with chronic cough that can be effectively treated by inhibiting P2X3.

Validation of JRS atypical pneumonia score in patients with community-acquired Chlamydia psittaci pneumonia

INTRODUCTION

The Japanese Respiratory Society (JRS) atypical pneumonia score is a useful tool for the rapid presumptive diagnosis of atypical pneumonia. We investigated the clinical features of community-acquired pneumonia (CAP) due to Chlamydia psittaci and validated the JRS atypical pneumonia score in patients with C. psittaci CAP.

METHODS

This study was conducted at 30 institutions and assessed a total of 72 sporadic cases with C. psittaci CAP, 412 cases with Mycoplasma pneumoniae CAP, and 576 cases with Streptococcus pneumoniae CAP.

RESULTS

Sixty-two of 72 patients with C. psittaci CAP had a history of avian exposure. Among the six parameters of the JRS score, matching rates of four parameters were significantly lower in the C. psittaci CAP than the M. pneumoniae CAP in the following parameters: age <60 years, no or minor comorbid illness, stubborn or paroxysmal cough, and absence of chest adventitious sounds. The sensitivity of the diagnosis of atypical pneumonia in patients with C. psittaci CAP was significantly lower than the M. pneumoniae CAP (65.3% and 87.4%, p < 0.0001). When the diagnostic sensitivity was analyzed for different ages, the diagnostic sensitivities for the C. psittaci CAP were 90.5% for non-elderly patients and 30.0% for elderly patients.

CONCLUSIONS

The JRS atypical pneumonia score is a useful tool for distinguishing between C. psittaci CAP and bacterial CAP in patients aged <60 years, but not in patients aged ≥60 years. A history of avian exposure in middle-aged patients with normal white blood cell count may be suggestive of C. psittaci pneumonia.

Efficacy of gefapixant, a P2X3 antagonist, for lung cancer-related cough: a case report

Cough is a frequent symptom accompanied by lung cancer. More potent antitussive treatment for this complex and distressing symptom is required, but anti-cancer chemotherapy cannot fully manage the cough. Inhibition of vagal nerves might control coughing in patients with troublesome lung cancer-related cough and P2X3 inhibitory therapy may be useful for targeting neuronal function. We report the case of a woman in her late 70s who never smoked and had advanced lung cancer. She visited our hospital complaining of serious deterioration of a non-productive cough. She was diagnosed with relapse of lung cancer, but she requested 2-week anti-tussive therapy before second-line chemotherapy. Gefapixant (P2X3 antagonist) add-on at a dose of 90 mg/day (45 mg twice daily as the usual dosage in Japan) improved her cough as indicated by an improvement in the visual analog scale for cough from 70 to 20 mm and in the Japanese version of the Leicester Cough Questionnaire from 8.2 to 16.3, despite a deterioration in lung cancer after 2 weeks. There are no current guidelines for cough accompanied by lung cancer; however, our findings suggest that P2X3 inhibition is a potent therapeutic option for lung cancer-related cough.

Clinical Efficacy of the Neutralizing Antibody Therapy Sotrovimab in Patients with SARS-CoV-2 Omicron BA.1 and BA.2 Subvariant Infections

Sotrovimab, an antibody active against severe acute respiratory syndrome coronavirus 2 that neutralizes antibodies, reduced the risk of COVID-19-related hospitalization or death in studies conducted before the emergence of the Omicron variant. The objective of this study is to evaluate the clinical efficacy of sotrovimab in patients with mild to moderate COVID-19 Omicron BA.1 and BA.2 subvariant infections using a propensity score matching method. The propensity score-matched cohort study population was derived from patients who received sotrovimab. We derived a comparator group from an age- and sex-matched population who were recuperating in a medical facility after COVID-19 infection or from elderly person entrance facilities during the same period who were eligible for but did not receive sotrovimab treatment. In total, 642 patients in the BA.1 subvariant group and 202 in the BA.2 subvariant group and matched individuals were analyzed. The outcome was the requirement for oxygen therapy. In the treatment group, 26 patients with the BA.1 subvariant and 8 patients with the BA.2 subvariant received oxygen therapy. The administration of oxygen therapy was significantly lower in the treatment group than in the control group (BA.1 subvariant group, 4.0% vs. 8.7%, p = 0.0008; BA.2 subvariant group, 4.0% vs. 9.9%, p = 0.0296). All these patients were admitted to our hospitals and received additional therapy and then recovered. No deaths were observed in either group. Our results demonstrate that the sotrovimab antibody treatment may be associated with a reduction in the requirement for oxygen therapy among high-risk patients with mild to moderate COVID-19 Omicron BA.1 and BA.2 subvariants.

Alectinib in a patient with ALK-positive non-small lung cancer unable to swallow capsules

INTRODUCTION

The treatment landscape of metastatic non-small-cell lung cancer (NSCLC) has changed dramatically in the last decade. Anaplastic lymphoma kinase (ALK) rearrangement has been a focus of interest since ALK inhibitors produced outstanding clinical results compared with chemotherapy with cytotoxic agents in patients with ALK-positive NSCLC.

CASE REPORT

We present the case of a 56-year-old woman with metastatic ALK-positive NSCLC and an inability to swallow capsules or tablets. Unfortunately, all ALK inhibitors are capsule or tablet formulations.

MANAGEMENT AND OUTCOME

We, therefore, decided to administer alectinib orally by opening the capsules and suspending the contents in water. Clinical imaging performed 12 months after initiating alectinib therapy indicated a complete response (CR). After 54 months of follow-up, CR has been maintained, and oral alectinib therapy has continued with no recurrence of the swallowing disturbance.

DISCUSSION

There are no current guidelines for oral targeted therapy in patients with swallowing disturbance, but alectinib administered orally by opening the capsules and suspending the contents in water can be a treatment option in patients with ALK-positive NSCLC and swallowing difficulty.

Association of High Mobility Group Box-Protein 1 and Platelet Microparticles in Patients After Hematopoietic Stem Cell Transplantation

Thrombotic complications after allogeneic hematopoietic stem cell transplantation (allo-HSCT) significantly impact transplant outcomes. We focused on high mobility group box-protein (HMGB)1, one causative agent of thrombotic lesions in allo-HSCT, and investigated its association with platelets. We statistically analyzed available data from 172 patients with hematopoietic malignancies receiving allo-HSCT. A significant enhancement of monocyte-chemotactant protein-1, HMGB1, and platelet-derived microparticle (PDMP) levels was observed at day 0 after transplantation as compared to pre-transplantation. Multivariate analysis of the association among HMGB1 and 16 factors on day 0 revealed a significant correlation of HMGB1 levels with thrombin-antithrombin complex, interleukin-6, and PDMPs. High mobility group box-protein 1-induced procoagulant platelet induction and PDMP generation were performed in vitro using healthy platelets. High mobility group box-protein 1-induced PDMP generation was suppressed by toll-like receptor inhibitors and recombinant thrombomodulin. These results suggest that HMGB1 contributes to platelet activation in patients after allo-HSCT and is associated with PDMP-related thrombotic complications.

