Kanako Kobayashi

Doppler estimation of pulmonary artery end-diastolic pressure using contrast enhancement of pulmonary regurgitant signals

Pulmonary artery (PA) end-diastolic pressure is used as an estimate of PA wedge pressure. We evaluated contrast enhanced pulmonary regurgitant signals in the assessment of PA end-diastolic pressure in 24 patients in a critical care unit. Right atrial pressure was estimated by the percent decrease of the inferior vena caval diameter with inspiration. Weak or absent pulmonary regurgitant signals were enhanced by sonicated albumin (Albunex) in 23 patients (96%). The Doppler-determined PA end-diastolic pressure (the sum of the pulmonary regurgitant pressure gradient at end-diastole and the right atrial pressure) was significantly correlated with the catheter-determined PA end-diastolic pressure (y = 0.85x + 1.72, r = 0.93). Compared with invasive hemodynamic monitoring, the contrast-enhanced Doppler technique using Albunex is effective for measuring PA end-diastolic pressure, even in critically ill patients.

An analysis of etiology, causal pathogens, imaging patterns, and treatment of Japanese patients with bronchiectasis

BACKGROUND Bronchiectasis (BE), a syndrome that presents with persistent or recurrent bronchial sepsis related to irreversibly damaged and dilated bronchi, has not been well-characterized in Asians. This study aims to review the etiology, causal pathogens, imaging patterns, and treatment of BE and to define the prognostic factors for acute exacerbation in a Japanese population. METHODS We performed a retrospective cohort study of 147 patients (104 women; median age, 73 years; range, 30-95 years) with BE at our institution using high-resolution computed tomography to identify imaging patterns and the area of pulmonary involvement. RESULTS Common BE etiologies were idiopathic (N=50 [34%]), sinobronchial syndrome (N=37 [25%]), non-tuberculous mycobacteriosis (NTM; N=26 [18%]), and previous respiratory infection (N=21[14%]). Pseudomonas aeruginosa was the most common causal pathogen (24%). Common imaging patterns were cylindrical (66%) and mixed including cylindrical pattern (47%). The median number of involved lobes was 2; 49% of the patients had ≥ 3 involved lobes, and 49% had middle lobe and left lingula dominant BE. Patients with predominantly lower lobe BE comprised 4% of the NTM group and 48% of the non-NTM group (P<0.001). In multivariate analysis, cystic BE was a predictor for frequent exacerbations in non-NTM patients (OR=7.947; P=0.004) which led to increased hospital admissions (OR=4.691; P=0.004). CONCLUSIONS Idiopathic and sinobronchial syndrome were common causes of BE. Etiology did not contribute to imaging pattern or predictors of exacerbations. Cystic BE was a predictor for frequent exacerbations in the non-NTM BE patients.

Bronchocentric granulomatosis due to Aspergillus terreus in an immunocompetent and non-asthmatic woman.

This is the first report of bronchocentric granulomatosis due to Aspergillus terreus in a healthy and non-asthmatic 74-year-old Japanese woman. Following identification of the fungus, oral itraconazole therapy was begun after intrabronchial infusion of amphotericin B. No recurrence has occurred after treatment for 24 months. We should consider the possibility of bronchocentric granulomatosis including Aspergillus terreus, when an intrabronchial lesion is found even in a healthy and non-asthmatic person. Oral itraconazole after intrabronchial infusion of amphotericin B seems to be effective in such cases.

Sarcoid-like reaction in Cryptococcus neoformans infection

We report a patient with Cryptococcus (C.) neoformans infection, who developed a case of sarcoid-like reaction (SLR). There have been reports of SLRs associated with malignancies. Although differentiating sarcoidosis from SLR is difficult, the patient was diagnosed as SLR because propionibacterium acnes bacterial (PAB) antibody staining of biopsy specimens was negative and the chest radiological findings improved after antifungal treatment. To our knowledge, this is the first report of SLR occurring during cryptococcal infection, and we believe that cryptococcal infection should be considered as a potential cause of SLR.

Progressive Overlap Syndrome due to Small Cell Lung Cancer as a Paraneoplastic Syndrome

The association between rheumatic diseases and malignancy has been documented in many studies. Polymyositis and especially dermatomyositis are associated with a higher risk of malignant disease. Furthermore, lung cancer usually develops in patients with a prolonged history of systemic sclerosis accompanied by pulmonary fibrosis. Though overlap syndrome is rarely reported in the associated cancer, this is the first report describing progressive overlap syndrome in small cell lung cancer as a paraneoplastic syndrome.

Influence of Cardiac Pacing Mode on Left Atrial Appendage Flow Velocity: Implication to Systemic Embolism During VVI Pacing.

