Ultrasonic humidifier lung with a reversed halo sign: A case report

The reversed halo sign was initially reported as a representative computed tomography scan finding of cryptogenic organizing pneumonia. Since then, however, it has been reported in various diseases and is now considered a nonspecific finding. However, there are no cases of humidifier lung with the reversed halo sign. An 82-year-old Japanese male patient presented with moving difficulties 48 days after starting darolutamide treatment for prostate cancer. He was admitted to the hospital due to acute pneumonia, which presented as bilateral extensive nonsegmental ground-glass opacities in the peripheral regions and extensive areas of ground-glass opacity with a circumferential halo of consolidation, with the reversed halo sign on computed tomography scan. After darolutamide discontinuation with the concomitant administration of antibiotics, the patient's pneumonia improved, and he was discharged from the hospital. However, within a few days, he was again admitted to the hospital due to pneumonia. He was found to have been using an ultrasonic humidifier at home and was then diagnosed with humidifier lung based on the bronchoscopy and provocative testing findings. Hence, ultrasonic humidifier lung should be considered as a differential diagnosis in patients presenting with the reversed halo sign, and a detailed medical history must be taken.

Solitary pulmonary nodule caused by pulmonary Mycobacterium lentiflavum infection

An 82-year-old Japanese man who previously had descending colon cancer and underwent partial resection showed a growing solitary pulmonary nodule, suspected as lung cancer, on follow-up computed tomography. Thoracoscopic partial lobectomy was therefore performed. The surgical specimen showed granulomatous lesions with necrosis. Mass spectrometry was performed on the sputum specimen collected after surgery, which identified Mycobacterium lentiflavum infection. Antibiotics were not prescribed following surgery, and the patient has not experienced recurrence 2 years since the surgery. To our knowledge, this is the second case of solitary pulmonary nodule and the first case of M. lentiflavum infection treated via surgical resection.

The SARC-F Score on Admission Predicts Falls during Hospitalization in Older Adults

OBJECTIVES

Community-dwelling older adults with sarcopenia are likely to fall. However, few studies have investigated whether sarcopenia is associated with falls during hospitalization in older adults. The purpose of this study was to determine whether the SARC-F when used as a simple screening tool for sarcopenia at the time of admission, predicts in-hospital falls.

DESIGN

A retrospective, observational study.

SETTING

A 900-bed university hospital.

PARTICIPANTS

A total of 9,927 patients aged 65 years and older were hospitalized at the hospital between April 2019 and March 2020.

MEASUREMENTS

The SARC-F contains five items: strength, assistance in walking, rise from a chair, climb stairs, and falls were evaluated at hospital admission. To investigate the relationship between the SARC-F score and falls, a ROC curve analysis was performed. Multivariate analysis adjusted for fall-related confounding factors such as age, gender, ADL, and disease were performed.

RESULTS

Mean age: 75.9±6.7 years; male: 56.2% were analyzed, and 159 patients (1.6%) fell during hospitalization. SARC-F scores at admission were significantly higher in the fall group than in the control group (3 [1-6] points vs. 0 [¬0-2] point, p<0.001). Statistical association was observed between the SARC-F and in-hospital fall (area under the curve = 0.721 [0.678-0.764], p < 0.001). The cut-off value for the highest sensitivity and specificity of the SARC-F score for in-hospital falls was two (sensitivity = 0.679, specificity = 0.715). Among the subitem of the SARC-F, the hazard ratios for climbing stairs were significantly higher (HR = 1.52 [1.10-2.09], p = 0.011) and for a history of fall was significantly higher (HR = 1.41 [1.02-1.95], p = 0.036). A SARC-F score ≥ 2 had a significantly higher incidence of in-hospital falls compared to a SARC-F score <2 (3.7% vs. 0.7%, p < 0.001). Also, a SARC-F score ≥ 2 had a significantly higher hazard ratio for falls (2.11 [1.37-3.26], p < 0.001).

CONCLUSION

SARC-F can help predict falls among hospitalized older adults.

SARC-F Predicts Mortality Risk of Older Adults during Hospitalization

OBJECTIVES

To determine the association between SARC-F scores and the in-hospital mortality risk among older patients admitted to acute care hospitals.

DESIGN

Single-center retrospective study.

SETTING

A university hospital.

PARTICIPANTS

All consecutive patients aged older than 65 were admitted and discharged from the study hospital between July 2019 and September 2019.

MEASUREMENTS

Relevant patient data included age, sex, body mass index, nutritional status, fat-free mass, disease, activities of daily living (ADL), duration of hospital stay, SARC-F, and occurrence of death within 30 days of hospitalization. The diseases that caused hospitalization and comorbidities (Charlson Comorbidity Index; CCI) were obtained from medical records. The Eastern Cooperative Oncology Group-performance status (PS) was used to determine ADL, and the in-hospital mortality rate within 30 days of hospitalization as the outcome.

