Yoko Hanaoka

ACE inhibitors prevent aspiration pneumonia in Asian, but not Caucasian, elderly patients with stroke

To the Editors: In a recent issue of the European Respiratory Journal , van de Garde et al. 1 demonstrated that the use of angiotensin-converting enzyme (ACE) inhibitors is not associated with a decreased risk of hospitalisation for community-acquired pneumonia (CAP) in a general, essentially white population. Their conclusion that the beneficial effect of ACE inhibitors on pneumonia risk is not observed in a general white population is in contrast with previous findings in Asian populations 1. This was an excellent good study examining the association of ACE inhibitor treatment of cardiovascular disease with a risk reduction of CAP using a large sample size. The results are acceptable and not surprising; however, the discussion and conclusion are misleading. As shown in table 1⇓, there are controversies regarding the ACE inhibitor effects on the risk reduction of pneumonia even in Asian countries; furthermore, the study samples are very different among the studies. In a prospective study …

Lower respiratory tract infection outcomes are predicted better by an age >80 years than by CURB-65

To the Editors: In a recent issue of the European Respiratory Journal , Bont et al. 1 demonstrated that increasing age, previous hospitalisation, heart failure, diabetes, use of oral glucocorticoids, previous use of antibiotics, a diagnosis of pneumonia and an exacerbation of chronic obstructive pulmonary disease were independent predictors of 30-day hospitalisation or death in patients with lower respiratory tract infections (LRTI). They provided a new scoring system using the variables above for the prognostic predictors in the elderly primary-care patients with LRTI 1. Although some of the predictor variables have been confirmed by other studies, we would like to point out that their results are very important, much more so than previous results. Age is a …

Improvement of endothelial function with allopurinol may occur in selected patients with OSA: effect of age and sex.

To the Editors: In a recent issue of the European Respiratory Journal , El Solh et al. 1 demonstrated that allopurinol improves endothelial dysfunction in patients with moderate-to-severe obstructive sleep apnoea (OSA). Because xanthine oxidase inhibition with allopurinol prevents the formation of superoxide free radicals, which leads to better endothelial function, El Solh et al. 1 speculated that excess activity of xanthine oxidase contributes significantly to vasodilatory impairment in patients with OSA. The study was a sophisticated prospective, randomised, crossover design, minimising the presence of confounding variables and eliminating inherent individual variations in terms of the generation of free radicals, hyperaemic vascular reactivity or response to treatment. However, a number of arguable assumptions were made in the article of El Solh et al. 1. First, endothelial function assessment using hyperaemia-induced flow-mediated vasodilation (FMD) is not always …

Cardiovascular and metabolic effects of CPAP in obese obstructive sleep apnoea patients.

To the Editors: In a recent issue of the European Respiratory Journal , Coughlin et al. 1 demonstrated that, in Caucasians with untreated obstructive sleep apnoea (OSA), continuous positive airway pressure (CPAP) can improve baroreceptor responsiveness and reduce waking blood pressure within 6 weeks, but that this treatment period was insufficient to modify insulin resistance or change the metabolic profile. This is the first randomised placebo-controlled blinded crossover trial comparing cardiovascular and metabolic outcomes after 6 weeks of therapeutic and sham CPAP in obese symptomatic Caucasians with OSA. We have found similar CPAP effects in obese Japanese OSA patients (table 1⇓). The authors suggested that there is a need to offer multiple modalities of treatment to obese OSA patients if their cardiovascular risk profile is to be successfully modified. We totally agree with their conclusion. However, it may be necessary to address the following unresolved issues. View this table: Table 1— Effect of 6-week continuous positive airway pressure …

Acute exogenous lipoid pneumonia caused by accidental kerosene ingestion in an elderly patient with dementia: a case report.

Acute exogenous lipoid pneumonia is an uncommon condition caused by aspiration of oil‐based substances, occurring mainly in children. Here, we report the case of an 83‐year‐old patient with Alzheimers disease who presented with coughing and hypoxia. The diagnosis of acute exogenous lipoid pneumonia caused by accidental kerosene ingestion was made on the basis of the patients clinical history, and typical radiological and cytological findings. The patients cognitive impairment and an unsafe environment, in which the patients 91‐year‐old husband stored kerosene in an old shochu bottle, were responsible for the accidental ingestion. Acute exogenous lipoid pneumonia should be considered in the differential diagnosis for acute respiratory disorders in the rapidly aging population. Geriatr Gerontol Int 2013; 13: 222–225.