Assessment of the pneumonia severity score in community-acquired and nursing and healthcare-associated pneumonia due to COVID-19

INTRODUCTION

The Japanese Respiratory Society (JRS) pneumonia guidelines recommend simple predictive rules, the A-DROP scoring system, for assessment of the severity of community-acquired pneumonia (CAP) and nursing and healthcare-associated pneumonia (NHCAP). We evaluated whether the A-DROP system can be adapted for assessment of the severity of coronavirus disease 2019 (COVID-19) pneumonia.

METHODS

Data from 1141 patients with COVID-19 pneumonia were analyzed, comprising 502 patients observed in the 1st to 3rd wave period, 338 patients in the 4th wave and 301 patients in the 5th wave in Japan.

RESULTS

The mortality rate and mechanical ventilation rate were 0% and 1.4% in patients classified with mild disease (A-DROP score, 0 point), 3.2% and 46.7% in those with moderate disease (1 or 2 points), 20.8% and 78.3% with severe disease (3 points), and 55.0% and 100% with extremely severe disease (4 or 5 points), indicating an increase in the mortality and mechanical ventilation rates in accordance with severity (Cochran-Armitage trend test; p = <0.001). This significant relationship between the severity in the A-DROP scoring system and either the mortality rate or mechanical ventilation rate was observed in patients with COVID-19 CAP and NHCAP. In each of the five COVID-19 waves, the same significant relationship was observed.

CONCLUSIONS

The mortality rate and mechanical ventilation rate in patients with COVID-19 pneumonia increased depending on severity classified according to the A-DROP scoring system. Our results suggest that the A-DROP scoring system can be adapted for the assessment of severity of COVID-19 CAP and NHCAP.

Changes in diagnostic usefulness of the JRS scoring system in COVID-19 pneumonia by SARS-CoV-2 vaccination

Introduction

The Japanese Respiratory Society (JRS) scoring system is a useful tool for the rapid presumptive diagnosis of atypical pneumonia in non-elderly (aged <60 years) patients. As SARS-CoV-2 vaccination progresses, COVID-19 in elderly people has markedly reduced. We investigated changes in diagnostic usefulness of the JRS scoring system in COVID-19 pneumonia between the Delta variant group (vaccination period) and non-Delta variant group (before the vaccination period).

Methods

This study was conducted at five institutions and assessed a total of 1121 patients with COVID-19 pneumonia (298 had the Delta variant). During the vaccination period, the Delta variant has spread and replaced the Alfa variant. We evaluated the vaccination period as the Delta variant group.

Results

Among the six parameters of the JRS scoring system, matching rates of two parameters were higher in the Delta variant group than the non-Delta variant group (pre-vaccination period): age <60 years (77.5% vs 42.2%, P < 0.0001) and no or minor comorbid illness (69.1% vs 57.8%, p = 0.0007). The sensitivity of the diagnosis of atypical pneumonia in patients with COVID-19 pneumonia was significantly higher in the Delta variant group compared with the non-Delta variant group (80.2% vs 58.3%, p < 0.0001). When the diagnostic sensitivity was analyzed for different ages, the diagnostic sensitivities for the Delta variant and non-Delta variant groups were 92.6% and 95.5% for non-elderly patients and 39.1% and 32.5% for elderly patients, respectively.

Conclusions

Our results demonstrated that the JRS scoring system is a useful tool for distinguishing between COVID-19 pneumonia and bacterial pneumonia in the COVID-19 vaccination period, but not before the vaccination period.

Clinical efficacy of casirivimab-imdevimab antibody combination treatment in patients with COVID-19 Delta variant

Introduction

Casirivimab-imdevimab, an antibody cocktail containing two severe acute respiratory syndrome coronavirus 2 neutralizing antibodies, reduces the viral load and the risk of coronavirus disease 2019 (COVID-19)-related hospitalization or death. The objective of this study was to evaluate the clinical efficacy of casirivimab-imdevimab in patients with COVID-19 Delta variant in Japan.

Methods

This study was conducted at five institutions and assessed a total of 461 patients with COVID-19 who met the inclusion criteria. The treatment group received a dose of casirivimab-imdevimab consisting of a cocktail of two monoclonal antibodies, (casirivimab 600 mg and imdevimab 600 mg intravenously). The control consisted of age- and sex-matched COVID-19 patients (n = 461) who sufficed the inclusion criteria but did not receive casirivimab-imdevimab. The outcome was the requirement of oxygen therapy.

Results

In the treatment group, patients received oxygen therapy (n = 30), nasal canula (n = 23), high flow nasal cannula (n = 5), and mechanical ventilation (n = 2). In the control group, patients received oxygen therapy (n = 56), nasal canula (n = 45), high flow nasal cannula (n = 8), and mechanical ventilation (n = 3). The administration of oxygen therapy was significantly lower in the treatment group than the control group (6.5% vs. 12.1%, P = 0.0044). All these patients admitted to our hospitals and received additional therapy and recovered.

Conclusions

Our results demonstrate that the casirivimab-imdevimab combination antibody treatment is associated with reduced rates of requiring oxygen therapy among high-risk patients with COVID-19 Delta variant.

Tiotropium Add-On and Treatable Traits in Asthma-COPD Overlap: A Real-World Pilot Study

Purpose

The ‘treatable traits’ strategy for patients with chronic inflammatory airway diseases, especially asthma and chronic obstructive pulmonary disease (COPD), is a focus of interest, because it implements precision and personalized medicine. Asthma-COPD overlap (ACO), a phenotype involving both asthma and COPD, is an important disease entity because patients with ACO have significantly worse outcomes, conferring greater economical and social burdens. Some guidelines for ACO recommend add-on therapy of long-acting muscarinic antagonists to inhaled corticosteroids and long-acting β₂ agonists. However, this approach is based on extrapolation from patients with asthma or COPD alone. Consequently, a ‘treatable traits’ approach suitable for ACO remains obscure.

Methods

A 12-week open-label cross-over pilot study was conducted in patients with ACO to investigate the effect of tiotropium bromide (TIO) 5 µg/day add-on therapy to fluticasone propionate/formoterol fumarate (FP/FM) 500/20 µg/day compared with FP/FM 500/20 µg/day alone. A 4-week run-in period and two 4-week treatment periods were included.