RESULTS

We analyzed 2,424 patients. The mean age was 75.9±6.9 and 55.5% were male. Fifty-three in-hospital mortalities occurred among the participants within the first 30 days of hospitalization. Patients who died in-hospital were older, had poorer nutritional status and severer PS scores, and more comorbidities than those who did not. A SARC-F score of ≥4 predicted a higher mortality risk within those 30 days with the following precision: sensitivity 0.792 and specificity 0.805. There were significantly more deaths in Kaplan-Meier curves regarding a score of SARC-F≥4 than a score of SARC-F<4 (p<0.001). Cox proportional hazard analysis was used to identify the clinical indicators most associated with in-hospital mortality. SARC-F≥4 (Hazard Ratio: HR 5.65, p<0.001), CCI scores (HR1.11, p=0.004), and infectious and parasitic diseases (HR3.13, p=0.031) were associated with in-hospital mortality. The SARC-F items with significant in-hospital mortality effects were assistance with walking (HR 2.55, p<0.001) and climbing stairs (HR 2.46, p=0.002).

CONCLUSION

The SARC-F questionnaire is a useful prognostic indicator for older adults because a SARC-F ≥4 score during admission to an acute care hospital predicts in-hospital mortality within 30 days of hospitalization.

Impact of emphysema on sputum culture conversion in male patients with pulmonary tuberculosis: a retrospective analysis

Background

Although cigarette smoking may have a negative impact on the clinical outcome of pulmonary tuberculosis (PTB), few studies have investigated the impact of smoking-associated lung diseases. Emphysema is a major pathological finding of smoking-related lung damage. We aimed to clarify the effect of emphysema on sputum culture conversion rate for Mycobacterium tuberculosis (MTB).

Methods

We retrospectively studied 79 male patients with PTB confirmed by acid-fast bacillus smear and culture at Jikei University Daisan Hospital between January 2015 and December 2018. We investigated the sputum culture conversion rates for MTB after starting standard anti-TB treatment in patients with or without emphysema. Emphysema was defined as Goddard score ≥ 1 based on low attenuation area < − 950 Hounsfield Unit (HU) using computed tomography (CT). We also evaluated the effect on PTB-related CT findings prior to anti-TB treatment.

Results

Mycobacterial median time to culture conversion (TCC) in 38 PTB patients with emphysema was 52.0 days [interquartile range (IQR) 29.0–66.0 days], which was significantly delayed compared with that in 41 patients without emphysema (28.0 days, IQR 14.0–42.0 days) (p < 0.001, log-rank test). Multivariate Cox proportional hazards analysis showed that the following were associated with delayed TCC: emphysema [hazard ratio (HR): 2.43; 95% confidence interval (CI): 1.18–4.97; p = 0.015), cavities (HR: 2.15; 95% CI: 1.83–3.89; p = 0.012) and baseline time to TB detection within 2 weeks (HR: 2.95; 95% CI: 1.64–5.31; p < 0.0001). Cavities and consolidation were more often identified by CT in PTB patients with than without emphysema (71.05% vs 43.90%; p = 0.015, and 84.21% vs 60.98%; p = 0.021, respectively).

Conclusions

This study suggests that emphysema poses an increased risk of delayed TCC in PTB. Emphysema detection by CT might be a useful method for prediction of the duration of PTB treatment required for sputum negative conversion.

A bolus of saline injection leads to increase in coronary flow based on the viscosity reduction effect: the mechanism of saline induced Pd/Pa ratio

Background

In conjunction with fractional flow reserve (FFR), our previous study has shown the accuracy and utility of saline induced Pd/Pa ratio (SPR) for the assessment of myocardial ischemia. However, the potential mechanism how saline injection leads to increase in coronary flow remains speculative.

Purpose

This study aimed to clarify the underlying mechanism of SPR by using swine models.

Methods

The study was conducted in four swine models, and bolus of 25°C saline, 40°C saline, and 25°C dextran was injected at rates of 40mL/5sec through a catheter inserted into the superior mesenteric artery. Its peripheral arterioles were observed and recorded by a digital microscope, and transit time of each fluid and a luminal diameter of arterioles before and after injection were measured.

Results

The result from arterioles diameters of pre- and post-injection (0.049±0.016mm vs. 0.050±0.016mm; P=0.636) indicated that luminal diameters remained unchanged regardless of fluid administration. The transit time of 25°C saline was significantly shorter than 25°C dextran (3.19±0.68sec vs. 6.15±1.19sec; P&lt;0.0001). Although the result showed no significance, the transit time of 40°C saline with lower viscosity was shorten compared to 25°C saline (3.1±0.43sec vs. 3.65±0.46sec; P=0.088).

Conclusions

Compared to 25°C dextran (viscosity of 4.991mPa·s) having the same viscosity as 37°C whole blood, 25°C saline (viscosity of 1.012mPa·s) caused increasing to double the intravascular flow volume without dilating arterioles. The results strongly suggested that the potential mechanism of SPR was viscosity reduction effect. Combined with FFR which is based on vasodilation-mediated hyperemia, these findings may contribute to clarifying the pathophysiology and especially the microcirculation in coronary artery diseases.

Funding Acknowledgement

Type of funding source: None

The developing mechanism of atherosclerotic lesion in coronary side branch on the ventricular free wall differs by the location of lesion

Background

The effective treating method of coronary side branch lesions such as ostial stenosis or thin arteries has not been established. On the other hand, tortuous side branch rarely has stenotic lesions.

