Safety and efficacy of 5-aminolevulinic acid phosphate/iron in mild-to-moderate coronavirus disease 2019: A randomized exploratory phase II trial

BACKGROUND

5-aminolevulinic acid (5-ALA), a natural amino acid that is marketed alongside sodium ferrous citrate (SFC) as a functional food, blocks severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) proliferation in vitro and exerts anti-inflammatory effects. In this phase II open-label, prospective, parallel-group, randomized trial, we aimed to evaluate the safety and efficacy of 5-ALA in patients with mild-to-moderate coronavirus disease 2019.

METHODS

This trial was conducted in patients receiving 5-ALA/SFC (250/145 mg) orally thrice daily for 7 days, followed by 5-ALA/SFC (150/87 mg) orally thrice daily for 7 days. The primary endpoints were changes in SARS-CoV-2 viral load, clinical symptom scores, and 5-ALA/SFC safety (adverse events [AE] and changes in laboratory values and vital signs).

RESULTS

A total of 50 patients were enrolled from 8 institutions in Japan. The change in SARS-CoV-2 viral load from baseline was not significantly different between the 5-ALA/SFC (n = 24) and control (n = 26) groups. The duration to improvement was shorter in the 5-ALA/SFC group than in the control group, although the difference was not significant. The 5-ALA/SFC group exhibited faster improvement rates in "taste abnormality," "cough," "lethargy," and "no appetite" than the control group. Eight AEs were observed in the 5-ALA/SFC group, with 22.7% of patients experiencing gastrointestinal symptoms (decreased appetite, constipation, and vomiting). AEs occurred with 750/435 mg/day in 25.0% of patients in the first phase and with 450/261 mg/day of 5-ALA/SFC in 6.3% of patients in the second phase.

CONCLUSION

5-ALA/SFC improved some symptoms but did not influence the SARS-CoV-2 viral load or clinical symptom scores over 14 days. The safety of 5-ALA/SFC in this study was acceptable. Further evaluation using a larger sample size or modified method is warranted.

A multicenter, double-blind, randomized, parallel-group, placebo-controlled study to evaluate the efficacy and safety of camostat mesilate in patients with COVID-19 (CANDLE study)

BACKGROUND

In vitro drug screening studies have indicated that camostat mesilate (FOY-305) may prevent SARS-CoV-2 infection into human airway epithelial cells. This study was conducted to investigate whether camostat mesilate is an effective treatment for SARS-CoV-2 infection (COVID-19).

METHODS

This was a multicenter, double-blind, randomized, parallel-group, placebo-controlled study. Patients were enrolled if they were admitted to a hospital within 5 days of onset of COVID-19 symptoms or within 5 days of a positive test for asymptomatic patients. Severe cases (e.g., those requiring oxygenation/ventilation) were excluded. Patients were enrolled, randomized, and allocated to each group using an interactive web response system. Randomization was performed using a minimization method with the factors medical institution, age, and underlying diseases (chronic respiratory disease, chronic kidney disease, diabetes mellitus, hypertension, cardiovascular diseases, and obesity). The patients, investigators/subinvestigators, study coordinators, and other study personnel were blinded throughout the study. Patients were administered camostat mesilate (600 mg qid; four to eight times higher than the clinical doses in Japan) or placebo for up to 14 days. The primary efficacy endpoint was the time to the first two consecutive negative tests for SARS-CoV-2.

RESULTS

One-hundred fifty-five patients were randomized to receive camostat mesilate (n = 78) or placebo (n = 77). The median time to the first test was 11.0 days (95% confidence interval [CI]: 9.0-12.0) in the camostat mesilate group and 11.0 days (95% CI: 10.0-13.0) in the placebo group. Conversion to negative viral status by day 14 was observed in 45 of 74 patients (60.8%) in the camostat mesilate group and 47 of 74 patients (63.5%) in the placebo group. The primary (Bayesian) and secondary (frequentist) analyses found no significant differences in the primary endpoint between the two groups. No additional safety concerns beyond those already known for camostat mesilate were identified.

CONCLUSIONS

Camostat mesilate did not substantially reduce the time to viral clearance, based on upper airway viral loads, compared with placebo for treating patients with mild to moderate SARS-CoV-2 infection with or without symptoms.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04657497. Japan Registry for Clinical Trials, jRCT2031200198.

Combined detection of lymphocyte clonality and MALT1 translocations in bronchoalveolar lavage fluid for diagnosing pulmonary lymphomas

Diagnosis of pulmonary lymphoma using small tissue samples is difficult and often requires surgical procedures; thus, a less invasive sampling method is desirable. We previously showed that pulmonary mucosa-associated lymphoid tissue (MALT) lymphoma can be diagnosed by detecting MALT lymphoma translocation gene 1 (MALT1) translocations in bronchoalveolar lavage fluid (BALF) cells. Analysis of B-cell clonality based on immunoglobulin heavy chain (IGH) gene rearrangements was also reportedly useful for diagnosing pulmonary lymphoma. The aim of this prospective multicenter study was to evaluate the yet unknown diagnostic potential of combined detection of MALT1 translocations and clonality using BALF. We analyzed B- and T-cell clonality based on IGH and T-cell receptor (TCR) rearrangements together with MALT1 translocations using BALF of patients with clinically suspected pulmonary lymphomas. In total, 39 patients were evaluated and categorized into three groups: B-cell lymphoma, lymphoproliferative disorders, and other diseases. IGH rearrangement detection for B-cell lymphoma diagnosis exhibited sensitivity and specificity of 88.9% and 90.0%, respectively. TCR rearrangements were not observed in patients with B-cell lymphomas. The presence of IGH rearrangements together with the absence of TCR rearrangements indicated 96.0% specificity for the diagnosis of B-cell lymphoma. The sensitivity and specificity of MALT1 translocations for diagnosing MALT lymphoma were 28.6% and 100%, respectively. The combined detection of lymphocyte clonality and MALT1 translocations using BALF is suitable for screening and diagnosis of B-cell lymphomas. Analysis of specific genes such as MALT1 should improve the precision of B-cell lymphoma diagnosis.