Marked improvement of elderly postprandial hypotension by dipeptidyl peptidase IV inhibitor

Postprandial hypotension (PPH) is an important and frequent problem, particularly in the elderly. Rapid drops of blood pressure after meals cause syncope, dizziness, falls and muscle weakness, and might result in angina pectoris and stroke. Accordingly, accurate diagnosis and effective treatment of PPH are Figure 1 Computed tomography (CT) images. (a,b) Delayed-phase images obtained by helical dynamic CT. (a) This CT image shows a giant liver cyst (GLC) measuring 18 cm in diameter. The cyst was occupying the right hepatic lobe and compressing the inferior vena cava (IVC; white arrow). (b) The caliber of the IVC on a 3-cm caudad slice from the furcation of the celiac artery was larger than that of the abdominal aorta. The shape of the IVC was round, which indicates a strained IVC (white short arrow). (c) Reconstructed CT image of GLC. This image shows that the caliber of the IVC narrowed on the same level as GLC (white arrow). (d,e) Plain CT images obtained 6 months after the drainage. CT images show no compression of the IVC. (d) This CT image shows that the caliber of the IVC on the 3-cm caudad slice from the furcation of the celiac artery was smaller than that of the abdominal aorta. The shape of the IVC changed to oval, which indicates a lax IVC (white short arrow). (e) The CT image on the same level as that in (b), indicated by paraspinal muscles, shows that the caliber of the IVC was smaller than that of the abdominal aorta (white short arrow). bs_bs_banner

PULMONARY FEATURES ASSOCIATED WITH BEING UNDERWEIGHT IN OLDER MEN

ACKNOWLEDGMENTS The authors wish to thank Angers University Hospital for technical support. Conflict of Interest: Prof. Beauchet serves as an unpaid consultant for Ipsen Pharma company and as a board member for Gériatrie, Psychologie et Neuropsychiatrie du Vieillissement. He has no relevant financial interest in this manuscript. Dr. Annweiler serves as an unpaid consultant for Ipsen Pharma Company. He has no relevant financial interest in this manuscript. Author Contributions: Annweiler had full access to the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analyses. Study concept and design: Annweiler and Beauchet. Acquisition of data: Calès, Redureau, and Abraham. Analysis and interpretation of data: Abraham, Calès, Redureau, Annweiler, and Beauchet. Drafting of the manuscript: Annweiler, Abraham, Beauchet, Calès, and Redureau. Critical revision of the manuscript for important intellectual content: Fantino and De Decker. Statistical expertise: Annweiler. Administrative, technical, or material support: Beauchet. Study supervision: Annweiler. Sponsor’s Role: None.

INCREASE IN OXIDATIVE STRESS LEVELS IN ELDERLY PATIENTS WITH OBSTRUCTIVE SLEEP APNEA SYNDROME: EFFECTS OF AGE AND SEX

1. Ellison DH, Berl T. Clinical practice. The syndrome of inappropriate antidiuresis. N Engl J Med 2007;356:2064–2072. 2. Robertson GL. Regulation of arginine vasopressin in the syndrome of inappropriate antidiuresis. Am J Med 2006;119:S36–S42. 3. McKeith IG, Dickson DW, Lowe J et al. Diagnosis and management of dementia with Lewy bodies: Third report of the DLB Consortium. Neurology 2005; 65:1863–1872. 4. Walker MP, Ayre GA, Cummings JL et al. The Clinician Assessment of Fluctuation and the One Day Fluctuation Assessment Scale. Two methods to assess fluctuating confusion in dementia. Br J Psychiatry 2000;177:252–256. 5. Sone H, Okuda Y, Bannai C et al. Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) and Gerhardt syndrome associated with ShyDrager syndrome. Intern Med 1994;33:773–778. 6. Bridges TE, Hillhouse EW, Jones MT. The effect of dopamine on neurohypophysial hormone release in vivo and from the rat neural lobe and hypothalamus in vitro. J Physiol 1976;260:647–666. 7. Renneboog B, Musch W, Vandemergel X et al. Mild chronic hyponatremia is associated with falls, unsteadiness, and attention deficits. Am J Med 2006; 119:e1–e8.

Effects of age and sex on plasma adrenomedullin levels in patients with obstructive sleep apnea syndrome.