Purpose

We focused on coronary side branches on the ventricular free wall, and examined coronary risk factors and bending and stretching motion of branch which can contribute to the development of atherosclerotic lesion.

Methods

In elective and first-time coronary angiograms, we included side branches on the ventricular free wall (&gt;2mm in diameter) and excluded previously treated ones. Study A; we divided arteries into proximal, middle, and distal segment, and examined the presence of tortuosity and stenotic lesions exceeding 50% diameter stenosis (DS) for each segment. A score of 1 was assigned to tortuous segment, and 0 to non-tortuous one. Study B; we included stenotic lesion (&gt;50% DS) in side branch ostium and excluded those extended across main coronary arteries. Relation between lesions and patients' characteristics was examined.

Results

Study A; in 1,828 side branches from 472 patients, middle and distal segments had significantly higher tortuosity score than proximal (0.68, 0.78 vs. 0.34; p&lt;0.0001). On the contrary, proximal segments had more stenotic lesions except ostial stenosis (230 vs. 69, 5; p&lt;0.0001). Study B; in 1,740 side branches from 465 patients, 122 ostial stenotic lesions were found (7.0%). Multivariate logistic regression analysis revealed diabetes mellitus and age as independent contributors to development of ostial stenosis (Table).

Conclusions

Side branch stenosis developed less frequently in middle and distal segments, where stronger ventricular wall motion reinforces bending and stretching motion and tortuosity of arteries. This fact indicates that those characteristics may prevent developing atherosclerosis through increasing shear stress. On the other hand, diabetes mellitus strongly contributes to the development of ostial stenosis. Thus, the developing mechanism of atherosclerotic lesion in side branch on the ventricular free wall differs by the location of lesion.

Funding Acknowledgement

Type of funding source: None

Clinical utility of thoracoscopy in elderly tuberculous pleurisy patients under local anesthesia

INTRODUCTION

Diagnosing tuberculous pleurisy is important in Japan because it currently has a moderate tuberculosis prevalence. However, physicians often have difficulty making a diagnosis. It was reported that thoracoscopy under local anesthesia is useful for the diagnosis of tuberculous pleurisy, but there are no reports focusing on elderly patients.

METHODS

In this study, the usefulness of thoracoscopy under local anesthesia was evaluated in elderly patients. Among 170 patients who underwent thoracoscopy under local anesthesia at our hospital during 11 years from January 2008 to December 2018, those aged 75 years or older (n = 75) were investigated retrospectively.

RESULTS

A total of 55 patients underwent thoracoscopy under local anesthesia for detailed examination of pleural effusion of unknown cause. Of these, 18 were diagnosed as tuberculous pleurisy. The median age was 82 years (range: 75-92 years). The diagnosis of tuberculous pleurisy was made in 11 patients in whom Mycobacterium tuberculosis was detected and in four patients whose pathological findings indicated epithelioid granuloma accompanied by caseous necrosis. Clinical diagnosis was made in the remaining three patients based on thoracoscopic findings of the pleural cavity and a high level of adenosine deaminase in pleural fluid. No serious complications attributable to the examination were observed in any patient.

CONCLUSIONS

Thoracoscopy under local anesthesia was useful for the diagnosis of tuberculous pleurisy in elderly patients, with useful information being also obtained for the treatment of tuberculosis.

SARC-F as a Screening Tool for Sarcopenia and Possible Sarcopenia Proposed by AWGS 2019 in Hospitalized Older Adults

OBJECT

The SARC-F questionnaire is a sarcopenia screening tool. However, the validity of the SARC-F score ≥4 (SARC-F≥4) for the evaluation of sarcopenia in the hospital setting has not been investigated. This study investigated the validity of SARC-F≥4 as a screening tool for sarcopenia among hospitalized older adults.

DESIGN

Cross-sectional retrospective study.

SETTING

A university hospital.

PARTICIPANTS

This study included older adult patients (age ≥65 years) who were hospitalized at, and subsequently discharged from, the hospital between April and September 2019 and underwent a nutritional assessment by the nutrition support team during their hospitalization.

MEASUREMENTS

SARC-F was recorded at the time of admission, and the criteria specified by the Asia Working Group for Sarcopenia in 2019 (AWGS 2019) were applied to diagnose sarcopenia and possible sarcopenia. Appendicular muscle mass was estimated through validated equations, and three different models were developed for sarcopenia diagnosis. The sensitivity, specificity, and positive/negative likelihood ratios were calculated to analyze the accuracy of the SARC-F≥4 for sarcopenia and possible sarcopenia. Receiver-operating characteristic analyses were conducted to calculate the area under the curve (AUC).

