Yuka Miura

Screening for tinea unguium by Dermatophyte Test Strip

The direct microscopy, fungal culture and histopathology that are necessary for the definitive diagnosis of tinea unguium are disadvantageous in that detection sensitivity is affected by the level of skill of the person who performs the testing, and the procedures take a long time.

Method for detection of aspiration based on B-mode video ultrasonography

In this study, we aimed to develop a new method for detection of aspiration based on B-mode video ultrasonography and to evaluate its performance. To detect aspirated boluses by B-mode video ultrasonography in patients with dysphagia, we placed a linear array transducer above the thyroid cartilage and observed the area around the vocal folds. Forty-two ultrasonographic measurements were obtained from 17 patients with dysphagia who also underwent videofluoroscopy or videoendoscopy measurements at the same time. Aspirated boluses were observed in B-mode video ultrasonographic images as hyperechoic, long, narrow objects that passed through the vocal folds beneath the anterior wall of the trachea, with movement different from that of the surrounding structure. The sensitivity of aspiration detection was 0.64, and the specificity was 0.84. This newly developed detection method will enable patients with dysphagia to receive appropriate daily swallowing care.

Diagnosis of tinea pedis by the Dermatophyte Test Strip.

DEAR EDITOR, Tinea pedis is highly prevalent and is often seen in daily practice. However, it is difficult to diagnose tinea pedis visually because there are many similar diseases. Thus, a definitive diagnosis by mycological examination is necessary before the initiation of treatment for tinea pedis. Direct microscopy and fungal culture are used as test methods. However, direct microscopy has the disadvantage that the detection sensitivity is affected by the skill of the person who performs the test, while fungal culture takes 2–3 weeks for the identification of pathogenic fungi and has a low identification rate. The Dermatophyte Test Strip (JNC Corp., Tokyo, Japan) is a recently developed product that permits detection of mycotic antigens by immunochromatography in samples such as scales and nails. This test strip is likely to be useful clinically because it does not require special devices or skills, and can detect dermatophyte antigens from clinical samples in a short period of time. Compared with the standard method of direct microscopy, we have previously shown that the Dermatophyte Test Strip has sufficient sensitivity and specificity for the diagnosis of tinea unguium. There have also been some preliminary reports on the diagnosis of tinea pedis using the Dermatophyte Test Strip. In this study, we investigated, using scale samples, the capacity of the Dermatophyte Test Strip to detect tinea pedis. This test strip detects dermatophytic antigen by immunochromatography using monoclonal antibodies that react with dermatophytes. Screening was performed on scale samples collected from the interdigital or plantar area of cases including tinea pedis and other diseases, such as dyshidrotic eczema, palmoplantar pustulosis, pitted keratolysis and tylosis. The presence of dermatophytes in each scale sample was examined by direct microscopy and with the Dermatophyte Test Strip, as described previously. Briefly, a scale sample was added to the extraction solution in a test tube, mixed and left to stand for 5 min. The test strip was then added and a positive judgement was made after 5 min if a brown line was visible on the test strip (Fig. 1). The detection rate of tinea pedis was examined in samples from 162 patients (75 men, 87 women; mean SD age 61 9 16 8 years) (Table 1). Of the 58 samples that were positive in direct microscopy, 49 were also positive with the Dermatophyte Test Strip, giving a sensitivity of 84%. Of the 104 samples that were negative in direct microscopy, 80 were negative with the Dermatophyte Test Strip, giving a specificity of 77%. The positive predictive value (PPV) was 67%, the negative predictive value (NPV) was 90%, and the positive and negative concordance rate was 80%.

Screening for tinea unguium by thermography in older adults with subungual hyperkeratosis

The purpose of the present study was to assess the difference in foot temperature between tinea unguium‐positive older adults with subungual hyperkeratosis and tinea unguium‐negative older adults with subungual hyperkeratosis to develop a temperature‐based screening method for tinea unguium.

The prevalence of skin eruptions and mycoses of the buttocks and feet in aged care facility residents: A cross-sectional study

The prevalence of skin mycoses in the elderly remains unclear. The proportion of people with skin eruptions who are positive for mycoses using direct microscopy is not known. The purpose of this study is to identify the prevalence of skin eruptions and skin mycoses (e.g. candidiasis and tinea) in the buttocks and feet, which are common sites of skin mycoses in residents of long-term care facilities. This multi-site cross-sectional study used visual inspection and direct microscopy to diagnose the type of skin eruption. Subjects were residents of facilities covered by long-term care insurance schemes in Japan. Of the 171 residents enrolled in this study, 72.5% had a skin eruption. Only 4.8% of participants had tinea in the buttocks; 2.4% had buttock candidiasis. In those with a nail abnormality, 58.3% of residents had tinea unguium. For tinea pedis, residents who had any form of interdigital or plantar region skin eruption, 22.5% and 31.4% of residents were positive, respectively. The prevalence of observed skin mycoses was: buttock candidiasis 1.8%; buttock tinea 3.5%; tinea unguium 56.2%; interdigital tinea pedis 20.5%; and plantar tinea pedis 22.5%. The very low proportion of residents with mycoses in the buttocks suggests that anti-inflammatory agents, such as steroids, should be used as first choice. Our observation that not all residents with skin eruptions on the feet had tinea, should remind clinicians to perform direct microscopy before initiating antifungal treatments.