To the Editor: It has been recognized that obstructive sleep apnea syndrome (OSAS) is one of the risk factors of cardiovascular disorders, including hypertension, ischemic heart disease, and cerebrovascular diseases. Although the incidence of sleep apnea increases with age, the pathological roles of OSAS have not been fully established. OSAS-induced hypoxic stress and oxidative stress increase circulating inflammatory mediators, including adhesion molecules, inflammatory cytokines, and high-sensitivity C-reactive protein, leading to hypertension and cardiovascular events. The stress and its related inflammatory molecules are implicated in the production of adrenomedullin (AM), which is a potent endothelial-derived vasodilator. Circulating AM levels are higher in adults with untreated OSAS than in adults without OSAS. Because plasma AM is closely correlated with pulse wave velocity and atherosclerosis progression in middle-aged and elderly patients, higher levels of AM may be a surrogate marker for hypertension and the progression of atherosclerosis. Furthermore, treatment with nasal continuous positive airway pressure (nCPAP) mostly reversed the higher AM levels in subjects with OSAS. Thus, OSAS treatment may prevent atherosclerosis and cardiovascular events, although circulating AM levels and therapeutic response to OSAS have not been examined in elderly people. Furthermore, female sex hormones increase AM-induced vasodilation by increasing the expression of AM2 receptor components in rats. Sex may affect circulating AM levels in humans. Age and sex differences in AM levels in patients with OSAS were examined. Eighty middle-aged (aged 40–60) and 80 elderly (aged 60) patients were compared with OSAS and 80 middle-aged and 80 elderly ageand body mass index (BMI)-matched subjects without OSAS. The patients had to fulfill the following criteria: absence of renal and renovascular hypertension, systolic blood pressure (BP) greater than 160 mmHg or diastolic BP greater than 95 mmHg, chronic renal and hepatic diseases, and diabetes mellitus. Patients who smoked or had systemic infections at the time of the study or within 4 weeks before the study were excluded. No patients were being treated with antihypertensive agents. These subjects were examined using polysomnography; subjects with an apnea-hypopnea index (AHI) less than five were controls, and those with an AHI of five or greater were determined to have OSAS. To assess OSAS-induced hypoxia quantitatively, the oxyhemoglobin desaturation index (ODI) was used in this study as previously described. ODI was defined as ODI 5S(90 oxygen saturation)t, where t is time of desaturation (hours). Circulating AM levels and sleep study variables were compared. Then 3 months of nCPAP treatment was performed in the patients. Peripheral blood was obtained from the subjects at 7:30 a.m. to 8:00 a.m. before and after the 3 months treatment with nCPAP. The AM was measured using a specific radioimmunoassay. There were no significant differences in BMI between the patients and controls in each age group, whereas AHI in subjects OSAS was markedly greater than in controls (Table 1). There were no significant differences in BP or metabolic indices. The AHI values in elderly (50.1 3.2 events/h) and middle-aged (51.6 3.0) subjects with OSAS were considerably greater than in age-matched controls (3.8 0.3 and 3.6 0.4, respectively). There were significant differences in baseline ODI between patients with OSAS and controls, suggesting that the patients with OSAS were exposed to a

Removal of the CPAP Therapy Device During Sleep and Its Association With Body Position Changes and Oxygen Desaturations

BACKGROUND: Some patients with obstructive sleep apnea syndrome remove the CPAP device during sleep, although they start CPAP at bedtime. We hypothesized that body position changes and oxygen desaturations may be associated with patient removal of the CPAP device. METHODS: We consecutively enrolled 36 poor CPAP adherers and 25 good CPAP adherers. Body positions and oxygen desaturations were evaluated when these subjects used CPAP during sleep for 2 nights, permitting the removal of the CPAP device during the recording. RESULTS: Twelve poor CPAP adherers exhibited subject removal of the CPAP device within 4 h from the start of body position recording. The frequency of body position changes was significantly higher within 15 min before the CPAP removal than during other periods when CPAP was used. At the same time, oxygen desaturations were significantly more frequent within 15 min before CPAP removal than during other periods when CPAP was used. In addition, the majority (66.7%) of the CPAP removal events were followed by a change from a supine position to a non-supine position within 5 min. The number of body position changes during the first 4-h recording was significantly higher in the poor CPAP adherers who had removed their CPAP device compared with the poor CPAP adherers who had not removed their device. However, the number of body position changes or oxygen desaturation index under CPAP during the first 4-h recording was not significantly different between the poor CPAP adherers and good CPAP adherers. CONCLUSIONS: Our findings are the first to indicate associations among CPAP removal, body position changes, and oxygen desaturations during sleep in poor CPAP adherers. However, our findings also indicated that most good CPAP adherers make frequent body position changes without removal of CPAP device, suggesting that patients can adapt to the discomfort of CPAP therapy at the time of body position changes.