RESULTS

In total, 1,689 patients (mean age: 77.2±7.3 years; male: 54.4%) were analyzed, and 636 patients (37.7%) had SARC-F≥4. Patients with SARC-F≥4 had a statistically significant higher prevalence of AWGS 2019-defined sarcopenia than patients with SARC-F <4 in the models (65.4-78.9% vs 40.9-45.2%, p<0.001). The sensitivity, specificity, and positive/negative likelihood ratios of SARC-F≥4 for sarcopenia and possible sarcopenia were 49.1-51.3%, 73.9-81.2%, and 1.88-2.72/0.60-0.69 and 48.0%, 84.5%, and 3.11/0.62, respectively. The AUC for sarcopenia and possible sarcopenia were 0.644-0.695 and 0.708, respectively. The AUC of SARC-F for possible sarcopenia was equivalent to or larger than that for sarcopenia (DeLong test p=0.438, 0.088, and <0.001 vs the three models).

CONCLUSIONS

SARC-F≥4 is suitable as a screening tool for sarcopenia in hospitalized older adults. SARC-F assessment could facilitate the detection and exclusion of sarcopenia at hospitalization and may lead to early adoption of a therapeutic and preventive approach.

A case of invasive pulmonary aspergillosis diagnosed by transbronchial lung biopsy during treatment for diabetic ketoacidosis in a type 1 diabetic patient

Invasive pulmonary aspergillosis (IPA) patients with non-hematological malignancy are far less than with hematological malignancy patients. We encountered a very rare case of IPA in which type 1 diabetes was the only conceivable risk factor. Further, according to the diagnostic categories of the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) criteria for IPA, the frequency of proven diagnosis is very low. Here we report a proven IPA, which rapidly developed when the patient with type 1 diabetes was being treated for diabetic ketoacidosis, which was successfully treated with the combination therapy of voriconazole (VRCZ) and micafungin (MCFG), based on early diagnosis using bronchoscopy.

Pulmonary alveolar proteinosis developing during steroid treatment in a patient with organizing pneumonia in association with atypical chronic myeloid leukemia

Organizing pneumonia (OP) and pulmonary alveolar proteinosis (PAP) are rare complications in patients with hematologic disorders. We herein report a case of PAP that developed during steroid treatment for OP in a patient with atypical chronic myeloid leukemia. Physicians should pay close attention to these complications in patients with hematologic malignancies.

Long-lasting response to afatinib that persisted after treatment discontinuation in a case of EGFR-mutated lung adenocarcinoma

It is unknown whether tyrosine kinase inhibitors targeting epidermal growth factor receptor (EGFR) can be discontinued in patients in whom EGFR-mutated lung cancer has well stabilised. We present a case of a 73-year-old Japanese woman with no history of smoking. Right pulmonary lower lobectomy, lymph node dissection and segmental resection of the right middle lobe were performed. Additionally, she underwent adjuvant chemotherapy for stage IIIB adenocarcinoma harbouring an EGFR exon 19 deletion. Afatinib was administered for liver metastases after 15 months. A complete response of metastatic disease was achieved for 2 years. However, afatinib was unavoidably discontinued due to splenectomy for the treatment of idiopathic thrombocytopenic purpura. Although afatinib was not resumed, due to the abscess formation as surgery complication, a drug-free complete response was sustained for over 18 months. The present case suggests that exceptional and durable responses to afatinib can be achieved in individual cases.

Burden of Premorbid Consumption of Texture Modified Diets in Daily Life on Nutritional Status and Outcomes of Hospitalization

OBJECTIVES

Due to the water-rich cooking process required to soften texture modified diets (TMDs), TMDs may have poorer nutrition. The aim of this study was to investigate the associations between daily premorbid TMD consumption and nutritional status at the time of hospitalization, and its burden on hospitalization outcomes.

DESIGN

Retrospective observational study.

SETTING

An academic hospital.

PARTICIPANTS

The cohort comprised 3,594 older adult patients aged ≥65 years admitted to the hospital.

MEASUREMENTS

Patients were interviewed on admission using a premorbid daily consumption meal form to determine whether the patient ate a TMD. Nutritional status was examined using nutritional screening tools (Mini-Nutritional Assessment Short Form [MNA-SF], Malnutrition Universal Screening Tool [MUST], Geriatric Nutritional Risk Index [GNRI]) and the European Society of Clinical Nutrition and Metabolism (ESPEN)-defined criteria of malnutrition at admission. Length of hospital stay (LOS) and in-hospital mortality were considered outcomes of hospitalization. Multivariate analyses were performed to detect associations between premorbid TMD consumption and nutritional status and outcomes.

RESULTS

The mean age of the subjects was 75.9±7.0 years, including 58% males. Overall, 110 (3.1%) patients consuming a premorbid TMD were identified. They were older (p<0.001), had poor nutritional status (lower MNA-SF score [p<0.001] and GNRI value [p<0.001], higher MUST score [p<0.001], and more prevalent ESPEN-defined malnutrition [61.8% vs. 14.0%, p<0.001] than did patients without a TMD. The mortality rate and LOS of patients with TMD was higher (7.3% vs. 2.9%, p=0.017) and longer (19 days vs. 8 days, p<0.001) than those without TMD. Multivariate analyses showed that TMD consumption was independently associated with poor nutritional status and prolonged LOS after adjusting confounders.

CONCLUSION

Daily consumption of a TMD during the premorbid period affects nutritional status at the time of hospitalization and outcomes. Further studies are necessary to investigate whether nutritional intervention can improve outcomes for people on a TMD.