Nationwide surveillance of bacterial respiratory pathogens conducted by the surveillance committee of Japanese Society of Chemotherapy, the Japanese Association for Infectious Diseases, and the Japanese Society for clinical microbiology in 2014: General view of the pathogens' antibacterial susceptibility

The nationwide surveillance on antimicrobial susceptibility of bacterial respiratory pathogens from the patients in Japan was conducted by Japanese Society of Chemotherapy, the Japanese Association for Infectious Diseases, and the Japanese Society for Clinical Microbiology in 2014. The isolates were collected from clinical specimens obtained from well-diagnosed adult patients with respiratory tract infections during the period between January 2014 and April 2015 by three societies. Antimicrobial susceptibility testing was conducted at the central reference laboratory according to the method recommended by Clinical Laboratory Standards Institute. Susceptibility testing was evaluated in 1534 strains (335 Staphylococcus aureus, 264 Streptococcus pneumoniae, 29 Streptococcus pyogenes, 281 Haemophilus influenzae, 164 Moraxella catarrhalis, 207 Klebsiella pneumoniae, and 254 Pseudomonas aeruginosa). Ratio of methicillin-resistant S. aureus was 43.6%, and those of penicillin-susceptible S. pneumoniae was 100%. Among H. influenzae, 8.2% of them were found to be β-lactamase-producing ampicillin-resistant strains, and 49.1% to be β-lactamase-non-producing ampicillin-resistant strains. Extended spectrum β-lactamase-producing K. pneumoniae and multi-drug resistant P. aeruginosa with metallo β-lactamase were 9.2% and 0.4%, respectively.

Evaluation of Bioequivalence Between the New Procaterol Hydrochloride Hydrate Dry Powder Inhaler and the Approved Dry Powder Inhaler in Patients With Asthma in a Randomized, Double-Blind, Double-Dummy, Crossover Comparison Study: A Phase 3 Study

Procaterol hydrochloride hydrate (procaterol) is a β₂‐adrenergic receptor agonist that induces a strong bronchodilatory effect. The procaterol dry powder inhaler (DPI) has been frequently used in patients with bronchial asthma or chronic obstructive pulmonary disease. We evaluated the bioequivalence and safety between the new procaterol DPI (new DPI) and the approved procaterol DPI (approved DPI). This study was a randomized, double‐blind, double‐dummy, crossover comparison to evaluate the pharmacodynamic equivalence of the new DPI and the approved DPI in patients with bronchial asthma. Primary efficacy variables were area under the concentration‐time curve (AUC) forced expiratory volume in the first second (FEV₁)/h and maximum FEV₁ during the 480‐minute measurement period. Patients were divided into 2 groups, New‐DPI‐First (n = 8) and Approved‐DPI‐First (n = 8), according to the investigational medical product that was administered first. Patients inhaled 20 μg of procaterol in each period. FEV₁ was measured by a spirometer at predose and at 15, 30, 60, 90, 120, 180, 240, 360, and 480 minutes after each investigational medical product administration. Equivalence was evaluated by confirming that the 2‐sided 90%CIs for the difference between the new and the approved DPI in means of AUC (FEV₁)/h and maximum FEV₁ were within the acceptance criteria of –0.15 to 0.15 L. The difference in means of AUC (FEV₁)/h and maximum FEV₁ was 0.041 L and 0.033 L, respectively, and the 90%CI was 0.004 to 0.078 L and –0.008 to 0.074 L, respectively. These CIs were both within the acceptance criteria. The new DPI was assessed as being bioequivalent to the approved DPI.

Nationwide surveillance of bacterial respiratory pathogens conducted by the surveillance committee of Japanese Society of Chemotherapy, the Japanese Association for Infectious Diseases, and the Japanese Society for Clinical Microbiology in 2012: General view of the pathogens' antibacterial susceptibility

The nationwide surveillance on antimicrobial susceptibility of bacterial respiratory pathogens from the patients in Japan was conducted by Japanese Society of Chemotherapy, Japanese association for infectious diseases and Japanese society for Clinical Microbiology in 2012. The isolates were collected from clinical specimens obtained from well-diagnosed adult patients with respiratory tract infections during the period between January and December in 2012 by three societies. Antimicrobial susceptibility testing was conducted at the central reference laboratory according to the method recommended by Clinical Laboratory Standard Institutes. Susceptibility testing was evaluated in 1236 strains (232 Staphylococcus aureus, 225 Streptococcus pneumoniae, 16 Streptococcus pyogenes, 231 Haemophilus influenzae, 147 Moraxella catarrhalis, 167 Klebsiella pneumoniae and 218 Pseudomonas aeruginosa). Ratio of methicillin-resistant S. aureus was 51.3%, and those of penicillin-intermediate S. pneumoniae was 0.4%. Among H. influenzae, 5.6% of them were found to be β-lactamase-producing ampicillin-resistant strains, and 37.2% to be β-lactamase-non-producing ampicillin-resistant strains. Extended spectrum β-lactamase-producing K. pneumoniae and multi-drug resistant P. aeruginosa with metallo β-lactamase were 4.2% and 3.2%, respectively. Continuous national surveillance is important to determine the actual situation of the resistance shown by bacterial respiratory pathogens to antimicrobial agents.

