Kosaku Komiya

Healthcare-associated Pneumonia and Aspiration Pneumonia

Healthcare-associated pneumonia (HCAP) is a new concept of pneumonia proposed by the American Thoracic Society/Infectious Diseases Society of America in 2005. This category is located between community-acquired pneumonia and hospital-acquired pneumonia with respect to the characteristics of the causative pathogens and mortality, and primarily targets elderly patients in healthcare facilities. Aspiration among such patients is recognized to be a primary mechanism for the development of pneumonia, particularly since the HCAP guidelines were published. However, it is difficult to manage patients with aspiration pneumonia because the definition of the condition is unclear, and the treatment is associated with ethical aspects. This review focused on the definition, prevalence and role of aspiration pneumonia as a prognostic factor in published studies of HCAP and attempted to identify problems associated with the concept of aspiration pneumonia.

Reversion rates of QuantiFERON-TB Gold are related to pre-treatment IFN-gamma levels

OBJECTIVE The quantitative interferon (IFN)-gamma in response to Mycobacterium tuberculosis-specific antigens declines in tuberculosis patients after starting treatment, however, in some cases remains high despite clinical improvements. Our aim was to evaluate clinical parameters associated with remaining QuantiFERON-TB Gold (QFT-G) positive after treatment. METHODS A prospective cohort study of 101 culture-positive, positive QFT-G, HIV-uninfected patients with pulmonary tuberculosis. QFT-G was performed at diagnosis, at the end of intensive phase, at treatment completion, and 5-7 months post-treatment completion. RESULTS There were 80 patients with complete results, 34 (43%) remaining QFT-G positive and 46 (58%) reverting to QFT-G negative at the 5-7 month post-treatment time point. There was a significant decline in IFN-gamma levels in response to both CFP-10 and ESAT-6 with tuberculosis treatment. Multivariate analysis revealed significant associations between IFN-gamma levels detected before treatment and remaining QFT-G positive post-treatment after adjustment for smear status, presence of cavitation, and positive sputum culture two months after starting treatment. CONCLUSIONS Quantitative QFT-G responses drop significantly in active tuberculosis patients undergoing treatment, with almost 60% becoming test negative. Reversion to a negative QFT-G result was closely associated with the magnitude of the IFN-gamma response prior to treatment and increasing age.

Medical Professionals' Attitudes Toward Tube Feeding for Themselves or Their Families: A Multicenter Survey in Japan

BACKGROUND Many studies have shown a lack of advantages to tube feeding for elderly with advanced dementia, but tube feeding is still considered standard care in Japan. The aim of this study is to investigate what nutrition method health care professionals want for themselves or their families, if they fall into a bedridden state due to irreversible impaired cognition in old age. METHODS In 2010 we surveyed 1321 Japanese health care professionals including 251 medical doctors and 1070 nurses. Their attitudes toward tube feeding were assessed by using an anonymous questionnaire, which included desired feeding methods for themselves or their families and propriety of card-based declaration of intent for end-of-life care. RESULTS Rates of accepting tube feeding for themselves and their families were 14.4% and 43.4%, respectively. In multivariate analyses, working at a municipal hospital and high frequency of taking care of tube-fed elderly patients were predictors of refusing tube feeding for themselves. Working at a municipal hospital and being a medical doctor were predictors of refusing tube feeding for their families. The rate of welcoming card-based declaration of intent for end-of-life care including feeding methods was 65.2%. CONCLUSIONS Many doctors and nurses, especially with more frequent contact with tubefed patients, rejected tube feeding for themselves on their own deathbed, but did not always refuse this option for their families.

Comparison of chest computed tomography features in the acute phase of cardiogenic pulmonary edema and acute respiratory distress syndrome on arrival at the emergency department.