Radiological images of interstitial pneumonia in mixed connective tissue disease compared with scleroderma and polymyositis/dermatomyositis

OBJECTIVE

Little has been reported on the radiological and pathological findings of interstitial pneumonia in mixed connective tissue disease (MCTD). There may be possible difference in treatment response and prognosis between the imaging patterns of systemic sclerosis (SSc)-like and polymyositis/dermatomyositis (PM/DM)-like. The purpose of this study was to examine whether the radiological images of interstitial pneumonia in MCTD presented SSc-like or PM/DM-like pattern, and to assess whether the imaging patterns corresponded to clinical and pathological features.

MATERIALS AND METHODS

This retrospective study included 29 patients with interstitial pneumonia who underwent surgical lung biopsy; 10 with SSc, 10 with PM/DM, and 9 with MCTD. High resolution computed tomography (HRCT) images were classified as SSc, PM/DM, or the other pattern by two radiologists independently without clinical information. The pathology of the lung specimens from MCTD patients were evaluated and compared with the imaging pattern.

RESULTS

The concordance rate between clinical diagnosis and radiological pattern was 100% in SSc patients, and 80% in PM/DM patients. Among patients with MCTD, imaging patterns were classified as SSc pattern in 4 (MCTD-SSc), PM/DM pattern in 4 (MCTD-PM/DM) and other in one. The imaging patterns did not always correlate with the clinical findings in MCTD patients. Pathologically, plasma cell infiltration and organizing pneumonia were relatively more frequent in MCTD-PM/DM, and smooth muscle hyperplasia was relatively more frequent in MCTD-SSc.

CONCLUSION

HRCT images in MCTD patients can be classified as SSc pattern or PM/DM pattern. MCTD-SSc and MCTD-PM/DM were corresponded to similar pathological findings of SSc and PM/DM.

Emphysematous change with scleroderma-associated interstitial lung disease: the potential contribution of vasculopathy?

Background

Pulmonary emphysema combined with systemic sclerosis (SSc)-associated interstitial lung disease (ILD) occurs more often in smokers but also in never-smokers. This study aimed to describe a new finding characterized by peculiar emphysematous change with SSc-associated ILD (SSc-ILD).

Methods

We conducted a retrospective review of 21 consecutive patients with SSc-ILD diagnosed by surgical lung biopsy and focused on the radio-pathological correlation of the emphysematous change.

Results

Pathological pulmonary emphysema (p-PE) with SSc-ILD was the predominant complication in 16 patients (76.2%) with/without a smoking history, of whom 62.5% were never-smokers. A low attenuation area (LAA) within interstitial abnormality on high-resolution computed tomography (HRCT) was present in 31.3%. Diffusing capacity of the lung for carbon monoxide (D_LCO) was lower, disease extent on HRCT higher, and intimal/medial thickening in muscular pulmonary arteries more common in the patients with p-PE with SSc-ILD. However, forced vital capacity (FVC) was well preserved regardless of whether p-PE was observed. Most SSc-ILD patients had pulmonary microvasculature changes in arterioles (90.5%), venules (85.7%), and interlobular veins (81.0%).

Conclusions

Pulmonary emphysematous changes (LAA within interstitial abnormalities on HRCT and destruction of fibrously thickened alveolar walls) are specific and novel radio-pathological features of SSc-ILD. Peripheral vasculopathy may help to destroy the fibrously thickened alveolar walls, resulting in emphysematous change in SSc-ILD.

Afatinib Therapy for Brain Metastases Aggravated by a Reduction in the Dose of Erlotinib Due to the Development of Hepatotoxicity

We report an 80-year-old woman with EGFR-mutant lung adenocarcinoma with multiple brain metastases (BMs). All lesions including BM showed a successful resolution after initiating daily 150 mg erlotinib. However, a grade 2 bilirubin-increase developed, and it was necessary to reduce the dose of erlotinib to 50 mg every other day, which aggravated BM. Switching erlotinib to afatinib led to the resolution of BM without an increase in the bilirubin level. Our results indicate that afatinib is an important treatment option when erlotinib-induced hepatotoxicity develops, regardless of the patients' age. Particularly in those patients with BM, switching to afatinib may be preferable to reducing the dose of erlotinib.

Low body surface area predicts hepatotoxicity of nintedanib in patients with idiopathic pulmonary fibrosis

After the commercialization of nintedanib in Japan, a high incidence of hepatotoxicity resulting in treatment interruption was noted in idiopathic pulmonary fibrosis (IPF) patients treated with nintedanib in our hospital. This study aimed to clarify the risk factors for hepatotoxicity of nintedanib. Sixty-eight consecutive cases of IPF newly treated with nintedanib at a dose of 150 mg twice daily from September 2015 to September 2016 were enrolled: 46 patients (67.6%) exhibited aspartate aminotransferase (AST) and/or alanine aminotransferase (ALT) elevation and 16 patients (23.5%) also had a Common Terminology Criteria for Adverse Events (CTCAE) grade ≥2. Body surface area (BSA) was significantly lower in the CTCAE grade ≥2 group than in another group. A multivariate logistic regression analysis showed that the association between BSA and AST/ALT elevation with CTCAE grade ≥2 was statistically significant. Eight of 10 patients who resumed nintedanib at a reduced dose of 100 mg twice daily after interruption due to hepatotoxicity did not again develop AST/ALT elevation. In conclusion, a low BSA was associated with hepatotoxicity of nintedanib at a dose of 150 mg twice daily. It would be a good option for patients with a small physique to start nintedanib at a dose of 100 mg twice daily and then increase if possible after confirming its safety.