Previous studies have shown that the incidence of thromboembolism is higher in patients with single‐chamber ventricular demand (VVI) pacemakers than in patients with dual‐chamber (DDD) pacemakers. However, data on left atrial appendage flow velocity in pacing patients are limited. To investigate the influence of the pacing mode on the left atrial appendage flow velocity, we studied 19 patients with permanent DDD pacemakers and measured the left atrial appendage flow velocity by transesophageal echocardiography at baseline (during DDD pacing) and after switching to VVI pacing. The indications for pacemaker implantation were second‐ and third‐degree atrioventricular block (AVB group, n = 11) and sick sinus syndrome (SSS group, n = 8). Compared with the DDD pacing mode, there was a significant decrease in the left atrial appendage flow velocity during VVI pacing in both the SSS group (43 ± 14 vs 23 ± 7 cm / sec, P < 0.05) and the AVB group (59 ± 18 vs 41 ± 18 cm / sec, P < 0.05). In eight patients with persistent retrograde ventriculoatrial conduction during VVI pacing, the left atrial appendage flow velocity was markedly decreased (from 43 ± 16 to 25 ± 9 cm / sec, P < 0.05). In five (63%) of the eight patients, left atrial appendage flow velocity was less than 25 cm/sec. A reduction in left atrial appendage flow velocity when switching from DDD to VVI pacing may account for an increased risk of thrombus formation in the left atrial appendage (an increased thromboembolic risk in patients in sinus rhythm with VVI pacemakers).

Low-intensity noninvasive ventilation: Lower pressure, more exacerbations of chronic respiratory failure.

Background: For patients with chronic respiratory failure (CRF) who are treated with noninvasive positive pressure ventilation (NPPV), a little is known regarding the effects of low-intensity NPPV (LI-NPPV) on the clinical course of CRF and the frequency of adjustments in these patients. Objectives: This study investigated the effects of LI-NPPV on the clinical course of patients with CRF as compared with patients who were treated with conventional NPPV (C-NPPV) and determined how frequently NPPV was adjusted during therapy. Methods: Clinical data from 21 patients who received long-term NPPV were retrospectively analyzed. Patients were categorized into two groups based on the level of initial pressure support (PS): C-NPPV group (PS ≥ 10 cm H2O) and LI-NPPV group (PS < 10 cm H2O). Results: Patients in the LI-NPPV group had significantly more exacerbations of CRF (P < 0.05). There was no significant difference in the number of patients who required adjustments of NPPV settings between the two groups. There was no significant difference in PaCO2levels 1 month after the start of NPPV between the two groups; however, PaCO2levels were significantly lower after 1 year in the C-group (P < 0.001). Seventy-one percent of LI-NPPV patients and 43% of C-NPPV patients needed NPPV adjustments. Conclusions: Attention should be paid to CRF patients who are initially administered LI-NPPV; they should be carefully observed because they can develop more exacerbations of CRF than patients undergoing C-NPPV. If possible, higher initial PS should be administered to prevent CRF exacerbations.

Multidrug-resistant tuberculosis that required 2 years for diagnosis

Isoniazid (H) or rifampicin (R) mono-resistant disease can be treated easily and effectively with first-line drugs, while combined H and R resistance (ie, multidrug-resistant tuberculosis (MDRTB)) requires treatment with at least four agents, including a quinolone and an injectable agent. Drug-resistant Mycobacterium tuberculosis strains are reported to be extremely difficult to cultivate invitro. The authors report a case of MDRTB that required 2 years for diagnosis, and was detected only in sputum culture on solid medium. Physicians should consider MDRTB if TB is suspected but pathogens are not detected.

Successful treatment of severe bronchiectasis in the elderly using trimethoprim/sulfamethoxazole

ZBI found that the discontinuation of donepezil treatment resulted in improved BPSD and in a reduction of the caregivers’ burden related to FTD. These results suggest that donepezil given to patients with FTD can worsen BPSD and increase the burden on caregivers. Several limitations of the present study should be considered. First, the observation period in the present study was 2 weeks, which is quite short. Second, the study was open-label and had no control group. The present results therefore might be partially explained by the nocebo effect. Third, the sample population investigated might not represent the whole population of FTD patients, as patients were recruited from only one outpatient clinic. To overcome these limitations, we propose carrying out a 4-week blinded withdrawal study of donepezil in FTD patients using larger samples.

Clinical evaluation of patients with pulmonary tuberculosis during the past 10 years in our hospital

The background of patients who died of active pulmonary tuberculosis during 10 years period (1989 to 1998). Of 973 tuberculosis patients, 76 patients died, of which 56 died of non-tuberculosis, and 20 died of tuberculosis. A total of 12 patients died within 3 months after being hospitalized. The period from hospitalization to death was significantly shorter in tuberculosis patients with independent gait failure, original treatment, without tuberculosis medical history, and no drug resistance. We considered that in tuberculosis death, severe tuberculosis itself is the cause of early death, and recurrence and drug resistance patients are the most serious problems in later deaths.