Results

A total of 18 male patients with stable ACO participated in this pilot study. All patients were ex-smokers. Mean values ± standard deviation (SD) for forced expiratory volume in 1 second (FEV₁) were 1.21 ± 0.49 L after the run-in period, 1.20 ± 0.51 L after the FP/FM combination therapy period, and 1.30 ± 0.48 L after the TIO add-on therapy to FP/FM period. FEV₁ values after the TIO add-on therapy FP/FM period were significantly higher than those after the run-in period (p < 0.01).

Conclusion

TIO add-on therapy to FP/FM in patients with ACO, considered difficult to treat because of the presence of both asthma and COPD, resulted in improvements in lung function parameters in this real-world pilot study, indicating the potential value of TIO add-on therapy as a “treatable traits” option for standard treatment for ACO.

Clinical features of nursing and healthcare-associated pneumonia due to COVID-19

Introduction

The objective of this study was to clarify the clinical differences between nursing and healthcare-associated pneumonia (NHCAP) and community-acquired pneumonia (CAP) due to COVID-19. We also investigated the clinical characteristics to determine whether there is a difference between the variant and non-variant strain in patients with NHCAP due to COVID-19. In addition, we analyzed the clinical outcomes in NHCAP patients with mental disorders who were hospitalized in a medical institution for treatment of mental illness.

Methods

This study was conducted at five institutions and assessed a total of 836 patients with COVID-19 pneumonia (154 cases were classified as NHCAP and 335 had lineage B.1.1.7.).

Results

No differences in patient background, clinical findings, disease severity, or outcomes were observed in patients with NHCAP between the non-B.1.1.7 group and B.1.1.7 group. The median age, frequency of comorbid illness, rates of intensive care unit stay, and mortality rate were significantly higher in patients with NHCAP than in those with CAP. Among the patients with NHCAP, the mortality rate was highest at 37.5% in patients with recent cancer treatment, followed by elderly or disabled patients receiving nursing care (24.3%), residents of care facilities (23.0%), patients receiving dialysis (13.6%), and patients in mental hospitals (9.4%).

Conclusions

Our results demonstrated that there were many differences in the clinical characteristics between NHCAP patients and CAP patients due to COVID-19. It is necessary to consider the prevention and treatment content depending on the presence or absence of applicable criteria for NHCAP.

Early identification of novel coronavirus (COVID-19) pneumonia using clinical and radiographic findings

Introduction

The Japanese Respiratory Society (JRS) scoring system is a useful tool for identifying Mycoplasma pneumoniae pneumonia. Most COVID-19 pneumonia in non-elderly patients (aged <60 years) are classified as atypical pneumonia using the JRS scoring system. We evaluated whether physicians could distinguish between COVID-19 pneumonia and M. pneumoniae pneumonia using chest computed tomography (CT) findings. In addition, we investigated chest CT findings if there is a difference between the variant and non-variant strain.

Methods

This study was conducted at five institutions and assessed a total of 823 patients with COVID-19 pneumonia (335 had lineage B.1.1.7.) and 100 patients with M. pneumoniae pneumonia.

Results

In COVID-19 pneumonia, at the first CT examination, peripheral, bilateral ground-glass opacity (GGO) with or without consolidation or crazy-paving pattern was observed frequently. GGO frequently had a round morphology (39.2%). No differences were observed in the radiological findings between the non-B.1.1.7 groups and B.1.1.7 groups. The frequency of pleural effusion, lymphadenopathy, bronchial wall thickening and nodules (tree-in-bud and centrilobular) was low. In contrast to COVID-19 pneumonia, bronchial wall thickening (84%) was observed most frequently, followed by nodules (81%) in M. pneumoniae pneumonia. These findings were significantly higher in M. pneumoniae pneumonia than COVID-19 pneumonia.

Conclusions

Our results demonstrated that a combination of the JRS scoring system and chest CT findings is useful for the rapid presumptive diagnosis of COVID-19 pneumonia in patients aged <60 years. However, this clinical and radiographic diagnosis is not adapted to elderly people.

A Single-Center Retrospective Observational Study Evaluating the Favorable Predictive Factors for the Disease Control Time of Treatment with Tocilizumab in Patients of Rheumatoid Arthritis

Background

Tocilizumab (TCZ) is humanized monoclonal antibody against the interleukin-6 (IL-6) and receptor that has prominent efficacy for the treatment of rheumatoid arthritis (RA). We conducted a retrospective observational study to determine how long TCZ controls RA.

Patients and Methods

We retrospectively reviewed the medical records of RA patients treated with TCZ. The aim of this study was to evaluate the contribution of clinical parameters to disease control time (DCT) in RA patients.

Results

Overall, 144 patients were enrolled in the study. The median age of patients was 66 years (range: 34–85 years). In univariate analysis, DCT was significantly increased in patients who had never received previous biologic disease-modifying anti-rheumatic drugs treatment (P = 0.0064). We also analyzed the contribution of the base line value of C-reactive protein (CRP) to DCT. We divided the patients with RA into two groups according to a cutoff value of 1.000 mg/dl. The median control times were 77.5 months (95% confidence interval [CI]: 44.8–not reached to median) and 34.5 months (95% CI: 17.0–79.3) for patients with high and low CRP value, respectively. In univariate analysis, DCT was significantly increased in patients with a high CRP value (P = 0.0283). Multivariate analysis clearly revealed that a high baseline CRP value was an independent favorable predictive factor for longer DCT (hazard ratio, 0.608, 95% CI: 0.378–0.981, P = 0.0416).

Conclusion

These data clearly demonstrate that the baseline value of CRP was closely associated with long time DCT in patients of RA treated with TCZ.

Evaluation of a novel urinary antigen test kit for diagnosing Legionella pneumonia

OBJECTIVES

The aim of this study was to evaluate the diagnostic utility of a novel test kit that could theoretically detect all serogroups of Legionella pneumophila for diagnosing Legionella pneumonia, in comparison with existing kits.

METHODS

This study was conducted in 16 hospitals in Japan from April 2016 to December 2018. Three urinary antigen test kits were used: the novel kit (LAC-116), BinaxNOW Legionella (Binax), and Q-line Kyokutou Legionella (Q-line). In addition, sputum culture and nucleic acid detection tests and serum antibody tests were performed where possible. The diagnostic accuracy and correlations of the novel kit with the two existing kits were analyzed.

