Masaru Yanai

Interventions to Prevent Pneumonia Among Older Adults

Pneumonia is a common cause of death in older people. Antimicrobial drugs do not prevent pneumonia and, because of increasingly resistant organisms, their value in curing infection will become more limited. Establishing new strategies to prevent pneumonia through consideration of the mechanisms of this devastating illness is essential. The purpose of this review is to discuss how pneumonia develops in older people and to suggest preventive strategies that may reduce the incidence of pneumonia among older adults. Aspiration of oropharyngeal bacterial pathogens to the lower respiratory tract is one of the most important risk factors for pneumonia; impairments in swallowing and cough reflexes among older adults, e.g., related to cerebrovascular disease, increase the risk for the development of pneumonia. Thus, strategies to reduce the volumes and pathogenicity of aspirated material should be pursued. For example, since both swallowing and cough reflexes are mediated by endogenous substance P, pharmacologic therapy using angiotensin‐converting enzyme inhibitors, which decrease substance P catabolism, may improve both reflexes and result in the lowering of the risk of pneumonia. Similarly, since the production of substance P is regulated by dopaminergic neurons in the cerebral basal ganglia, treatment with dopamine analogs or potentiating drugs such as amantadine (and, of course, prevention of cerebral vascular disease, which can result in basal ganglia strokes) should affect the incidence of pneumonia. The purpose of this review is to consider promising pharmacologic treatments as methods of preventing pneumonia in older adults and to review other proven strategies, e.g., infection control and cerebrovascular disease prevention that will lessen the incidence of pneumonia.

Increased blood carboxyhaemoglobin concentrations in inflammatory pulmonary diseases.

Background: Exhaled carbon monoxide has been reported to increase in inflammatory pulmonary diseases and to be correlated with blood carboxyhaemoglobin (Hb-CO) concentration. A study was undertaken to determine whether arterial blood Hb-CO increases in patients with inflammatory pulmonary diseases. Methods: The Hb-CO concentration in arterial blood was measured with a spectrophotometer in 34 normal control subjects, 24 patients with bronchial asthma, 52 patients with pneumonia, and 21 patients with idiopathic pulmonary fibrosis (IPF). Results: The mean (SE) Hb-CO concentrations in patients with bronchial asthma during exacerbations (n=24, 1.05 (0.05)%), with pneumonia at the onset of illness (n=52, 1.08 (0.06)%), and with IPF (n=21, 1.03 (0.09)%) were significantly higher than those in control subjects (n=34, 0.60 (0.07)%) (mean difference 0.45% (95% confidence interval (CI) 0.23 to 0.67), p<0.01 in patients with bronchial asthma, mean difference 0.48% (95% CI 0.35 to 0.60), p<0.0001 in patients with pneumonia, and mean difference 0.43% (95% CI 0.26 to 0.61) p<0.001 in patients with IPF). In 20 patients with bronchial asthma the Hb-CO concentration decreased after 3 weeks of treatment with oral glucocorticoids (p<0.001). In 20 patients with pneumonia the Hb-CO concentration had decreased after 3 weeks when patients showed evidence of clinical improvement (p<0.001). The values of C-reactive protein (CRP), an acute phase protein, correlated with Hb-CO concentrations in patients with pneumonia (r=0.74, p<0.0001) and in those with IPF (r=0.46, p<0.01). In patients with bronchial asthma changes in Hb-CO concentrations were significantly correlated with those in forced expiratory volume in 1 second (FEV1) after 3 weeks (r=0.67, p<0.01). Exhaled carbon monoxide (CO) concentrations were correlated with Hb-CO concentrations (n=33, r=0.80, p<0.0001). Conclusions: Hb-CO concentrations are increased in inflammatory pulmonary diseases including bronchial asthma, pneumonia, and IPF. Measurement of arterial Hb-CO may be a useful means of monitoring pulmonary inflammation.