A case of bilateral hilar and mediastinal lymphadenopathy developing during treatment for Mycobacterium avium complex

We report a rare case of an immunocompetent patient with Mycobacterium avium complex (MAC) disease in which bilateral hilar lymphadenopathy developed during anti-MAC treatment. This case indicates that Propionibacterium acnes would be present and might be a cause of sarcoidosis even in patients with MAC.

Serum KL-6 and surfactant protein-D as monitoring and predictive markers of interstitial lung disease in patients with systemic sclerosis and mixed connective tissue disease

BACKGROUND

Interstitial lung disease (ILD) is frequent complication of systemic sclerosis (SSc) and mixed connective tissue disease (MCTD). The disease is heterogeneous, and its outcome is unpredictable. Some patients have severe and progressive deterioration of ILD, which is the leading cause of mortality. We aimed to determine whether serum levels of Krebs von den Lungen-6 (KL-6) and surfactant protein-D (SP-D) correlate with SSc/MCTD-associated ILD activity.

METHODS

We retrospectively analyzed the medical records of 40 patients with SSc/MCTD-associated ILD: 29 patients with SSc and 11 patients with MCTD. Measurement of serum KL-6 and SP-D levels, pulmonary function tests, and high-resolution computed tomography (HRCT) performed in parallel were reviewed.

RESULTS

Serum KL-6 correlated positively with diffusing capacity of the lung for carbon monoxide (DLCO) (% predicted) and disease extent on HRCT, and the changes in serum levels of KL-6 were significantly related to the changes in forced vital capacity (FVC) in SSc/MCTD-associated ILD. On the other hand, multivariate logistic regression analyses with calculation of the area under the curve of the receiver-operating characteristic curve suggested that a higher serum level of SP-D was a significant predictor of FVC decline in SSc/MCTD-associated ILD.

CONCLUSIONS

Our study suggests that serum KL-6 can be a useful monitoring tool of SSc/MCTD-associated ILD activity. In contrast, serum SP-D may be a significant predictor of potential FVC decline in the short term.

Pathologically Proven Spontaneous Remission of IgG4-related Retroperitoneal Fibrosis

Some forms of idiopathic retroperitoneal fibrosis (RF) have recently been considered to be a part of the spectrum of immunoglobulin G4 (IgG4)-related disease. This case report is the first description of a spontaneous remission in a patient with pathologically proven IgG4-related RF. Although the pathogenesis and long-term disease behavior of IgG4-related RF remains unknown, we believe that an initial assessment consisting of only careful monitoring might be one important strategy, especially in asymptomatic IgG4-related RF patients without nephropathy, while carefully monitoring these patients for the risk of recurrence.

A 16-year Follow-up Case of Interstitial Pneumonia with Systemic Sclerosis-rheumatoid Arthritis Overlap Syndrome

Interstitial pneumonia is a common and major comorbidity affecting the prognosis of patients with systemic sclerosis (SSc). However, there are few reported cases of SSc-rheumatoid arthritis (RA) overlap-associated interstitial pneumonia. We herein report a case in which the clinical behavior and histopathology of interstitial pneumonia with SSc-RA overlap syndrome was followed over a long clinical course. When clinicians are deciding on the treatment strategy for patients with SSc-RA overlap syndrome-associated interstitial pneumonia, a pathological examination of a surgical lung biopsy may be useful.

Desquamative Interstitial Pneumonia Complicated with IgG4-related Lung Disease

As an idiopathic interstitial pneumonia, desquamative interstitial pneumonia (DIP) is an uncommon form of interstitial lung disease and is considered to be a smoking- or dust inhalation-related interstitial pneumonia in the majority of cases. However, the details regarding immunoglobulin G4 (IgG4)-related lung disease remain unclear and controversial. We herein report the first case of DIP complicated with IgG4-related lung disease. Even if a patient has a smoking history, we emphasize the importance of exploring the association between DIP and IgG4-related lung disease to clarify the pathogenesis of these two disorders.

A case of severe arthralgia with malignant mesothelioma‐associated hypertrophic osteoarthropathy

Hypertrophic osteoarthropathy (HOA) is a rare syndrome characterized by the abnormal proliferation of dermato‐osseous tissue. We report a rare case of malignant mesothelioma‐associated HOA who suffered from refractory painful osteoarthropathy. HOA can be associated with malignant mesothelioma and that may be resistant to any treatment.

Clinical Features of Idiopathic Interstitial Pneumonia with Systemic Sclerosis-Related Autoantibody in Comparison with Interstitial Pneumonia with Systemic Sclerosis

Background

Patients with idiopathic interstitial pneumonias sometimes have a few features of connective tissue disease (CTD) and yet do not fulfil the diagnostic criteria for any specific CTD.