RESULTS

In total, 56 patients were diagnosed with Legionella pneumonia. The sensitivities of LAC-116, Binax, and Q-line were 79%, 84%, and 71%, respectively. The overall match rate between LAC-116 and Binax was 96.8% and between LAC-116 and Q-line was 96.4%. One patient had L. pneumophila serogroup 2, and only LAC-116 showed a positive result, whereas Binax and Q-line did not.

CONCLUSIONS

The novel Legionella urinary antigen test kit was useful for diagnosing Legionella pneumonia. In addition, it could detect Legionella pneumonia caused by non-L. pneumophila serogroup 1.

Triple Therapy with Budesonide/Glycopyrrolate/Formoterol Fumarate Improves Inspiratory Capacity in Patients with Asthma-Chronic Obstructive Pulmonary Disease Overlap

Purpose

Asthma-chronic obstructive pulmonary disease overlap (ACO), characterized by airway limitation, is an important condition with high incidence and mortality. Although some guidelines recommend triple therapy with inhaled corticosteroids/long-acting muscarinic antagonists/long-acting β2 agonists, this treatment approach is based on the extrapolation of data from studies of asthma or chronic obstructive pulmonary disease (COPD) alone.

Methods

A 12-week, randomized, open-label cross-over pilot study was conducted in 19 patients with ACO to investigate the effect of triple therapy with glycopyrrolate (GLY) 50 µg/day on budesonide/formoterol fumarate (BUD/FORM) 640/18 µg/day. The study period included a 4-week wash-out, 4-week run-in, and 4-week treatment period. Respiratory function tests, fractional exhaled nitric oxide (FeNO), a COPD assessment test (CAT) and an asthma control questionnaire (ACQ) were carried out 0, 4, and 8 weeks after randomization.

Results

A total of 19 patients with stable ACO (19 males and no females) with a mean age of 70.7 ± 7.6 years (± standard deviation, SD; range 55-83 years) participated in this study. All patients were ex-smokers with a smoking history of 63.1 ± 41.1 pack-years (± SD). Mean values for inspiratory capacity (IC), an index of hyperinflation of the lung that causes exertional dyspnea and reduced exercise, were 1.93 L (± 0.47 L) after the run-in, 1.85 L (± 0.51 L) after the BUD/FORM dual therapy period and 2.11 L (± 0.58 L) after the BUD/GLY/FORM triple therapy period. IC values after the BUD/GLY/FORM triple therapy were significantly higher than those after the run-in (p < 0.02). FeNO values, ACQ, and CAT scores were not significantly different among the run-in, wash-out, and triple-therapy periods.

Conclusion

The present pilot study showed that triple therapy with BUD/GLY/FORM results in an improvement in lung function parameters including IC, indicating the potential value of triple therapy as standard treatment for ACO.

Localized lymphadenopathy with myelodysplastic syndrome associated with tuberculosis

We report the case of a man who developed myelodysplastic syndrome (MDS) and refractory cytopenia of unilineage dysplasia, 5 months after aortic valve replacement surgery. He also developed fever of unknown origin. After bone marrow- and other laboratory examinations, he was diagnosed with tuberculosis.

Effect of triple therapy in patients with asthma-COPD overlap

OBJECTIVE

Asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) is of increasing interest because ACO patients have significantly worse outcomes, leading to greater social and economic burdens compared with asthma or COPD alone. Some guidelines for ACO recommend triple therapy with inhaled corticosteroids, long-acting β2 agonists, and long-acting muscarinic antagonists. However, this approach is based on extrapolating data from patients with asthma or COPD alone. Therapeutic studies for ACO have not previously been conducted.

MATERIALS AND METHODS

A 12-week, randomized, open-label cross-over pilot study was conducted in 17 ACO patients to evaluate the effect of umeclidinium (UMEC) 62.5 µg once-daily added to fluticasone furoate/vilanterol (FF/VI) 200/25 µg once-daily. A 4-week run-in, a first and a second 4-week treatment period were included. Respiratory function, respiratory impedance, fractional exhaled nitric oxide, COPD assessment test, and asthma control test scores were evaluated 0, 4, and 8 weeks after randomization.

RESULTS

Mean values of post-bronchodilator forced expiratory volume in 1 second as a percentage of the predicted value (%FEV1), after UMEC was added to FF/VI, were significantly higher than after the run-in (p < 0.01). Mean values of resonant frequency during inspiration (Fres), after UMEC was added to FF/VI, were significantly lower than after the run-in (p < 0.01).

CONCLUSION

Adding UMEC to FF/VI provides greater improvement in lung function, indicating that triple therapy is a suitable regular treatment for ACO.

Efficacy of daikenchuto, a traditional Japanese Kampo medicine, for postoperative intestinal dysfunction in patients with gastrointestinal cancers: meta-analysis

BACKGROUND

The Japan Society for Oriental Medicine makes a compilation of structured abstracts of randomized controlled trials (RCTs) of Kampo medicines available on its Evidence Reports of Kampo Treatment (EKAT) website.

METHODS

Using EKAT, we conducted a systematic review and meta-analysis on the efficacy of using daikenchuto ( https://mpdb.nibiohn.go.jp/stork ) for bowel dysfunction after surgery for gastrointestinal cancer. The primary outcomes were the time to first postoperative flatus and the time to first postoperative bowel movement (BM).

RESULTS

We found nine relevant RCTs. The mean differences between the daikenchuto group and control group (daikenchuto was not administered) were - 0.43 (95% CI: - 0.77 to - 0.09) days for the time to first postoperative flatus, - 0.29 (95% CI: - 0.59 to 0.01) days for the time to first postoperative BM, and - 0.95 (95% CI: - 1.70 to - 0.21) days for the length of postoperative hospital stay, and the risk ratio of the incidence of intestinal obstruction was 0.60 (95% CI: 0.35-1.03). The time to first postoperative flatus and the length of postoperative hospital stay were significantly shorter in the daikenchuto group than those in the control group (P = 0.01). However, only double-blind studies were evaluated; the results turned to be non-significant.

CONCLUSION

As a result of meta-analysis by all retrieved according to the registered protocol, daikenchuto was efficacious in improving postoperative bowel dysfunction in patients with gastrointestinal cancers. However, limiting to articles with description of COI and blindness, significance disappeared.