Detecting pharyngeal post-swallow residue by ultrasound examination: a case series.

AIMS Prevention of aspiration pneumonia is a great concern in the era of global aging. The assessment of pharyngeal post-swallow residue is important because remaining food and liquid in the pharyngeal area has a possibility of flowing into the lower airway which can cause aspiration pneumonia. Ultrasound examination has been recently used to assess swallowing disorders because of its noninvasiveness. The aim of this study was to investigate the performance for detecting pharyngeal post-swallow residue using an ultrasound examination by comparing with those using a fiberoptic endoscopic evaluation of a swallowing study as a reference. MATERIAL AND METHODS A linear array transducer attached to the thyroid cartilage to visualize the vocal folds in the sagittal plane. The pharyngeal post-swallow residue in the ultrasound movie was interpreted as a misty hyperechoic area above the vocal folds that remained after swallowing. Nineteen ultrasound images simultaneously obtained with fiberoptic endoscopic evaluation of swallowing study images from nine participants (eight men) with a median age of 70 years at a dysphagia outpatient clinic were analyzed by the montage of swallowing examinations. RESULTS Misty hyperechoic areas above the vocal folds that remained after swallowing were detected in 10 ultrasound images. Eight US images out of ten correctly detected pharyngeal post-swallow residue. The sensitivity for detecting pharyngeal post-swallow residue of 19 images from nine participants by US examination was 62%, and the specificity was 67%. CONCLUSIONS The proposed detection method of pharyngeal post-swallow residue by ultrasound examination enabled the real-time assessment for swallowing of people with dysphagia. Ultrasound assessment-based daily swallowing care which detects pharyngeal residue will be useful for preventing aspiration pneumonia.

Prevalence of asteatosis and asteatotic eczema among elderly residents in facilities covered by long-term care insurance.

Dear Editor, Asteatosis (AS), or senile xerosis, is characterized by dry skin of the lower extremity, lumbar and buttock regions in elderly individuals and the AS may progress to asteatotic eczema (AE) along with worsening of these manifestations. Because of a lack of knowledge on prevalence of AS and AE, effective and efficient care protocols have not been established. The other important problem includes the underestimation in elderly people. The aims of this letter were to investigate the prevalence in elderly residents in facilities covered by long-term care insurance in Japan, and whether nurses correctly identify these skin conditions. This cross-sectional study comprised a questionnaire survey of the nurses and direct patient examination by a dermatologist. This study enrolled all residents of one long-term care health facility (LTCF) and one special nursing home (SNH) for the elderly in Tokyo in fall to winter season. LTCF is the institution for residents who undertake rehabilitation for facilitating the home care. On the other hand, SNH is the residential institution for elderly persons until their end of life. Residents who did not consent to this study were excluded. Residents were also excluded when the primary physician determined that participation would be impossible. This study was approved by the ethics committee of each facility. The subjects were residents from one LTCF (n = 61, female = 45 (73.8%), mean age = 85.0 9.7 years) and one SNH for the elderly (n = 34, female = 30 (88.2%), mean age = 86.8 7.2 years). Table 1 shows the prevalence of AS and AE. The overall prevalence for AS was 70.5% and 94.1% and the prevalence for AE was 16.4% and 41.2% in the LTCF and SNH, respectively. We then examined nurse awareness of AS and AE of the legs, where AS and AE were frequently observed. In the questionnaire survey, the nurses described AS and AE as “dry skin”, “scratching” and “xerotic eczema”. We categorized all of these terms as “dry skin”. Of all subjects diagnosed with AS or AE of the legs, we calculated the proportion correctly identified as having “dry skin”. The proportions were 44.4% and 5.0% for AS, and 14.3% and 0.0% for AE, in the LTCF and SNH, respectively. Asteatosis and AE are common skin conditions in the elderly; however, there are no reports regarding their prevalence and related factors among elderly residents in long-term care facilities in Japan. This letter revealed an extremely high prevalence of AS/AE among residents in facilities covered by long-term care insurance in Japan for the first time; the prevalence found was higher than that in other countries. This letter clearly indicates the low awareness of these skin conditions among nurses, which would lead to undertreatment, causing reduction in well-being of the residents. For an accurate and efficient technique to detect AS or AE, education should be provided including a simple visual assessment method for dry skin. Despite limited sample size, this study is meaningful in showing the high prevalence of AS and AE and the very low awareness of these conditions.