Purpose: Discriminating cardiogenic pulmonary edema (CPE) from acute respiratory distress syndrome (ARDS) is a serious problem in emergency departments, and the ability of chest radiographs to differentiate between these 2 entities is limited. We compared the chest computed tomography (CT) findings in the acute phase of CPE with those of ARDS. Materials and Methods: Outpatients with acute respiratory failure presenting to emergency departments with bilateral pulmonary opacities were enrolled. The patients included not only those who visited our hospital first but also those referred from other hospitals. Two intensivists who were blinded to the results of the chest imaging studies reviewed the patients’ clinical records independently in order to determine a diagnosis of CPE or ARDS, and the chest CT findings were independently evaluated by 2 radiologists who were unaware of the patients’ clinical information. The positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy of the statistically different findings were calculated using standard definitions. Results: Forty-one patients with CPE and 20 patients with ARDS were assessed. Upper-lobe–predominant ground-glass attenuation, central-predominant ground-glass attenuation, and central airspace consolidation were associated with high PPVs (95.2%, 92.3%, and 92.0%, respectively) and moderate NPVs (47.5%, 51.4%, and 50.0%, respectively) to diagnose as CPE. Left-dominant pleural effusion and small ill-defined opacities revealed relatively high PPVs (71.4% and 58.3%, respectively) and NPVs (72.2% and 73.5%, respectively) to diagnose as ARDS. The overall accuracy of the diagnosis by chest CT was 88.5% (54/61). Conclusions: Chest CT may be a useful tool for differentiating CPE from ARDS in the emergency department setting.

Diagnostic utility of C-reactive Protein combined with brain natriuretic peptide in acute pulmonary edema: a cross sectional study

Introduction Discriminating acute lung injury (ALI) or acute respiratory distress syndrome (ARDS) from cardiogenic pulmonary edema (CPE) using the plasma level of brain natriuretic peptide (BNP) alone remains controversial. The aim of this study was to determine the diagnostic utility of combination measurements of BNP and C-reactive protein (CRP) in critically ill patients with pulmonary edema.MethodsThis was a cross-sectional study. BNP and CRP data from 147 patients who presented to the emergency department due to acute respiratory failure with bilateral pulmonary infiltrates were analyzed.ResultsThere were 53 patients with ALI/ARDS, 71 with CPE, and 23 with mixed edema. Median BNP and CRP levels were 202 (interquartile range 95-439) pg/mL and 119 (62-165) mg/L in ALI/ARDS, and 691 (416-1,194) pg/mL (p < 0.001) and 8 (2-42) mg/L (p < 0.001) in CPE. BNP or CRP alone offered good discriminatory performance (C-statistics 0.831 and 0.887), but the combination offered greater one [C-statistics 0.931 (p < 0.001 versus BNP) (p = 0.030 versus CRP)]. In multiple logistic-regression, BNP and CRP were independent predictors for the diagnosis after adjusting for other variables.ConclusionsMeasurement of CRP is useful as well as that of BNP for distinguishing ALI/ARDS from CPE. Furthermore, a combination of BNP and CRP can provide higher accuracy for the diagnosis.

A Case of Acute Eosinophilic Pneumonia Following Short-Term Passive Smoking : An Evidence of Very High Level of Urinary Cotinine

Acute eosinophilic pneumonia (AEP) is characterized by febrile illness, diffuse pulmonary infiltrates with eosinophilia. The pathogenesis is not well understood. We report a case of 22-year-old men who never smoke presented with AEP 2 days after acute passive smoke exposure. He developed acute respiratory failure despite having no history of the disease. Computed tomography of the lung revealed diffuse bilateral pulmonary infiltrates. Lung biopsy specimens revealed marked eosinophil infiltration in the alveolar septa without signs of vasculitis. Two days prior to the disease, he was exposed to cigarette smoke for 2 hours in a closed area. In the absence of other causes, passive smoking may cause lung inflammatory responses. The level of urinary cotinine, which is a biomarker of smoke exposure, was considerably higher (0.198 μg/ml [201 ng/mg Creatinine]) than that in nonsmokers, but never detected following period. This case suggests that short-term passive smoking may cause AEP.

Risk factors for unexpected death from suffocation in elderly patients hospitalized for pneumonia

Aim:  Unexpected death from suffocation as a result of ortholaryngeal mucinous secretions or vomitus during recovery from pneumonia is devastating for patients, their families and medical professionals. This study aimed to determine the risk factors for unexpected death from suffocation in elderly patients hospitalized for pneumonia.