[Effect of Japanese Traditional Medicine, Ninjin-Youei-To(TJ-108), on the Quality of Life of Patients with Non-Small Cell Lung Cancer Receiving Outpatient Chemotherapy]

An increasing number of patients with lung cancer are undergoing outpatient chemotherapy, and thus, it is very important to maintain the quality of life(QOL)of these patients. Ninjin-Youei-To(TJ-108), a Japanese traditional medicine, has been reported to improve the QOL of patients with advanced cancer. However, the effect of TJ-108 in patients with lung cancer undergoing outpatient chemotherapy is unknown. Therefore, we conducted this study. To investigate factors influencing the QOL of these patients, we administered a QOL questionnaire,"The QOL Questionnaire for Cancer Patients Treated with Anticancer Drugs"(QOL-ACD)to 15 patients with non-small cell lung cancer. Factors related to the overall QOL scores and other categories indicating"activity","physical condition","psychological condition","social relationship", and"face scale" were analyzed. No significant decrease in each of the evaluated factors was observed in this study.

A Comparison of the Efficacy of Once-Daily Fluticasone Furoate/Vilanterole with Twice-Daily Fluticasone Propionate/Salmeterol in Elderly Asthmatics

BACKGROUND

Asthma in the elderly population has been focused because it affects quality of life and results in a higher hospitalization rate and mortality. Fluticasone furoate (FF)/vilanterole (VI) is a novel inhaled corticosteroids (ICS)/long-acting β2 agonist (LABA) combination being developed for once-daily administration for asthma with greater anti-inflammatory activity and longer duration of bronchidilation. The Ellipta^TM dry powder inhaler (DPI) has also been available as a new device with high levels of satisfaction and preference.

METHODS

A 12-week, randomized, open-label cross-over, pilot study was conducted in 18 elderly patients with bronchial asthma to compare the effectiveness of once-daily FF/VI 200/25 µg via the Ellipta^TM DPI vs. twice-daily fluticasone propionate (FP)/salmeterol (SAL) 500/50 µg via the Diskus^TM DPI. The study period included a 4-week run-in, the first 4-week treatment, and the second 4-week treatment. Respiratory functions, fractional exhaled nitric oxide (FeNO) and asthma control test (ACT) scores were measured 0, 4, and 8 weeks after randomization. Preferences for their device were also assessed using a self-completed questionnaire.

RESULTS

Spirometric paramters, FeNO levels and ACT scores were not significantly different during the run-in period, the FP/SAL treatment period, and the FF/VI treatment period. FF/VI treatment via the Ellipta^TM DPI was preferred to the FP/SAL treatment via the Diskus^TM DPI (p<0.01).

CONCLUSIONS

These data indicate that FF/VI treatment via the Ellipta^TM DPI is preferred in elderly patients with asthma based on its ease-of-use, suggesting the potential to improve patient adherence and, as a result, overall disease management.

The measurement of cough response to bronchoconstriction induced by methacholine inhalation in healthy subjects: An examination using the Astograph method

BACKGROUND

We demonstrated that heightened cough response to bronchoconstriction is a fundamental feature of cough variant asthma (CVA). To evaluate this physiological feature of CVA in daily clinical practice, it is necessary to clarify the cough response to bronchoconstriction in healthy subjects. We evaluated cough response to methacholine (MCh)-induced bronchoconstriction in healthy subjects. A forced oscillometry technique was used to measure airway resistance changes with Mch.

METHODS

Healthy never-smokers (21 men, 20 women; mean 22.3 ± 3.7 years) participated. None had a >3-week cough history, clinically significant respiratory or cardiovascular disorders, or disorders that might put subjects at risk or influence the study results or the subjects' ability to participate. Twofold increasing concentrations of Mch chloride diluted in phosphate-buffered saline (0.039 to 160 mg/mL) were inhaled from nebulizers at 1-minute intervals during subjects' tidal breathing after the baseline respiratory resistance (Rrs) was recorded. Mch inhalation continued until Rrs reached twice the baseline value and forced expiratory volume in 1 second (FEV₁) decreased to <90% of baseline value. Spirometry was measured before Mch inhalation and immediately after Rrs had increased twofold. Coughs were counted during and for 30 minutes after Mch inhalation. The cough reflex sensitivity to capsaicin was also examined.

RESULTS

The number of coughs was 11.1 ± 14.3 (median, 7.0; range, 0 to 71; reference range, 0 to 39.7). There was no significant difference in the cough response between the sexes. The reproducibility of the cough response to bronchoconstriction was sufficient. No correlation existed between the bronchoconstriction-induced cough response and capsaicin cough-reflex sensitivity.

CONCLUSIONS

Using the Astograph method, cough response to bronchoconstriction could be measured easily, safely and highly reproducibly in healthy subjects.

[Effect of Japanese Traditional Medicine, TJ-48, on the Quality of Life of Patients with Non-Small Cell Lung Cancer Receiving Outpatient Chemotherapy]

An increasing number of patients with lung cancer are undergoing outpatient chemotherapy.It is very important to retain the quality of life (QOL) of these patients.Japanese traditional medicine, TJ-48, has been reported to improve the QOL of patients with advanced cancer. However, the effect of TJ-48 in patients with lung cancer undergoing outpatient chemotherapy is unknown. The present study was conducted to investigate the factors influencing the QOL of these patients. We used "The QOL questionnaire for cancer patients treated with anticancer drugs" (QOL-ACD) with 16 patients with non-small cell lung cancer. The medical factors related to the overall QOL scores and other variables indicating "activity," "physical condition, "psychological condition,""social relationships," "psychological condition," and "face scale" were analyzed. Significant improvement was observed in the total QOL score, mainly owing to the improvement in the patients "physical condition."

A comparison of the efficacy of once-daily fluticasone furoate/vilanterole with twice-daily fluticasone propionate/salmeterol in asthma-COPD overlap syndrome

BACKGROUND

Asthma-chronic obstructive pulmonary disease overlap syndrome (ACOS) is important because patients with ACOS have significantly worse outcomes compared with those with asthma or chronic obstructive pulmonary disease (COPD) alone. Inhaled corticosteroids (ICS), together with a long-acting β2 agonist (LABA), are recommended, but no therapeutic studies for ACOS have been conducted. Recently, fluticasone furoate/vilanterole (FF/VI) has been approved as the first once-daily ICS/LABA combination therapy for asthma and COPD.

METHODS

A 12-week, randomized, open-label cross-over study was conducted in 16 patients with ACOS to compare the effectiveness of once-daily FF/VI 200/25 μg vs. twice-daily fluticasone propionate/salmeterol (FP/SAL) 500/50 μg. The study period included a 4-week run-in, the first 4-week treatment, and the second 4-week treatment. Respiratory functions, including forced expiratory volume in 1 s (FEV1) and respiratory impedance using the forced oscillation technique (FOT), were measured, as was fractional exhaled nitric oxide (FeNO). A COPD assessment test (CAT) scores and asthma control test (ACT) scores were recorded 0, 4, and 8 weeks after randomization.