Nationwide surveillance of the antimicrobial susceptibility of Chlamydia trachomatis from male urethritis in Japan

Genital chlamydial infection is a principal sexually transmitted infection worldwide. Chlamydia trachomatis can cause male urethritis, acute epididymitis, cervicitis, and pelvic inflammatory disease as sexually transmitted infections. Fortunately, homotypic resistant C. trachomatis strains have not been isolated to date; however, several studies have reported the isolation of heterotypic resistant strains from patients. In this surveillance study, clinical urethral discharge specimens were collected from patients with urethritis in 51 hospitals and clinics in 2009 and 38 in 2012. Based on serial cultures, the minimum inhibitory concentration (MIC) could be determined for 19 isolates in 2009 and 39 in 2012. In 2009 and 2012, the MICs (MIC90) of ciprofloxacin, levofloxacin, tosufloxacin, sitafloxacin, doxycycline, minocycline, erythromycin, clarithromycin, and azithromycin were 2 μg/ml and 1 μg/ml, 0.5 μg/ml and 0.5 μg/ml, 0.125 μg/ml and 0.125 μg/ml, 0.063 μg/ml and 0.063 μg/ml, 0.125 μg/ml and 0.125 μg/ml, 0.125 μg/ml and 0.125 μg/ml, 0.016 μg/ml and 0.016 μg/ml, and 0.063 μg/ml and 0.063 μg/ml, respectively. In summary, this surveillance project did not identify any resistant strain against fluoroquinolone, tetracycline, or macrolide agents in Japan.

Angiopoietin-2 expression in patients with an acute exacerbation of idiopathic interstitial pneumonias

BACKGROUND AND OBJECTIVE

We hypothesized that increased pulmonary vascular permeability may play a role in the pathogenesis of an acute exacerbation of the idiopathic interstitial pneumonias (AE-IIPs). Angiopoietin-2 (Ang-2) promotes endothelial activation, destabilization, and inflammation. The purpose of this study was to examine whether Ang-2 expression was associated with the pathogenesis of AE-IIPs.

METHODS

Twenty-three patients with AE-IIP patients, 18 acute lung injury/acute respiratory distress syndrome (ALI/ARDS) patients, 37 idiopathic pulmonary fibrosis (IPF) patients, and 33 healthy volunteers (HVs) were enrolled. The serum level of Ang-2 was measured by an enzyme-linked immunosorbent assay.

RESULTS

The serum levels of Ang-2 were higher in AE-IIPs and ALI/ARDS patients than in IPF patients and HVs; the BALF levels of Ang-2 were also higher than in IPF patients. There was a positive correlation between the serum level of Ang-2 and the CRP in patients with AE-IIP patients, whereas a significant positive correlation was found between the serum Ang-2 level and the CRP or SOFA scores of the ALI/ARDS patients. Although the baseline Ang-2 level was not related to survival, the Ang-2 levels significantly declined in survivors during treatment, while they did not change in non-survivors.

CONCLUSIONS

Increased pulmonary vascular permeability and inflammation due to Ang-2 may play a role in the pathogenesis of AE-IIPs.

The second nationwide surveillance of the antimicrobial susceptibility of Neisseria gonorrhoeae from male urethritis in Japan, 2012-2013

Worldwide, the most important concern in the treatment of sexually transmitted infections is the increase in antimicrobial resistant Neisseria gonorrhoeae strains including resistance to cephalosporins, penicillins, fluoroquinolones or macrolides. To investigate the trends of antimicrobial susceptibility among N. gonorrhoeae strains isolated from male patients with urethritis, a Japanese surveillance committee conducted the second nationwide surveillance study. Urethral discharge was collected from male patients with urethritis at 26 medical facilities from March 2012 to January 2013. Of the 151 specimens, 103 N. gonorrhoeae strains were tested for susceptibility to 20 antimicrobial agents. None of the strains was resistant to ceftriaxone, but the minimum inhibitory concentration (MIC) 90% of ceftriaxone increased to 0.125 μg/ml, and 11 (10.7%) strains were considered less susceptible with an MIC of 0.125 μg/ml. There were 11 strains resistant to cefixime, and the MICs of these strains were 0.5 μg/ml. The distributions of the MICs of fluoroquinolones, such as ciprofloxacin, levofloxacin and tosufloxacin, were bimodal. Sitafloxacin, a fluoroquinolone, showed strong activity against all strains, including strains resistant to other three fluoroquinolones, such as ciprofloxacin, levofloxacin and tosufloxacin. The azithromycin MICs in 2 strains were 1 μg/ml.

Severe obstructive sleep apnoea is independently associated with pulmonary artery dilatation

BACKGROUND AND OBJECTIVE

We hypothesised that obstructive sleep apnoea (OSA) may cause pulmonary artery dilatation through excessively negative intrathoracic pressure generated during inspiratory efforts against the upper airway collapse during obstructive apnoeas. To test this hypothesis, we examined the association between OSA severity and pulmonary artery dilatation.