Long-term, low-dose erythromycin monotherapy for Mycobacterium avium complex lung disease: A propensity score analysis

Multidrug regimens are initially withheld in mild cases of pulmonary Mycobacterium avium complex (MAC) disease. Based on the anti-inflammatory effects of macrolides, some patients are treated with erythromycin, which does not appear to exhibit cross-resistance with clarithromycin in MAC. The aim of this study was to evaluate the effects and adverse events of erythromycin monotherapy in patients with pulmonary MAC disease. This was a retrospective propensity score analysis consisting of 31 patients treated with erythromycin alone and 72 patients on conservative therapy, all of whom met the ATS/IDSA criteria for pulmonary MAC disease. The primary outcome was exacerbation requiring administration of a multidrug regimen. The secondary outcome was the rate of response to the multidrug regimens after exacerbation as a surrogate variable for cross-resistance to clarithromycin. As a result, erythromycin monotherapy was found to be likely to suppress exacerbation throughout the 7-year observation period after the diagnosis of pulmonary MAC disease (P=0.045, Breslow test). Multivariate analysis showed that erythromycin tended to prevent exacerbation, albeit statistically insignificantly (hazard ratio=0.495, 95% confidence interval 0.198-1.235; P=0.132). In addition, the rate of response to the multidrug regimens after exacerbation in the erythromycin group (56%; 5/9) was similar to that observed in the control group (62%; 13/21) (P=0.528). Erythromycin monotherapy for patients with pulmonary MAC disease may have the potential to suppress exacerbation without inducing cross-resistance to clarithromycin. However, further prospective studies are needed to microbiologically verify the effectiveness and potential for cross-resistance of these drugs.

Clarithromycin attenuates IL-13–induced periostin production in human lung fibroblasts

BackgroundPeriostin is a biomarker indicating the presence of type 2 inflammation and submucosal fibrosis; serum periostin levels have been associated with asthma severity. Macrolides have immunomodulatory effects and are considered a potential therapy for patients with severe asthma. Therefore, we investigated whether macrolides can also modulate pulmonary periostin production.MethodsUsing quantitative PCR and ELISA, we measured periostin production in human lung fibroblasts stimulated by interleukin-13 (IL-13) in the presence of two 14-member–ring macrolides—clarithromycin or erythromycin—or a 16-member–ring macrolide, josamycin. Phosphorylation of signal transducers and activators of transcription 6 (STAT6), downstream of IL-13 signaling, was evaluated by Western blotting. Changes in global gene expression profile induced by IL-13 and/or clarithromycin were assessed by DNA microarray analysis.ResultsClarithromycin and erythromycin, but not josamycin, inhibited IL-13–stimulated periostin production. The inhibitory effects of clarithromycin were stronger than those of erythromycin. Clarithromycin significantly attenuated STAT6 phosphorylation induced by IL-13. Global gene expression analyses demonstrated that IL-13 increased mRNA expression of 454 genes more than 4-fold, while decreasing its expression in 390 of these genes (85.9%), mainly “extracellular,” “plasma membrane,” or “defense response” genes. On the other hand, clarithromycin suppressed 9.8% of the genes in the absence of IL-13. Clarithromycin primarily attenuated the gene expression of extracellular matrix protein, including periostin, especially after IL-13.ConclusionsClarithromycin suppressed IL-13–induced periostin production in human lung fibroblasts, in part by inhibiting STAT6 phosphorylation. This suggests a novel mechanism of the immunomodulatory effect of clarithromycin in asthmatic airway inflammation and fibrosis.

Pulmão dos criadores de aves complicado por nocardiose pulmonar

We report the case of an 84-year-old male who was admitted to the hospital with persistent cough and dyspnea. An initial chest X-ray revealed pulmonary infiltrates. Nocardia asteroides was detected in sputum, and the patient was treated with antibiotics. However, his symptoms did not completely resolve. He was admitted multiple times, and his symptoms relapsed after every discharge. He was finally suspected of having hypersensitivity pneumonitis and was diagnosed with bird fanciers lung. Pulmonary nocardiosis is likely to develop in patients with chronic pulmonary disorders, such as COPD, as well as in immunosuppressed hosts. To our knowledge, this is the first report of a case of bird fanciers lung complicated by pulmonary nocardiosis.We report the case of an 84-year-old male who was admitted to the hospital with persistent cough and dyspnea. An initial chest X-ray revealed pulmonary infiltrates. Nocardia asteroides was detected in sputum, and the patient was treated with antibiotics. However, his symptoms did not completely resolve. He was admitted multiple times, and his symptoms relapsed after every discharge. He was finally suspected of having hypersensitivity pneumonitis and was diagnosed with bird fanciers lung. Pulmonary nocardiosis is likely to develop in patients with chronic pulmonary disorders, such as COPD, as well as in immunosuppressed hosts. To our knowledge, this is the first report of a case of bird fanciers lung complicated by pulmonary nocardiosis.