RESULTS

The mean values for the FEV1 were 1.33 (±0.29) L in the run-in period, 1.38 (±0.39) L after the FP/SAL treatment period, and 1.47 (±0.38) L after the FF/VI treatment period. The FEV1 value after the FF/VI treatment was significantly greater than the value after the run-in period (p < 0.01). FOT parameters, FeNO levels, CAT scores, ACT scores, and other blood tests were not significantly different during the run-in period, the FP/SAL treatment period, and the FF/VI treatment period.

CONCLUSIONS

FF/VI, the first once-daily ICS/LABA, can provide substantial improvement in lung functions, indicating that FF/VI should be considered for the regular treatment of ACOS.

[Nab-Paclitaxel with platinum chemotherapy as sixth-line therapy for a non-small cell lung cancer patient]

A 48-year-old woman was admitted to our hospital for sixth-line chemotherapy. A chest X-ray film and computed tomographic (CT) scan revealed a right-sided massive tumor with multiple lung tumors. Repeated treatment with carboplatin (AUC 6) on day 1 and nab-paclitaxel (100mg/m2) on days 1, 8, and 15, every 28 days were effective in this patient. Chemotherapy with nab-paclitaxel may be effective for patients with multi-recurrent adenocarcinoma.

Beraprost, a stable analog of prostacyclin, enhances cough reflex sensitivity to capsaicin in bronchitic patients

AIMS

Inflammatory mediators are involved in the pathophysiology of neutrophilic bronchial disorders presenting with chronic productive cough. Accumulating evidence indicates that prostanoids are key elements in the pathophysiology of these disorders. However, little is known about the role of prostacyclin in neutrophilic bronchial inflammation.

METHODS

The effect of beraprost, a chemically and biologically stable analog of prostacyclin, on cough response to inhaled capsaicin was examined in 14 patients with chronic bronchitis, a neutrophilic bronchial disorder, in a randomized, placebo-controlled crossover study. Capsaicin cough threshold, defined as the lowest concentration of capsaicin eliciting five or more coughs, was measured as an index of the airway cough reflex sensitivity.

RESULTS

After a 2-week treatment with beraprost (80 μg twice a day orally), the cough threshold was significantly (P < .05) decreased as compared with placebo [12.2 (geometric standard error of the mean [GSEM] 1.5) μM vs. 24.4 (GSEM 1.3)].

CONCLUSIONS

These findings indicate that prostacyclin is involved in the pathophysiology of cough reflex sensitivity in patients with chronic bronchitis, a frequently encountered neutrophilic bronchial disorder presenting with chronic productive cough.

[Analysis of factors associated with the quality of life in patients with non-small cell lung cancer who received outpatient pemetrexed maintenance therapy]

Increasing number of patients with advanced non-small cell lung cancer are receiving outpatient maintenance chemotherapy. It is very important to maintain these patients' quality of life(QOL). Pemetrexed has been reported to be an effective maintenance chemotherapy. However, its effects on the QOL of patients with non-small cell lung cancer who are undergoing outpatient maintenance chemotherapy are unknown; therefore, we conducted this study. To investigate factors that influence the QOL of these patients, we provided a QOL questionnaire,"The QOL Questionnaire for Cancer Patients Treated with Anticancer Drugs(QOL-ACD)"to 7 patients with non-small cell lung cancer. The medical factors related to the overall QOL scores, as well as other categories indicating"activity","physical condition","psychological condition","social relationship", and"face scale", were analyzed. No significant reductions in any of the factors were observed in this study.

Asthma exacerbations after the East Japan Disaster

On March 11, 2011, a 9.0-magnitude earthquake struck east Japan, following tsunami. Many people are forced to live in evacuation shelters without enough life-saving drugs. Asthma control for management of health crisis is required, because asthma exacerbation is a major cause of morbidity, can need acute care and results in death. However, it remains obscure what parameter should be used in primary clinic of evacuation shelters. The objective of this study is to elucidate the practical efficacy of asthma assessment tool in primary clinic for victims of this disaster. Asthma control test (ACT), a brief and patient-based tool to evaluate asthma control, was conducted for 17 patients with asthma in evacuation shelters at Tohoku district. Total sum of ACT scores were significantly decreased after this disaster. Significant decreases were observed for the items; "Asthma keeps you from getting much done at work", "Shortness of breath", "Asthma symptoms wake you up" and "Patient rating of control". ACT, an easy and practicable tool, clearly demonstrated the asthma exacerbation in evacuation shelters without the use of lung function testing. ACT may contribute to the management of health crisis not only for this East Japan disaster but also for the other forthcoming unavoidable disasters.

[Effect of Japanese traditional medicine, TJ-41, on quality of life of patients with non-small cell lung cancer receiving outpatient chemotherapy]

An increasing number of patients with lung cancer are undergoing outpatient chemotherapy. It is very important to maintain good quality of life(QOL)for these patients, and Japanese traditional medicine, TJ-41, has been reported to improve the QOL of patients with advanced cancer. However, the effect of TJ-41 on patients with lung cancer undergoing outpatient chemotherapy is unknown. Therefore, we conducted this study. To investigate the factors influencing the QOL of these patients, we distributed a QOL questionaire,"The QOL Questionnaire for Cancer Patients Treated with Anticancer Drugs"(QOL-ACD)to 11 patients with non-small cell lung cancer. The medical factors related to the overall QOL scores and other categories, indicating"activity","physical condition","psychological condition","social relationships","psychological condition"and"face scale"were analyzed. A significant decrease in each of the factors was not observed in this study.

[Bevacizumab with platinum chemotherapy as 6th-line treatment in a case of non-small-cell lung cancer]

A 64-year-old man was admitted to our hospital for 6th-line chemotherapy. Chest X-ray film and computed tomographic (CT) scan showed right-sided pleural thickening with multiple lung tumors. Repeated treatment with carboplatin (AUC 6), paclitaxel (200 mg/m(2)) and bevacizumab (150 mg/kg) on day 1 every 21 days was effective for this patient. Chemotherapy with bevacizumab may be effective for patients with multi-recurrent adenocarcinoma.

Role of COX-2 in cough reflex sensitivity to inhaled capsaicin in patients with sinobronchial syndrome

BACKGROUND

Sinobronchial syndrome is a cause of chronic productive cough. Inflammatory mediators are involved in the pathophysiology of chronic productive cough. Accumulating evidences indicate that cyclooxygenase (COX)-2, one of the inducible isoforms of COX, is a key element in the pathophysiological process of a number of inflammatory disorders. However, little is known about the role of COX-2 in chronic productive cough in patients with sinobronchial syndrome known as neutrophilic bronchial inflammation.