METHODS

A total of 173 patients who were clinically suspected of having OSA underwent chest radiography and polysomnography. We measured the right descending pulmonary artery diametre (RDPAD) on the chest radiogram and defined an abnormal increase in the RDPAD as RDPAD > 16 mm in males and RDPAD > 15 mm in females.

RESULTS

An abnormal increase in the RDPAD was more prevalent in patients with severe OSA (46.3%) compared to those with no or mild OSA (14.5%) and those with moderate OSA (21.6%). A univariate logistic regression analysis showed that severe OSA was associated with an abnormal increase in the RDPAD (odds ratio 3.94, 95% confidence interval 1.98-7.87). After controlling for age, gender, body mass index, smoking history and partial pressure of arterial oxygen, severe OSA still remained significantly associated with an abnormal increase in the RDPAD (odds ratio 4.06, 95% confidence interval 1.82-9.07).

CONCLUSIONS

Severe OSA is independently associated with an abnormal increase in the RDPAD, suggesting that severe OSA may cause pulmonary artery dilatation.

Antibiotic susceptibility survey of blood-borne MRSA isolates in Japan from 2008 through 2011

We conducted an antibiotic susceptibility survey of 830 blood-borne methicillin resistant Staphylococcus aureus collected from nationwide hospitals in Japan over a three-year period from January 2008 through May 2011. Antibiotic susceptibility was judged according to the criteria recommended by the Clinical Laboratory Standard Institute. Over 99% of the MRSA showed to be susceptible to teicoplanin, linezolid, sulfamethoxazole/trimethoprim and vancomycin, and over 97% of them were susceptible to daptomycin, arbekacin and rifampin. The majority of the MRSA strains showed resistant to minocycline, meropenem, imipenem, clindamycin, ciprofloxacin, cefoxitin, and oxacillin in the rates of 56.6, 72.9, 73.7, 78.7, 89.0, 99.5, and 99.9%, respectively. Among the MRSA strains, 72 showed reduced susceptibility to vancomycin, including 8 strains (0.96%) of vancomycin-intermediate S. aureus (VISA), 54 (6.51%) of heterogeneous vancomycin-intermediate S. aureus (hVISA), and 55 (5.63%) of β-lactam antibiotics-induced vancomycin resistant S. aureus (BIVR). Unexpectedly, among the 54 hVISA and 55 BIVR, 45 isolates (83.3% and 81.8%, respectively) showed both hVISA and BIVR phenotypes. A new trend of vancomycin resistance found in this study was that VISA strains were still prevalent among the bacteremic specimens. The high rates of the hVISA/BIVR two-phenotypic vancomycin resistance, and the prevalence of VISA in the bloodborne MRSA call attention in the MRSA epidemiology in Japan.

Diagnosis of Measles Pneumonia from Bronchoalveolar Lavage Fluid by Reverse-Transcriptase Polymerase Chain Reaction: Case Report

A 24-year-old male contracted measles during treatment with prednisolone for bronchial asthma and eosinophilic pneumonia. Five days after the appearance of skin eruptions, infiltration shadows were detected in the hilum of the left lung on a chest X-ray and a chest computed tomography revealed diffuse macular and infiltration shadows in both lungs and in the left S6 segment, respectively. Pneumonia complicating measles may be caused by either the measles virus itself or by a secondary bacterial infection. Since this patient had been treated with prednisolone, pneumonia caused by a pathogen other than bacteria, or recurrence of eosinophilic pneumonia were suspected, and bronchoalveolar lavage was performed. Culture of the bronchoalveolar lavage fluid (BALF) was negative for bacteria, acid-fast bacilli, and mycetes, and polymerase chain reaction (PCR) analysis did not detect cytomegalovirus, but reverse transcriptase PCR did detect the measles virus. There were increased lymphocytes in the BALF with a significantly reduced CD4/CD8 ratio. Histological findings revealed alveolitis. Based on conventional diagnostic criteria, pneumonia due to the measles virus was confirmed. Since the criteria of pneumonia due to measles virus includes histological, serological and bacteriological studies which require an extended period of time, RT-PCR using BALF may be useful for the rapid diagnosis of measles pneumonia.

Association between obstructive sleep apnea and premature supraventricular contractions

OBJECTIVE

The exact association between obstructive sleep apnea (OSA) and premature supraventricular contractions (PSVCs) has not been established.

METHODS

We prospectively performed polysomnography together with 24-hour Holter electrocardiography in 431 patients who were clinically suspected of having OSA and examined the association between OSA severity and PSVCs during wakefulness and sleep. The patients were classified into 4 groups according to the apnea-hypopnea index (AHI) quartiles (Q1=patients with AHI<13.8, Q2=those with 13.8≤AHI<28.8, Q3=those with 28.8≤AHI<48.1, Q4=those with AHI≥48.1).

RESULTS

The number of PSVCs/hour during sleep differed significantly among the 4 groups, but the number of PSVCs/hour during wakefulness did not. The prevalence of PSVC≥5/hour during sleep was significantly higher in Q4 (21.0%) than the other 3 groups (Q1, 9.0%; Q2, 8.0%; Q3, 6.0%; all p<0.05 for Q4), but the prevalence of PSVC≥5/hour during wakefulness did not differ among the 4 groups. A multivariate logistic regression analysis showed that the highest AHI quartile was significantly associated with PSVC≥5/hour during sleep (odds ratio 3.04, 95% confidence interval 1.44-6.42, p=0.004).

CONCLUSIONS

Severe OSA can cause PSVCs during sleep, but its effect appears not to be strong. Further studies are needed to clarify the clinical significance of this small but significant increase in PSVCs during sleep in severe OSA patients.