A Randomized Controlled Trial to Investigate the Effectiveness of the Prevention of Aspiration Pneumonia Using Recommendations for Swallowing Care Guided by Ultrasound Examination

Prevention for aspiration pneumonia requires assessment of aspiration and adequate swallowing care. This randomized controlled trial aimed to investigate the effectiveness of ultrasound examination and recommendations for swallowing care for the reduction of aspiration and pharyngeal post-swallow residue as compared with standard swallowing care. Twenty-three participants were randomized to the intervention group and 23 to the control group. The intervention consisted of four ultrasound examinations during mealtimes and recommendations for swallowing care every 2 weeks during an 8 week period. No recommendations concerning swallowing care based on ultrasound examinations were provided to the control group. The frequency of aspiration or residue was defined as x/y × 100% when aspiration or residue were detected x times from y times concerning the total ultrasound measurements. The proportion of the residents with reduced frequency of aspiration which was detected by ultrasonography at eight weeks were 4.3% in the intervention group and 0% in the control group. The median reduction in the frequency of aspiration and residue in the intervention group was 31%, and that in the control group was 11%. In conclusion, swallowing care guided by frequent ultrasound examinations during mealtimes had a trend of reducing the frequency of aspiration and residue during an 8-week period in individuals relative to standard swallowing care alone.

Specimens processed with an extraction solution of the Dermatophyte Test Strip can be used for direct microscopy

DEAR EDITOR, The ‘dermatophyte test strip’ (DTS) is a recently developed product that permits the detection of dermatophyte antigens in samples such as scales and nails by immunochromatography using monoclonal antibodies that react with dermatophytes. We evaluated the efficiency of the DTS for the diagnosis of tinea unguium and tinea pedis, and have found that it is highly useful in detecting tinea unguium. The effectiveness of DTS in detecting tinea unguium has been demonstrated in a clinical study, and its application as an in vitro diagnostic test was approved by the Japanese drug regulatory agency, the Pharmaceuticals and Medical Devices Agency, in March 2016. In addition to dermatophytes, the DTS also reacts to contaminant microbes such as Aspergillus and Penicillium. Because antigens (and not fungus bodies) of these fungi may be adhering to nails and skin, it is recommended to confirm the diagnosis of tinea under direct microscopy, especially when a faint line is observed on the test strip. In this regard, it is ideal if the same specimen that is used for the DTS test can be used for direct microscopy. In this study, we investigated whether a specimen can be used for direct microscopy after antigens have been extracted using the extraction solution of the DTS. The concordance rate between direct microscopy and the DTS results was also determined to confirm the previous results. DTS was purchased from the JNC Corporation (Tokyo, Japan). A sample was added to the extraction solution and left to stand for 1 min. The test strip was then added and a judgement was made after 5 min. The extraction solution is a buffer solution containing surfactant with pH adjusted to neutral. The incubation of scales and nails in the extraction solution does not affect the gross appearance of the specimens. In this study, specimens were collected from 63 scale lesions and 62 nail lesions with suspected tinea. Each specimen was divided into two groups. The specimens in one group were incubated in the extraction solution and subjected to examination using the DTS. Then the specimen was removed from the extraction solution, and processed for direct microscopy (treated specimens) with a light microscope (CX31, Olympus, Japan). The untreated specimens in the other group were subjected to direct microscopy. A comparison of treated and untreated specimens inspected under direct microscopy showed that the concordance rate was 95 2% in scale and 93 5% in nail (Table 1). Fungal elements such as hyphae and arthrospores in the treated specimens were similar in morphology to those in the untreated specimens. Next, the results of direct microscopy and DTS were compared (Table 1). Samples judged by direct microscopy to have fungal elements for at least one of the treated or untreated specimens were classified as positive.

Life Pattern Estimation of the Elderly Based on Accumulated Activity Data and its Application to Anomaly Detection

A life pattern estimation method and its application to anomaly detection of a single elderly are proposed. Our observation system deploys some pyroelectric sensors in an elderly’s house and monitors and measures activities 24 hours a day to grasp residents’ life patterns. Activity data is successively forwarded to the nurse operation center and displayed to nurses at the center. The system reports status related to anomalies together with the basic activities of elderly residents to the nurses, who decide whether recent accumulated data expresses an anomaly or not based on suggestions from the system. In the system, residents whose lifestyle features resemble each other are categorized into the same group. Anomalies that occurred in the past are shared in the group and utilized in an anomaly detection algorithm. This algorithm is based on an “anomaly score.” The score is figured out by utilizing the activeness of the house’s elderly resident. This activeness is approximately proportional to the frequency of sensor response within one minute. The anomaly score is calculated from the difference between activeness in the present and in the past averaged over the long term. The score is thus positive if activeness in the present is greater than the average in the past, and the score is negative if the value in the present is less than average. If the score exceeds a certain threshold, it means that an anomaly event has occurred. An activity estimation algorithm is also developed that estimates the basic activities of residents such as getting up in the morning, or going out. The estimation is also shown to nurses with the anomaly score of residents. Nurses can understand the condition of elderly residents’ health by combining the information and planning the most appropriate way to respond.