METHODS

The effect of etodolac, a potent COX-2 inhibitor, on cough response to inhaled capsaicin was examined in 15 patients with sinobronchial syndrome in a randomized, placebo-controlled cross-over study. Capsaicin cough threshold, defined as the lowest concentration of capsaicin eliciting five or more coughs, was measured as an index of airway cough reflex sensitivity.

RESULTS

The cough threshold was significantly (p < 0.03) increased after two-week treatment with etodolac (200 mg twice a day orally) compared with placebo [37.5 (GSEM 1.3) vs. 27.2 (GSEM 1.3) muM].

CONCLUSIONS

These findings indicate that COX-2 may be a possible modulator augmenting airway cough reflex sensitivity in patients with sinobronchial syndrome.

Antitussive effects of the leukotriene receptor antagonist montelukast in patients with cough variant asthma and atopic cough

BACKGROUND

Chronic cough is the only symptom of cough variant asthma (CVA) and atopic cough (AC). Cysteinyl leukotriene receptor antagonists have been shown to be effective in CVA, but there are no reports on their effectiveness in AC. To evaluate the antitussive effect of montelukast, a leukotriene receptor antagonist, in CVA and AC.

METHODS

Seventy-five patients with chronic cough received diagnostic bronchodilator therapy with oral clenbuterol hydrochloride for 6 days. Of the 75 patients, 48 and 27 met the simplified diagnostic criteria for CVA and AC, respectively. Patients with CVA were randomly divided into 3 groups: montelukast, clenbuterol, and montelukast plus clenbuterol. Patients with AC were randomly divided into 2 groups: montelukast and placebo. The efficacy of cough treatment was assessed with a subjective cough symptom scale (0 meant "no cough" and 10 denoted "cough as bad as at first visit"). The cough scale, pulmonary function test, and peak expiratory flow rate (PEF) were evaluated before and after 2 weeks of treatment.

RESULTS

In patients with CVA, 2-week treatment with montelukast, clenbuterol, and montelukast plus clenbuterol all significantly decreased cough scores and treatment with montelukast plus clenbuterol was superior to treatment with montelukast alone. In the montelukast plus clenbuterol group, PEF values in the morning and evening significantly increased after 2 weeks compared with values before treatment. In patients with AC, scores on the cough scale did not differ significantly between the montelukast group and the placebo group.

CONCLUSIONS

Montelukast was confirmed to suppress chronic non-productive cough in CVA, whereas it was not effective in non-productive cough in AC.

[Analysis of factors associated with quality of life for older adult patients with non-small cell lung cancer receiving outpatient gemcitabine therapy as an alternative inpatient therapy]

An increasing number of patients with lung cancer are undergoing outpatient chemotherapy as an alternative to inpatient therapy. To investigate the factors influencing the quality of life (QOL) for these patients, we administered a QOL questionnaire, The QOL Questionnaire for Cancer Patients Treated with Anticancer Drugs (QOL-ACD) to 8 older adult patients with non-small cell lung cancer. The medical factors related to the overall QOL scores and other categories indicating activity, physical condition, psychological condition, social relationship, psychological condition and face scale were analyzed. No significant decrease in each factor was observed in this study.

A phase II study of gemcitabine and vinorelbine combination followed by sequential gefitinib monotherapy in elderly patients with non-small cell lung cancer

e19040

Background: Gemcitabine (GEM) and vinorelbine (VNR) combination have demonstrated activity as a 1st-line treatment in elderly patients with advanced non-small-cell lung cancer (NSCLC). Gefitinib (GEF) is effective as a 2nd-line treatment for NSCLC. We conducted a multicenter phase II trial to evaluate the efficacy and toxicity for treatment of GEM+VNR followed by sequential GEF in elderly patients (pts) with advanced or metastatic NSCLC. Primary endpoint is response rate, secondary endpoints were safety, progression-free survival (PFS), and overall survival (OS). Methods: Eligibility required hitologically or cytologically comfirmed NSCLC, no prior therapy, measurable lesion(s), ECOG PS 0–2, age equal to or over 70 years, and adequate organ functions. Patients were received 3 cycles, each at 4-week intervals, of GEM (1000 mg/m2, d 1, 15) and VNR (25mg/m2 d 1, 15), followed by 250 mg of GEF daily until disease progression or unacceptable toxicity. Results: Between June 2004 and November 2007, 60 pts were enrolled and 2 pts withdrew consent. Fifty-eight pts (35 male and 23 female, median age 77 years) were evaluated. Median number of GEM+VNR administrations was 3 (range 1–3). Median duration of GEF was 101 days (range 9–652 days). Grade 3/4 toxicities included leucopenia (29%), neutoropenia (40%), anemia (12%), febrile neutropenia (9%), and anorexia (9%) during GEM+VNR, anorexia (2%), and constipation (2%) during GEF. Best response rate of GEM+VNR was 17% and that after sequential GEF was 31%. Median PFS and median OS were 4.2 months and 12.6 months, respectively. Response rate, PFS, and OS were significantly favorable in female and never-smoker. Conclusions: Sequential treatment consisted with GEM+VNR and GEF was feasible with acceptable toxicities in elderly patients with NSCLC.

[Table: see text]

COX-2 inhibition attenuates cough reflex sensitivity to inhaled capsaicin in patients with asthma

BACKGROUND AND OBJECTIVE

Cyclooxygenase (COX) is an enzyme that converts arachidonic acid to prostanoids. There are two isoforms of COX, namely COX-1 and COX-2. COX-2 is highly inducible by several stimuli and is associated with inflammation. Recent studies have shown that COX-2 is upregulated in the airway epithelium of patients with asthma but little is known about the role it plays in cough, a common symptom of bronchial asthma. This study was designed to investigate the role of COX-2 in cough reflex sensitivity in patients with asthma.

PATIENTS AND METHODS

The effect of etodolac, a potent COX-2 inhibitor, on cough response to inhaled capsaicin was examined in 17 patients with stable asthma in a randomized, placebo-controlled crossover study. Capsaicin cough threshold, defined as the lowest concentration of capsaicin eliciting 5 or more coughs, was measured as an index of airway cough reflex sensitivity.

RESULTS

The geometric mean (geometric SEM) cough threshold was significantly increased after a 2-week treatment program with oral etodolac (200 mg twice a day) compared with placebo (36.7 [1.2] vs 21.6 [1.2] gM, P<.02).