[Two cases of refractory asthma presenting chest pain, which were successfully treated with noninvasive positive pressure ventilation]

We report here two cases of refractory asthma presenting chest pain, which were successfully treated by using intermittent noninvasive positive pressure ventilation (NPPV). Both patients were women, and were diagnosed to have bronchial asthma with the reversibility of airway contraction after administration of a bronchodilator. Although both patients were treated with several medicines for "treatment step 4" based on the guideline in Japan, their asthma could not be controlled well and their symptoms including the chest pain eroded their quality of life. We tried to use NPPV for 30 minutes in our clinic, and their symptoms improved. Therefore, we innovated for them intermittent NPPV as a home treatment. After 3 to 5 months, their asthma, including the symptom of chest pain, improved. In addition, pulmonary function tests revealed stable vital capacity and forced expiratory volume in 1 second in all cases after the NPPV therapy, while V50 and V25 were improved. These results suggest that NPPV may be a useful treatment option for patients with refractory asthma, especially those presenting chest pain.

Gender differences in symptoms during 60-second balloon occlusion of the coronary artery

Previous investigations have demonstrated the presence of gender differences in the symptoms of angina pectoris and acute coronary syndrome. However, most of these investigations have had certain limitations, including being retrospective, an interview-related bias, a various duration of myocardial ischemia, and a lack of multivariate analysis, all of which would have affected the results. Accordingly, we prospectively examined the presence or absence of chest pain and non-chest pain symptoms during a 60-second balloon inflation in the setting of percutaneous coronary intervention, which provides a unique model of transient myocardial ischemia, in 110 men and 80 women with coronary artery disease. Chest pain and/or non-chest pain symptoms (occipital pain, jaw pain, neck/throat pain, shoulder pain, upper arm pain, back pain, and nausea) were observed during the balloon inflation in 72 men and 52 women. In the 124 patients with any symptoms during the balloon inflation, non-chest pain symptoms were more common in women than in men (31% vs 14%, p = 0.02); however, the incidence of chest pain did not differ between the men and women. After adjustment for covariables, including age, body mass index, hypertension, diabetes mellitus, current smoking, previous myocardial infarction, target vessels, β-blocker use, and calcium antagonist use, female gender remained significantly associated with non-chest pain symptoms (odds ratio 3.3, 95% confidence interval 1.2 to 9.9, p = 0.02). In conclusion, non-chest pain symptoms during the 60-second balloon occlusion of the coronary artery were more common in women than in men, supporting the presence of the gender difference in myocardial ischemic symptoms.

Prevalence of gastroduodenal ulcers/erosions in patients taking low-dose aspirin with either 15 mg/day of lansoprazole or 40 mg/day of famotidine: the OITA-GF study 2

Background

The preventive effects of histamine 2 receptor antagonists vs. proton pump inhibitors on low-dose aspirin (LDA)-related gastroduodenal mucosal injury have not been fully investigated. We conducted a cross-sectional study to compare the prevalence of gastroduodenal ulcers or erosions in patients taking LDA with either 40 mg/day of famotidine or 15 mg/day of lansoprazole for at least three months.

Methods

Of 84 eligible patients, two taking 40 mg/day of famotidine and four taking 15 mg/day of lansoprazole refused to undergo upper gastrointestinal endoscopy. Ultimately, we performed upper gastrointestinal endoscopy in 78 patients taking either 40 mg/day of famotidine (group F, n = 31) or 15 mg/day of lansoprazole (group L, n = 47). The prevalence of gastroduodenal ulcers or erosions and the magnitude of gastric mucosal injury evaluated using modified Lanza scores were compared between the two groups.

Results

No patients in either group had gastroduodenal ulcers. Gastroduodenal erosions were more prevalent in group F than in group L (48.4% vs. 17.0%, p = 0.005). The modified Lanza scores (mean ± SD) were significantly higher in group F than in group L (0.9 ± 1.3 vs. 0.3 ± 0.7, p = 0.007). A multivariate logistic regression analysis showed that the use of lansoprazole was negatively associated with gastroduodenal erosions.

Conclusions

This study suggests that 15 mg/day of lansoprazole may be more effective in preventing the development of LDA-related gastroduodenal erosions than 40 mg/day of famotidine. The preventive effects of these two regimens on the development of LDA-related gastroduodenal ulcers require further investigation.

Thin-section CT findings in Pseudomonas aeruginosa pulmonary infection

OBJECTIVE

The aim of this study was to assess clinical and pulmonary thin-section CT findings in patients with acute Pseudomonas aeruginosa (PA) pulmonary infection.

METHODS

We retrospectively identified 44 patients with acute PA pneumonia who had undergone chest thin-section CT examinations between January 2004 and December 2010. We excluded nine patients with concurrent infections. The final study group comprised 35 patients (21 males, 14 females; age range 30-89 years, mean age 66.9 years) with PA pneumonia. The patients' clinical findings were assessed. Parenchymal abnormalities, enlarged lymph nodes and pleural effusion were evaluated on thin-section CT.

RESULTS

Underlying diseases included malignancy (n=13), a smoking habit (n=11) and cardiac disease (n=8). CT scans of all patients revealed abnormal findings, including ground-glass opacity (n=34), bronchial wall thickening (n=31), consolidation (n=23) and cavities (n=5). Pleural effusion was found in 15 patients.