Increased circulating endothelial microparticles in COPD patients: a potential biomarker for COPD exacerbation susceptibility

Rationale The influence of COPD exacerbation on the endothelium is not completely understood. Circulating endothelial microparticles (EMPs) are membrane vesicles in circulating blood that are shed by activated or apoptotic endothelial cells. Objective To compare EMP numbers in stable COPD patients with those during and after exacerbation. Methods We examined the EMP numbers in 80 stable COPD patients, 27 patients with exacerbated COPD, and 20 healthy non-COPD volunteers. EMPs were defined as CD144+ MPs (VE-cadherin EMPs), CD31+/CD41− MPs (PECAM EMPs), CD146 MPs (MCAM EMPs) and CD62E+ EMPs (E-selectin EMPs) as analysed by FACS. Von Willebrand factor (vWF) expression was utilised to identify the origins of the EMPs. Results VE-cadherin, PECAM and E-selectin EMP numbers were significantly higher in the stable COPD patients than in the non-COPD volunteers, and they were significantly higher in the patients with exacerbated COPD than in the stable COPD patients. The majority of these increased EMPs were vWF-negative, indicating a pulmonary capillary origin. Baseline E-selectin EMP levels were significantly higher in COPD patients who experienced frequent exacerbations than in those who did not have frequent exacerbations (p<0.001). Twenty-eight days after the onset of exacerbation, E-selectin EMP levels returned to those observed in stable COPD patients, whereas PECAM EMP levels remained high. MCAM EMP numbers were not elevated in stable or exacerbated-COPD patients. Conclusions Endothelial damage, mainly in pulmonary capillaries, occurs during exacerbation and continues even after clinical symptoms disappear. Higher baseline E-selectin EMP levels may indicate COPD patients who are susceptible to exacerbation.

Antithrombotic therapy for prevention of pneumonia

Forty-eight of 51 nonrandomly screened patients had topical dressings on their pressure ulcers, but only 21 had a written physician order. One patient with a physician order had a topical treatment in place that was different from what was ordered. At our hospital, nurses are allowed by policy to initiate treatment with hydrocolloid and film dressing without a physician order. However, our concern is that the lack of physician involvement may indicate several potential problems. Physician awareness and, therefore, documentation of the ulcer are usually required for reimbursement. Communication between physicians and nurses and an interdisciplinary plan are essential for ulcer healing. Most importantly, physicians may underrecognize the impact of the patient’s overall medical condition on ulcer healing. We are planning a future study on the factors that affect physician involvement in pressure ulcer management. Could the authors expand their report by providing us with the following data if they are available: (1) the specialties of the physicians who were responsible for signing the home care orders, and (2) any measure of nursing and physician communication about the condition of the ulcers? We believe that understanding how surgeons (compared with internists) treat pressure ulcers and that how physicians and nurses communicate will be necessary to design educational initiatives that might improve adherence to national guidelines. 2

The impact of the 2011 Great East Japan Earthquake on hospitalisation for respiratory disease in a rapidly aging society: a retrospective descriptive and cross-sectional study at the disaster base hospital in Ishinomaki

Objective To investigate the impact in an aging society of the 2011 Great East Japan earthquake on hospitalisation for respiratory disease at the disaster base hospital. Design Descriptive and cross-sectional study. Setting Emergency care in Japanese Red Cross Ishinomaki Hospital, a regional disaster base hospital in Miyagi, Japan. Participants 322 emergency patients who were hospitalised for respiratory disease from 11 March to 9 May 2011, and 99 and 105 emergency patients who were hospitalised in the corresponding periods in 2009 and 2010, respectively. Main outcome measures Description and comparison of patient characteristics and disease distribution in terms of age, time after the disaster and activities of daily living (ADL). Results 1769 patients were admitted to our hospital during the study period (compared to 850 in 2009 and 1030 in 2010), among whom 322 were hospitalised for respiratory disease (compared to 99 in 2009 and 105 in 2010). Pneumonia (n=190, 59.0%) was the most frequent cause of admission for pulmonary disease, followed by acute exacerbation of chronic obstructive pulmonary disease (AE-COPD) (n=53, 16.5%), asthma attacks (n=27, 8.4%) and progression of lung cancer (n=22, 6.8%). Compared with the corresponding periods in 2009 and 2010, the increase in the absolute numbers of admissions was highest for pneumonia, followed by AE-COPD and asthma attacks. At hospitalisation, 195 patients were ‘dependent’ and 54 patients were ‘partially dependent’. Respiratory admissions accompanied by deterioration of ADL after the disaster were more frequent in elderly and female patients. Conclusions After the Great East Japan Earthquake, admissions for pneumonia and exacerbation of chronic respiratory disease in the elderly increased at the disaster base hospital.

Impairment of the swallowing reflex in exacerbations of COPD.