CONCLUSIONS

These findings indicate that COX-2 may be a possible modulator augmenting airway cough reflex sensitivity in asthmatic airways.

Effect of an orally active Th2 cytokine inhibitor, suplatast on "atopic cough" tosilate

BACKGROUND

"Atopic cough" is a new clinical entity that presents with isolated chronic bronchodilator-resistant cough accepted in the Japanese Respiratory Society Guidelines for Management of Cough. The essential features are eosinophilic tracheobronchitis, increased cough reflex sensitivity and an atopic constitution. It has been suggested that activated helper T lymphocytes and the cytokines which are produced by these cells are involved in the pathogenesis, but the relationship between helper T cell-derived cytokines and the airway cough reflex sensitivity remains unknown.

METHODS

The effect of an orally active Th2 cytokine inhibitor, suplatast tosilate (CAS 94055-76-2, IPD; 300 mg/day), on the cough response to inhaled capsaicin (CAS 404-86-4) was examined in ten patients with atopic cough. The capsaicin cough threshold, defined as the lowest concentration of capsaicin eliciting five or more coughs, was measured as an index of airway cough reflex sensitivity. The serum total immunoglobulin E (IgE) level and the peripheral blood eosinophil count were also determined after treatment with suplatast tosilate.

RESULTS

The cough threshold measured after four weeks of treatment with suplatast tosilate was significantly increased compared to the value obtained with placebo, along with a decrease of the serum IgE level and peripheral eosinophil count.

CONCLUSIONS

Th2 cytokines may increase the airway cough reflex sensitivity in patients with atopic cough. Oral administration of suplatast tosilate may be a novel therapy for atopic cough.

[A case of synchronous triple cancer involving lung, stomach and bladder, responding to combination chemotherapy of S-1 and cisplatin]

A 77-year-old man was admitted to our hospital complaining of general malaise, loss of appetite and hemoptysis. Chest X-ray film and computed tomography (CT) scan showed right-sided pleural effusion with lung tumor. Succeeding upper gastro-intestinal fiberscopy and cystoscopy revealed poorly-differentiated adenocarcinoma of the stomach and urothelial carcinoma of the bladder. Repeated treatment with 100 mg/body of S-1 on day 1 followed by 60 mg/m(2) of cisplatin on day 8 was effective in this patient.

[Primary mucosa-associated lymphoid tissue lymphoma of the urinary bladder successfully treated by radiotherapy and rituximab]

A 64-year-old woman visited our hospital in December 2005 because of general malaise. Her hemoglobin level was 9.0 g/dl. Gastrointestinal fiberscopy detected a hemorrhagic gastric ulcer, which was considered as etiology of anemia. Abdominal ultrasonography showed bilateral hydronephroses and hydroureters. A urine test revealed pyuria and macroscopic hematuria, and urine culture revealed 10(8) colony-forming units of Escherichia coli per ml. Pelvic MRI showed thickening of the posterior wall and trigone of the urinary bladder. Transurethral resection was peformed, and biopsy of the mucous of the bladder gave a diagnosis of primary mucosa-associated lymphoid tissue (MALT) lymphoma of the urinary bladder. Ann Arbor clinical stage was IEA. It was planned to administer irradiation at a total dose of 36 Gy to the whole bladder and part of the tumor; however, radiotherapy was discontinued at a dose of 26 Gy because of the development of pollakisuria. Pelvic MRI and pathologic examination of the urinary bladder after radiotherapy showed that the lymphoma was in complete remission; however, she received retuximab therapy at a dose of 375 mg/m2/week, 8 times additionally, because of the reduced radiotherapy. The patient has remained in complete remission for 14 months.

[Successful use of cladribine in the treatment of an elderly woman with typical hairy cell leukemia]

A 78-year-old woman was admitted to our hospital because for pancytopenia and splenomegaly. The bone marrow examination revealed hairy cells in 11.6% of all nucleated bone marrow cells. Hairy cells were positive for tartaricresistance acid phosphatase (TRAP) staining, CD2, CD11c, CD19, CD20, sIgD, CD25, CD103 and k chain. In addition, abdominal enhanced computed tomography (CT) demonstrated splenomegaly and multiple nodular early stains in the spleen. She was diagnosed as having typical hairy cell leukemia (HCL). The patient was treated with cladribine infused continuously for 7 days at a dose of 0.09 mg/kg/day, which induced partial remission without severe adverse effects. Purine analogs such as cladribine and pentostatine are considered first-line agents for patients with HCL. Treatment with cladribine achieved a high overall response rate for patients with HCL and was safe even in elderly patients like ours. It is necessary to observe carefully the complications of severe infections, second malignancies and relapse of HCL after treatment with cladribine.

A 90-year-old woman with trachea-invading thyroid cancer requiring four-ring resection of cervical trachea because of airway stenosis

The patient was a 90-year-old woman with chief complaints of hemoptysis and wheezing. Cervical computed tomography (CT) scans revealed a mass (2.5x2.0 cm) in the right lobe of the thyroid. The mass was exposed into the tracheal lumen, causing marked stenosis of the airway. When examined by bronchoscopy, the maximal degree of airway stenosis was about 75% of the tracheal cross section. During surgery, a resection of the right lobe of the thyroid was combined with a resection of the second to fifth cartilage ring of the cervical trachea for the purpose of complete resection of the thyroid cancer. During the same operation, the trachea was reconstructed by end-to-end anastomosis. For 1 week after surgery, a Mini-Trach II tube was left inserted to aspirate sputum, and the neck was kept bent forward (in the position of flexion). When sleeve resection of the trachea and subsequent end-to-end anastomosis are being performed, it is essential to manipulate the trachea in a protective manner, to preserve the nourishing vessels, to perform operative manipulation aseptically, to appropriately move the trachea, and to ensure reliable suturing with the goal of minimizing the incidence of complications such as anastomotic failure and stenosis of the anastomosed area. Although the patient was in advanced old age, her postoperative course was uneventful.

[Analysis of factors associated with quality of life for patients with non-small lung cancer receiving outpatient vinorelbine therapy as alternative inpatient therapy]

An increasing number of patients with lung cancer are undergoing outpatient chemotherapy as an alternative inpatient therapy. To investigate the factors influencing the quality of life (QOL) for these patients,we used a QOL questionnaire, "The QOL Questionnaire for Cancer Patients Treated with Anticancer Drugs" (QOL-ACD) for 8 patients with non-small cell lung cancer. The medical factors related to the overall QOL scores and other categories indicating "activity," "physical condition," "psychological condition," "social relationship" and "face scale" were analyzed. Significant improvements in the factors indicating "psychological condition" were observed in this study.