CONCLUSION

PA pulmonary infection was observed in patients with underlying diseases such as malignancy or a smoking habit. The CT findings in patients with PA consisted mainly of ground-glass attenuation and bronchial wall thickening.

ADVANCES IN KNOWLEDGE

The CT findings consisted mainly of ground-glass attenuation, bronchial wall thickening and cavities. These findings in patients with an underlying disease such as malignancy or a smoking habit may be suggestive of pneumonia caused by PA infection.

Obstructive sleep apnea increases hemoglobin A1c levels regardless of glucose tolerance status

OBJECTIVE

We sought to clarify the association between the severity of obstructive sleep apnea (OSA) and hemoglobin A1c (HbA1c) levels.

METHODS

HbA1c levels were measured in 330 subjects who were suspected of having OSA and who underwent polysomnography. A 75-g oral glucose tolerance test was performed in 308 subjects who had not been diagnosed to have diabetes mellitus. Patients with use of hypoglycemic agents were excluded. The 330 subjects were divided into three subgroups: 164 with normal glucose tolerance, 111 with impaired glucose tolerance, and 55 with diabetes mellitus (DM).

RESULTS

Univariate regression analyses showed that natural logarithm(Ln)age, Lnbody mass index, hypertension, DM, Lnapnea-hypopnea index, Lnarousal index, and Lnlowest arterial oxyhemoglobin saturation (L-SpO(2)) were associated with LnHbA1c. A multiple regression analysis showed that Lnage (β=0.16, P=0.003), DM (β=0.39, P<0.001), and Ln L-SpO(2) (β=-0.29, P<0.001) were associated with LnHbA1c. Subgroup analyses showed that Ln L-SpO(2) was independently associated with LnHbA1c in each subgroup.

CONCLUSIONS

L-SpO(2) was independently associated with HbA1c regardless of the glucose tolerance status. This suggests that OSA-induced hypoxia could increase an individual's average blood glucose level.

Inhibitory effect of statins on inflammatory cytokine production from human bronchial epithelial cells

Statins are 3-hydroxy-3-methylglutaryl-co-enzyme A reductase inhibitors of cholesterol biosynthesis, and have been reported to exert pleiotropic effects on cellular signalling and cellular functions involved in inflammation. Recent reports have demonstrated that previous statin therapy reduced the risk of pneumonia or increased survival in patients with community-acquired pneumonia. However, the precise mechanisms responsible for these effects are unclear. In the present study, we examined the effects of statins on cytokine production from lipopolysaccharide (LPS)-stimulated human bronchial epithelial cells (BEAS-2B). Interleukin (IL)-6 and IL-8 mRNA expression and protein secretion in LPS-stimulated cells were inhibited significantly by the lipophilic statin pitavastatin and the hydrophilic statin pravastatin. As these inhibitory effects of statin were negated by adding mevalonate, the anti-inflammatory effects of statins appear to be exerted via the mevalonic cascade. In addition, the activation levels of Ras homologue gene family A (RhoA) in BEAS-2B cells cultured with pitavastatin were significantly lower than those without the statin. These results suggest that statins have anti-inflammatory effects by reducing cytokine production through inhibition of the mevalonic cascade followed by RhoA activation in the lung.

Association between the severity of obstructive sleep apnea and the ratio of low-density lipoprotein cholesterol to high-density lipoprotein cholesterol

The positive association between the ratio of serum low-density lipoprotein cholesterol (LDL-C) to serum high-density lipoprotein cholesterol (HDL-C) and cardiovascular events has recently been receiving much attention. However, the association between the severity of obstructive sleep apnea (OSA) and this ratio has not yet been investigated. Accordingly, we sought to clarify this association and the effect of continuous positive airway pressure (CPAP) therapy on the ratio. We performed polysomnography and LDL-C/HDL-C measurements in 215 patients who were suspected of having OSA. Furthermore, LDL-C/HDL-C was again evaluated 6 months after polysomnography in 30 OSA patients for whom CPAP therapy was initiated and continued, and in 11 age- and sex-matched OSA patients for whom the therapy could not be initiated. The LDL-C/HDL-C correlated positively with apnea-hypopnea index (ρ = 0.28, P < .001) and negatively with the lowest arterial oxyhemoglobin saturation (ρ = -0.30, P < .001). Multivariate regression analysis revealed that ln apnea-hypopnea index (or ln lowest arterial oxyhemoglobin saturation) was independently associated with LDL-C/HDL-C. The LDL-C/HDL-C decreased after 6 months in the CPAP group (2.29 ± 0.67 to 2.11 ± 0.74, P = .02), whereas it did not change in the non-CPAP group (2.65 ± 0.82 to 2.62 ± 0.66, P = .81). The severity of OSA was independently associated with LDL-C/HDL-C, and LDL-C/HDL-C was significantly reduced at 6 months after CPAP therapy. These findings suggest that LDL-C/HDL-C increases in proportion to the severity of OSA, which may contribute partly to an increased risk for cardiovascular events in OSA patients.