An exacerbation of chronic obstructive pulmonary disease (COPD) has a serious impact on disease progression and is associated with high medical costs, but the cause of about one-third of exacerbations cannot be identified.1 Adequate protective reflexes in the airways play an important role in the prevention of aspiration of bacteria-containing oropharyngeal or gastric secretions. Impairment of these reflexes, such as the swallowing reflex, therefore represents a potential risk factor for exacerbations of COPD. We have conducted a cross-sectional survey to evaluate the prevalence of impairment of the swallowing reflex in patients with COPD and to determine whether this is a risk factor for …

Preoperative use of inhaled tiotropium in lung cancer patients with untreated COPD.

Background and objective:  Lung cancer patients with COPD are at high risk during surgery. Tiotropium, a long‐acting bronchodilator, is a preferred maintenance therapy for COPD, but its efficacy in the perioperative period has not been clarified.

Prognosis of Elderly Patients with Dysphagia in Japan

Accessible online at: www.karger.com/journals/ger Dear Sir, Terminal medical care for older patients has been debated in terms of ethics [1] and costs [2]. In Japan it is very difficult to refuse feeding older patients suffering from dysphagia because of strong family emotions, religion, social customs, and public opinion. Here, we have studied three ways of feeding older patients with dysphagia in a geriatric hospital who could not live without tube feeding or intravenous hyperalimentation (IVH). We examined the survival period of 105 patients (mean age B SD 80 B 6 years): 60 females (81 B 6 years of age) and 45 males (80 B 6 years of age) who were bedridden at Miyama Hospital, a geriatric long-term care facility located in Mizusawa City, Japan. All of them suffered from dysphagia. Informed consent was obtained after talking with their families, and three courses of feeding were selected. Eleven patients (80 B 6 years of age) were not treated with any feeding course, 73 patients (81 B 6 years of age) were tube fed, and 21 patients (80 B 6 years of age) were treated with IVH. IVH was selected, if there were problems with tube feeding such as repeated pneumonia, extubation of the feeding tube, and so on. There were no systematic differences in age, cognitive impairments, or basic diseases. The median survival times of the patients were 2 months in those without treatment, 23 months in tube-fed patients, and 8 months in those with IVH. The median survival time of all patients was 15 months (table 1). The relative risks of death for patients treated with tube feeding and IVH as compared with those without treatment were 0.02 (95% CI 0.01–0.05, p ! 0.0001) and 0.06 (95% CI 0.02–0.20, p ! 0.0001), respectively. Of the Japanese population, 16% are older than 65 years. Among them, 11% or 2 million people need medical care and/or welfare care. In Japan about 80% of the patients die in either geriatric or general hospitals, and 20% die in homes. About 80,000 patients in geriatric hospitals all over Japan die per year,

The impact of a large-scale natural disaster on patients with chronic obstructive pulmonary disease: The aftermath of the 2011 Great East Japan Earthquake

BACKGROUND A large-scale natural disaster may exacerbate chronic respiratory diseases, such as chronic obstructive pulmonary disease (COPD). The aftermath of a natural disaster can include poor access to medication, medical equipment, and medical supplies. Little is known about the impact on patients with COPD. METHODS A retrospective cohort study was conducted at a regional medical center in Ishinomaki, the area affected most severely by the Great East Japan Earthquake in 2011. The study was performed 6 months after the disaster. The characteristics, clinical courses, and outcomes of COPD patients hospitalized after emergency visits during the study period were investigated and compared. RESULTS One hundred patients (112 episodes) were identified. Within a few days after the disaster, patients undergoing oxygen therapy at home came to the hospital to receive oxygen. In the subacute phase (from the third to the fifth week), the number of hospitalizations due to COPD exacerbations was significantly increased compared to the numbers observed before the earthquake (p<0.05). On admission, COPD patients reported significantly reduced participation in the activities of daily living (ADLs) after as compared to before the disaster. The incidence of cases of exacerbated COPD normalized 6 weeks after the earthquake. CONCLUSIONS The large-scale natural disaster that hit Japan in 2011 had a serious negative impact on the clinical outcomes of COPD patients in the disaster-affected area.

Production and secretion of adrenomedullin in cultured human alveolar macrophages

To explore the role of adrenomedullin (ADM) in macrophages, we investigated the secretion of ADM by alveolar macrophages. Human alveolar macrophages obtained from bronchoalveolar lavage were cultured for 24 h. Northern blot analysis revealed ADM mRNA expression in alveolar macrophages. The levels of immunoreactive ADM in the media were 0.89+/-0.12 fmol/10(5) cells/24 h (n = 10). Reverse-phase high-performance liquid chromatography of the extract of culture media showed one major peak eluting in the position of the human ADM standard. The present study shows that alveolar macrophages produce and secrete ADM.