Objective

This study was conducted to elucidate the characteristics, prognosis, and disease behavior in patients with interstitial lung disease (ILD) associated with systemic sclerosis (SSc)-related autoantibodies.

Methods

We retrospectively analyzed medical records of 72 ILD patients: 40 patients with SSc (SSc-ILD) and 32 patients with SSc-related autoantibody-positive ILD but not with CTD (ScAb-ILD), indicating lung-dominant CTD with SSc-related autoantibody.

Results

Patients with SSc-ILD were predominantly females and non-smokers, and most had nonspecific interstitial pneumonia confirmed by high-resolution computed tomography (HRCT) and pathological analysis. However, about half of the patients with ScAb-ILD were male and current or ex-smokers. On HRCT analysis, honeycombing was more predominant in patients with ScAb-ILD than with SSc-ILD. Pathological analysis showed the severity of vascular intimal or medial thickening in the SSc-ILD patients to be significantly higher than that in the ScAb-ILD patients. Survival curves showed that the patients with ScAb-ILD had a significantly poorer outcome than those with SSc-ILD.

Conclusion

Data from this study suggest that lung-dominant CTD with SSc-related autoantibody is a different disease entity from SSc-ILD.

Temporospatial localization of dentine matrix protein 1 following direct pulp capping with calcium hydroxide in rat molars

AIM

To examine the temporospatial expression of dentine matrix protein 1 (DMP1; a noncollagenous protein involved in mineralized tissue formation), osteopontin (another noncollagenous protein detected during reparative dentinogenesis) and nestin (a marker of differentiating/differentiated odontoblasts), following direct pulp capping with calcium hydroxide in rat molars.

METHODOLOGY

The maxillary first molars of 8-week-old Wistar rats had their pulps exposed and capped with calcium hydroxide. The pulp-capped teeth were collected from 6 h to 14 days postoperatively and processed for immunohistochemistry for DMP1, osteopontin and nestin. Cell proliferation was monitored using 5-bromo-2'-deoxyuridine (BrdU) labelling.

RESULTS

The capped pulps initially exhibited superficial necrotic changes followed by the formation of new matrix and its mineralization. DMP1 immunoreactivity was observed in the matrix beneath the necrotic layer from 6 h onwards and present in the outer portion of the newly formed mineralized matrix from 7 days onwards. Osteopontin displayed a similar expression pattern, although it occupied a narrower area than DMP1 at 6 and 12 h. Nestin-immunoreactive cells appeared beneath the DMP1-immunoreactive area at 1 day, were distributed beneath the newly formed matrix at 5 days and exhibited odontoblast-like morphology by 14 days. BrdU-positive cells significantly increased at 2 and 3 days (P < 0.05) and then decreased.

CONCLUSIONS

The deposition of DMP1 at exposed pulp sites preceded the appearance of nestin-immunoreactive cells, active cell proliferation and new matrix formation after pulp capping with calcium hydroxide in rat molars, suggesting that DMP1 acts as a trigger of pulp repair. The colocalization of DMP1 and osteopontin suggests that these two proteins play complementary roles.

Comparison of three dimensional and radiographic measurements in the analysis of distal radius malunion

To estimate the accuracy of radiographic deformity evaluation for distal radius malunion, we compared the results obtained from radiographic measurements (palmar tilt, radial angle, and ulnar variance) with those from the three-dimensional (3D) method using computer bone models in 20 dorsally tilted malunions. Dorsal tilt deformity, radial tilt deformity, and shortening deformity were calculated using the unaffected side as a reference. The 3D method showed a slightly lower value for dorsal tilt deformity than the radiographic evaluation, but the difference was < 10° in all cases. In patients with dorsal tilt ≥ 40°, notable differences in radial tilt evaluation were observed between the two methods compared with patients with less dorsal tilt. The 3D shortening showed positive correlations with radiographic evaluation, but a discrepancy of ≥ 2 mm was observed in eight cases. Palmar tilt is reliable for surgical planning, but radial angle and ulnar variance may be less accurate than previously thought.

Three-dimensional deformity analysis of malunited distal radius fractures and their influence on wrist and forearm motion

Little information exists about three-dimensional (3-D) deformity patterns of malunited distal radius fractures including axial deformity. The current study aimed to clarify the 3-D deformity pattern of malunited distal radius fractures and reveal the influence of osseous deformities, including axial rotation deformity, on wrist and forearm motion. The deformity of 20 dorsally tilted malunions were evaluated using 3-D computer models created from CT data, and correlations between deformity components and range of motion were assessed. The 3-D deformity analysis showed that axial malalignment in pronation, which showed a correlation with the degree of radial tilt deformity, was very common. A radial tilt deformity of > 5° was observed in only 45% of cases. Although the range of wrist flexion and extension showed a correlation with dorsal tilt deformity, the range of forearm pronation and supination did not correlate with distal radius deformities.