Upright T waves in lead aVR are associated with cardiac death or hospitalization for heart failure in patients with a prior myocardial infarction

The aim of the present study was to clarify the prognostic significance of upright T waves (amplitude > 0 mV) in lead aVR in patients with a prior myocardial infarction (MI). We retrospectively examined 167 patients with a prior MI. The primary end point was cardiac death or hospitalization for heart failure. During a follow-up period of 6.5 ± 2.8 years, 34 patients developed the primary end point. A Kaplan-Meier analysis showed a lower primary event-free rate in patients with upright T waves in lead aVR than in those with nonupright T waves in lead aVR (P = 0.001). Univariate Cox proportional hazards regression analyses showed that age, gender, chronic kidney disease, anterior wall MI, upright T waves in lead aVR, left ventricular ejection fraction, loop diuretic use, and spironolactone use were significantly associated with the primary end point. A multivariate Cox proportional hazards regression analysis selected age [hazard ratio (HR) 1.10, 95% confidence interval (CI) 1.05-1.16, P < 0.001], upright T waves in lead aVR (HR 3.10, 95% CI 1.23-7.82, P = 0.017), and loop diuretic use (HR 4.61, 95% CI 1.55-13.67, P = 0.006) as independent predictors of the primary end point. In conclusion, the presence of upright T waves in lead aVR is an independent predictor of cardiac death or hospitalization for heart failure in patients with a prior MI. The analysis of T-wave amplitude in lead aVR provides useful prognostic information in patients with a prior MI.

ST-segment deviation in lead aVR on admission is not associated with left ventricular function at predischarge in first anterior wall ST-segment elevation acute myocardial infarction

Previous studies have shown that the analysis of ST-segment deviation in lead aVR on admission provides useful information on angiographic coronary anatomy and risk stratification in acute coronary syndromes. However, the association between ST-segment deviation in lead aVR on admission and left ventricular (LV) function has not been fully investigated in anterior wall acute ST-segment elevation myocardial infarction. In this study, 237 patients with first anterior wall acute ST-segment elevation myocardial infarction were examined. The patients were divided into the following 3 groups according to ST-segment deviation in lead aVR on admission: 85 with ST-segment elevation ≥0.5 mm (group A), 106 without ST-segment deviation (group B), and 46 with ST-segment depression ≥0.5 mm (group C). LV ejection fractions at predischarge were compared among the 3 groups. Among the 3 groups, there were significant differences in the prevalences of proximal left anterior descending coronary artery (LAD) occlusion (group A 75.3%, group B 56.6%, group C 45.7%, p = 0.002), long LAD (group A 27.1%, group B 31.1%, group C 56.5%, p = 0.002), and good collaterals to the LAD (group A 40.0%, group B 25.4%, group C 17.4%, p = 0.01). LV ejection fractions at predischarge did not differ among the 3 groups (group A 56.4 ± 12.5%, group B 56.9 ± 12.7%, group C 53.3 ± 12.2%, p = 0.26). On a multiple regression analysis, establishment of Thrombolysis In Myocardial Infarction grade 3 flow, proximal LAD occlusion, and long LAD were associated with the LV ejection fraction at predischarge. In conclusion, ST-segment deviation in lead aVR on admission is not associated with LV function at predischarge in first anterior wall acute ST-segment elevation myocardial infarction.

A new electrocardiographic criterion to differentiate between Takotsubo cardiomyopathy and anterior wall ST-segment elevation acute myocardial infarction

Several studies have examined the ability of electrocardiography to differentiate between takotsubo cardiomyopathy (TC) and anterior wall acute ST-segment elevation myocardial infarction (AA-STEMI). In those studies, the magnitude of ST-segment elevation was not measured at the J point. The American Heart Association, American College of Cardiology Foundation, and Heart Rhythm Society guidelines recommend that the magnitude of ST-segment elevation should be measured at the J point. Accordingly, the aim of this study was to retrospectively examine whether electrocardiography, using the magnitude of ST-segment elevation measured at the J point, could differentiate 62 patients with TC from 280 with AA-STEMI. Patients with AA-STEMI were divided into following subgroups: 140 with left anterior descending coronary artery occlusions proximal to the first diagonal branch (AA-STEMI-P), 120 with left anterior descending occlusions distal to the first diagonal branch and proximal to the second diagonal branch (AA-STEMI-M), and 20 with left anterior descending occlusions distal to the second diagonal branch (AA-STEMI-D). TC had a much lower prevalence of ST-segment elevation ≥1 mm in lead V(1) (19.4%) compared to AA-STEMI (80.4%, p <0.01), AA-STEMI-P (80.7%, p <0.01), AA-STEMI-M (80%, p <0.01), and AA-STEMI-D (80%, p <0.01). ST-segment elevation ≥1 mm in ≥1 of leads V(3) to V(5) without ST-segment elevation ≥1 mm in lead V(1) identified TC with sensitivity of 74.2% and specificity of 80.6%. Furthermore, this criterion could differentiate TC from each AA-STEMI subgroup, with similar diagnostic values. In conclusion, using the magnitude of ST-segment elevation measured at the J point, a new electrocardiographic criterion is proposed with an acceptable ability to differentiate TC from AA-STEMI.

Associations of positive T wave in lead aVR with hemodynamic, coronary, and left ventricular angiographic findings in anterior wall old myocardial infarction

BACKGROUND

No information is available on the clinical significance of a positive T wave in lead aVR in myocardial infarction (MI). Accordingly, in the present study, we sought to clarify the associations of the positive T wave in lead aVR with hemodynamic, coronary angiographic, and left ventriculographic findings in anterior wall old MI.

METHODS

We examined 122 patients with anterior wall old MI who underwent diagnostic or follow-up cardiac catheterization including coronary angiography and left ventriculography. The patients were classified into the following 2 groups: patients with a positive (≥ 1mm) T wave in lead aVR (n=20, group A) and those without (n=102, group B).

RESULTS

Group A had higher pulmonary arterial, pulmonary capillary wedge, and left ventricular (LV) end-diastolic pressures and a lower cardiac index than group B. The prevalence of a long left anterior descending coronary artery (LAD) was higher in group A than in group B (60% vs 30.4%, p=0.01), and none of group A patients had an LAD that did not reach the apex. Group A had a lower LV ejection fraction than group B (36.4 ± 11.6% vs 48.4 ± 12.7%, p<0.001).

CONCLUSIONS

The positive T wave in lead aVR is related to severely reduced cardiac function, with an LAD wrapping the apex, in anterior wall old MI. Further studies are needed to clarify whether the positive T wave in lead aVR is associated with an adverse outcome in patients with anterior wall old MI.

A case of pneumonitis and encephalitis associated with human herpesvirus 6 (HHV-6) infection after bone marrow transplantation

Human herpesvirus 6 (HHV-6)-associated encephalitis or pneumonitis has been reported in immunocompetent and immunosuppressed individuals. Several MRI studies in patients with HHV-6-associated encephalitis have been presented. However, to the best of our knowledge, no studies describing thin-section CT imaging in patients with HHV-6-associated pneumonitis have been reported. Here we describe a case of HHV-6-associated encephalitis and pneumonitis that developed after bone marrow transplantation. Thin-section CT images of the chest revealed ground-glass attenuation, consolidation and centrilobular nodules in both lungs.

Prevalence and independent factors for gastroduodenal ulcers/erosions in asymptomatic patients taking low-dose aspirin and gastroprotective agents: the OITA-GF study

BACKGROUND

Although it is well known that aspirin causes gastroduodenal mucosal injury and that aspirin-induced gastroduodenal mucosal injury is often asymptomatic, the prevalence and independent factors for gastroduodenal mucosal injury have not been clarified in asymptomatic patients taking low-dose aspirin and gastroprotective agents.

AIM

To clarify the prevalence and independent factors for gastroduodenal ulcers/erosions in asymptomatic patients taking low-dose aspirin and gastroprotective agents.

DESIGN

Prospective observational study.

METHODS

We performed endoscopy in 150 asymptomatic patients taking low-dose aspirin and gastroprotective agents for at least 3 months.

RESULTS

Gastroduodenal ulcers/erosions were observed in 37.3% [ulcers (4.0%); erosions (34.0%)]. Univariate logistic regression analyses showed that proton-pump inhibitor (PPI) use was negatively associated with gastroduodenal ulcers/erosions [odds ratio (OR) 0.35, 95% confidence interval (95% CI) 0.17-0.75, P=0.007]. A multivariate logistic regression analysis selected PPI use as the only independent factor for gastroduodenal ulcers/erosions (OR 0.35, 95% CI 0.14-0.86, P=0.02). None of the 53 patients with PPI use had any gastroduodenal ulcers, and 11 with standard-dose PPI use tended to have a lower prevalence of gastroduodenal erosions than 42 with low-dose PPI use (0% vs. 28.6%, P=0.052).

CONCLUSION

Gastroduodenal ulcers/erosions were observed in about one-third of asymptomatic patients taking low-dose aspirin and gastroprotective agents, and PPI use was a negative independent factor for gastroduodenal ulcers/erosions in those patients. In addition, standard-dose PPI therapy might be more effective in the prevention of aspirin-induced gastroduodenal mucosal injury than low-dose PPI therapy.

Localised right upper-lobe pulmonary oedema caused by extension of giant cell carcinoma to the mitral valve

Giant cell carcinoma of the lung is a very rare primary malignant tumour and localised right upper-lobe pulmonary oedema is also unusual. We report a case of giant cell carcinoma, which invaded the left atrium through the left pulmonary vein and caused localised right upper-lobe pulmonary oedema.

Comparison of pulmonary thin section CT findings and serum KL-6 levels in patients with sarcoidosis

OBJECTIVE

This study aimed to compare thin-section CT images from sarcoidosis patients who had either normal or elevated serum KL-6 levels.

METHODS

101 patients with sarcoidosis who underwent thin-section CT examinations of the chest and serum KL-6 measurements between December 2003 and November 2008 were retrospectively identified. The study group comprised 75 sarcoidosis patients (23 male, 52 female; aged 19-82 years, mean 54.1 years) with normal KL-6 levels (152-499 U ml(-1), mean 305.7 U ml(-1)) and 26 sarcoidosis patients (7 male, 19 female; aged 19-75 years, mean 54.3 years) with elevated KL-6 levels (541-2940 U ml(-1), mean 802.4 U ml(-1)). Two chest radiologists, unaware of KL-6 levels, retrospectively and independently interpreted CT images for parenchymal abnormalities, enlarged lymph nodes and pleural effusion.

RESULTS

CT findings in sarcoidosis patients consisted mainly of lymph node enlargement (70/75 with normal KL-6 levels and 21/26 with elevated KL-6 levels), followed by nodules (50 and 25 with normal and elevated levels, respectively) and bronchial wall thickening (25 and 21 with normal and elevated levels, respectively). Ground-glass opacity, nodules, interlobular septal thickening, traction bronchiectasis, architectural distortion and bronchial wall thickening were significantly more frequent in patients with elevated KL-6 levels than those with normal levels (p<0.001, p<0.005, p<0.001, p<0.001, p<0.001 and p<0.001, respectively). By comparison, there was no significant difference in frequency of lymph node enlargement between the two groups.

CONCLUSION

These results suggest that serum KL-6 levels may be a useful marker for indicating the severity of parenchymal sarcoidosis.