Preserved autonomic function in patients with POEMS syndrome

AIM

We systematically performed autonomic testing on patients with polyneuropathy, organomegaly, endocrinopathy, M-protein and skin changes syndrome (POEMS) to determine whether autonomic function is preserved in such patients.

METHODS

We studied 17 POEMS patients, 17 diabetic neuropathy (DN) patients and 17 age-matched normal subjects. Blood pressure responses to the head-up tilt test and heart rate variability were used to evaluate cardiovascular autonomic function. Sweat responses and cutaneous vasoconstriction to several stimuli were recorded via the finger tips to estimate cutaneous sympathetic function. In addition, motor nerve conduction studies were performed.

RESULTS

Although the results of the autonomic testing were normal in POEMS patients, motor disability was severe, and motor nerve conduction studies provided evidence of extensive axonal loss. The DN patients showed significantly impaired autonomic responses despite mild motor dysfunction.

CONCLUSIONS

Autonomic function was normal in POEMS patients, indicating the preservation of autonomic fibers and selective involvement of large fibers.

Lysine392, a K63-linked ubiquitination site in NEMO, mediates inflammatory osteoclastogenesis and osteolysis

PMMA particles released from bone implants are considered major contributor to osteolysis and subsequent implant failure. Although the ensuing inflammatory response has been described, the mechanisms underlying PMMA particulate-induced osteolysis remain enigmatic. In previous studies, we have established that activation of Nuclear factor kappa-B (NF-κB) and MAP kinase pathways plays a central role in the pathogenesis of inflammatory osteolysis. Specifically, we have shown that impeding IKK complex assembly, and thus subsequent NF-κB activation, dampens particle-induced osteolysis. The IKK complex consists of IKKα, IKKβ, and IKKγ, also known as NEMO. NEMO has no catalytic activity and serves as a scaffold protein facilitating assembly and distal activation of NF-κB signaling. In fact, blocking binding of NEMO with IKKα/β abolishes NF-κB activity. In the current study, we identify Lysine 392 residue in NEMO as crucial mediator of PMMA particle-induced inflammatory osteoclastogenesis and osteolysis. Using mice in which NEMO-K392R mutation has been introduced, we provide evidence that PMMA-induced osteoclasts and osteolytic responses are impaired. Furthermore, we show that this impairment is likely due to poor activation of NF-κB and Erk, but not other MAP kinases. Our findings suggest that NEMO Lysine392, a well-established K63-linked polyubiquitination site, is an important mediator of PMMA-induced osteolysis. Therefore, this NEMO motif should be considered as a target to combat PMMA particle-induced osteolysis.

Long-term results of conventional varus half-wedge proximal femoral osteotomy for the treatment of osteonecrosis of the femoral head

We have previously described the mid- to long-term results of conventional simple varus intertrochanteric osteotomy for osteonecrosis of the femoral head, showing that 19 of the 26 hips had good or excellent results. We extended the follow-up to a mean of 18.1 years (10.5 to 26) including a total of 34 hips in 28 patients, with a mean age at surgery of 33 years (19 to 53). There were 18 men and ten women and 25 hips (74%) had a satisfactory result with a Harris hip score ≥ 80. In all, six hips needed total hip replacement (THR) or hemiarthroplasty. The collapse of the femoral head or narrowing of the joint space was found to have progressed in nine hips (26%). Leg shortening after osteotomy was a mean of 19 mm (8 to 36). With conversion to THR or hemiarthroplasty as the endpoint, the ten-year survival rate was 88.2% (95% confidence interval (CI) 82.7 to 93.7) and the 20-year survival rate was 79.7% (95% CI 72.1 to 87.3); four hips were converted at ten years and other two hips were converted at 20 years.

Shortening of the leg after osteotomy remains a concern; however, the conventional varus half-wedge osteotomy provides favourable long-term results in hips with less than two-thirds of the medial part of the femoral head affected by necrotic bone and with normal bone superolaterally.

Preoperative concurrent chemoradiotherapy for stages II-IV oral squamous cell carcinoma: a retrospective analysis and the future possibility of this treatment strategy

This study evaluated survival in 154 patients with stages II-IV oral squamous cell carcinoma (OSCC) treated with preoperative concurrent chemoradiotherapy and assessed the future use of this treatment strategy. 14 patients exhibited advanced stage II, 73 exhibited stage III and 67 exhibited stage IV. All patients received 40Gy irradiation and concurrent cisplatin-based chemotherapy in two courses. Radical surgery was undertaken after 2-6 weeks. The clinical tumour response, histopathologic regression grade, residual tumour grade (RGrade) in the primary tumour and the level of residual pN+ were associated with prognosis. 90% of patients with complete response and 73% of patients with good partial response in the primary tumour were RGrade 0 (no residual tumour cells) or RGrade 1 (viable tumour cells remained within central superficial portion). In patients with complete response in the neck, residual pN+ was only seen in levels IB (8%) and IIA (8%); the higher the level of residual pN+, the lower the survival rate (p<0.0001). This treatment strategy was excellent for stages II-IV OSCC. It may be possible to perform minimally invasive surgery in which the extent of resection in primary tumour and neck is reduced in patients who achieve good response following preoperative chemoradiotherapy.