Estimating the Effect of Engagement in Community-Based Going-Out Program on Incidence Disability in Older Adults

OBJECTIVES

Although going out has been reported to be associated with the incidence of disability, few studies have investigated the effect of community-based programs to promote going out on the incidence of disability. This study aimed to estimate the effects of a program fostering going-out on the incidence of disability in community-dwelling older adults.

DESIGN

Longitudinal, observational study.

SETTING AND PARTICIPANTS

Nonengaged (n = 1086) and engaged older adults (n = 1086) enrolled in the National Center for Geriatrics and Gerontology Study of Geriatric Syndrome by using a one-to-one nearest neighbor propensity score-matching scheme.

METHODS

After the baseline assessments, participants in the community-based going-out program received a specialized physical activity tracker, monitored their daily physical activity, and received personalized feedback on going out to community facilities with a system for reading the device for 12 months. Disability onset was defined as a new case of long-term care under the public insurance certification in Japan within 48 months of program completion. The absolute risk reduction and the number needed to treat for the incidence of disability were calculated for the nonengaged and engaged groups. Cox proportional hazard regression analysis, using inverse probability weighting was used to obtain the hazard ratio.

RESULTS

Disabilities occurred in 112 individuals in the matched nonengaged group and 51 individuals in the engaged group. The absolute risk reduction was 5.67% (95% CI 3.46%-7.88%). The number needed to treat was 18 (95% CI 13-29). The hazard ratio, with the nonengaged group as the reference, was 0.49 (95% CI 0.36-0.67).

CONCLUSIONS AND IMPLICATIONS

This longitudinal observational study suggested that a community-based program could prevent 1 disability in every 18 participants. This program does not require a professional instructor, only the distribution of devices and system installation, and it could be beneficial as a population-based approach to preventing disabilities.

Association between COVID-19 emergency declarations and physical activity among community-dwelling older adults enrolled in a physical activity measurement program: Evidence from a retrospective observational study using the regression discontinuity design

BACKGROUND

The current study examines the negative impact of the coronavirus disease 2019 (COVID-19) emergency declarations on physical activity among the community-dwelling older adults, the participants of a physical activity measurement program, in Japan.

METHODS

This retrospective observational study included 1,773 community-dwelling older adults (aged 74.6 ± 6.3 years, 53.9% women) who had participated in the physical activity measurement project from February 2020 to July 2021. We measured physical activity using a tri-axial accelerometer during 547 consecutive days. Three emergency declarations, requesting people to avoid going outside, occurred during the observational period. We multiply-imputed missing values for daily physical activity, such as steps, light physical activity (LPA), and moderate-to-vigorous physical activity (MVPA) for several patterns of datasets according to the maximum missing rates on a person level. We mainly report the results based on less than 50% of the maximum missing rate (n = 1,056). Other results are reported in the supplemental file. Changes in physical activity before and after the start of each emergency declaration were examined by the regression discontinuity design (RDD) within 14-, 28-, and 56-day bandwidths.

RESULTS

For all the participants in the multiply-imputed data with the 14-day bandwidth, steps (coefficients [[Formula: see text]][Formula: see text] 964.3 steps), LPA ([Formula: see text] 5.5 min), and MVPA ([Formula: see text] 4.9 min) increased after the first emergency declaration. However, the effects were attenuated as the RDD bandwidths were widened. No consistent negative impact was observed after the second and third declarations. After the second declaration, steps ([Formula: see text]-609.7 steps), LPA ([Formula: see text]-4.6 min), and MVPA ([Formula: see text]-2.8 min) decreased with the 14-day bandwidth. On the other hand, steps ([Formula: see text] 143.8 steps) and MVPA ([Formula: see text] 1.3 min) increased with the 56-day bandwidth. For the third declaration, LPA consistently decreased with all the bandwidths ([Formula: see text]-2.1, -3.0, -0.8 min for the 14, 28, 56-day bandwidth), whereas steps ([Formula: see text]-529 steps) and MVPA ([Formula: see text]-2.6 min) decreased only with the 28-day bandwidth.

CONCLUSIONS

For the community-dwelling older adults who regularly self-monitor their physical activity, the current study concludes that there is no evidence of consistently negative impacts of the emergency declarations by the COVID-19 pandemic.

Association between daily gait speed patterns and cognitive impairment in community-dwelling older adults

Gait speed over a short distance is associated with cognitive impairment in older adults. Recently, daily gait speed has been assessed using accelerometers. However, because daily gait speed is only weakly correlation with gait speed over a short distance, its association with cognitive impairment needs to be investigated. The present study compared the daily gait speed patterns of normal cognition (NC), mild cognitive impairment (MCI), and general cognitive impairment (GCI) subjects measured every 3 h for two weeks using accelerometers. A total of 1959 participants were classified into the NC (N = 1519), MCI (N = 353), and GCI groups (N = 87). The results showed that the average daily gait speed of the GCI group was significantly lower than that of the NC group (p = 0.03). Furthermore, the average daily gait speeds of the MCI and NC groups were the same. However, the average daily gait speed of the MCI group during a specific time (12-15 o'clock) was significantly lower than that of the NC group (p < 0.01). These results suggest that changes in daily patterns may be detected by measuring daily gait speed, which depends on the degree of cognitive function.

Light intensity physical activity is beneficially associated with brain volume in older adults with high cardiovascular risk

Background

Older people with high cardiovascular risk, including those without cardiovascular diseases, are an at-risk population for dementia. Regular physical activity is generally recommended to maintain brain health; however, the optimal intensity of physical activity for maintaining brain volume in older adults with cardiovascular risk remains unclear. We examined the associations between intensity-specific physical activity and brain volume stratified by absolute cardiovascular risk level in older adults without cardiovascular diseases.

Methods and results

This cross-sectional study involved 725 community-dwelling older Japanese adults without cardiovascular diseases. We estimated absolute cardiovascular risk using the World Health Organization risk estimation charts, which include variables such as age, sex, diabetes mellitus, smoking, systolic blood pressure, and total cholesterol, and stratified cardiovascular risk level into three risk categories: low (≤ 9%), moderate (10–14%), and high (≥15%). We measured daily physical activity using a triaxial accelerometer, and calculated the average time spent in moderate-to-vigorous intensity physical activity (MVPA) and light intensity physical activity (LPA). We performed brain T1-weighted magnetic resonance imaging and calculated the volume of the cortical gray matter, subcortical gray matter, and cerebral white matter, using the FreeSurfer software. In the overall sample, multivariable linear regression analysis showed that greater MVPA was significantly associated with greater volume of the cortical gray matter and cerebral white matter, and greater LPA was significantly associated with greater volume of the cerebral white matter. Additionally, in the analysis of the sample stratified by absolute cardiovascular risk level, cerebral white matter volume was significantly associated with both MVPA and LPA in the high cardiovascular risk group.

Conclusions

The association between physical activity and brain volume differed according to cardiovascular risk level in community-dwelling older adults. In a population at high cardiovascular risk, maintaining or increasing LPA might be a practical and achievable strategy for healthy brain aging.

Isotemporal Substitution of Sedentary Behavior With Moderate to Vigorous Physical Activity Is Associated With Lower Risk of Disability: A Prospective Longitudinal Cohort Study

OBJECTIVE

The purpose of the study was to estimate, using an isotemporal substitution model, the effect of replacing sedentary behavior (SB) with physical activity on the incidence of disability in community-dwelling older adults.

METHODS

This 2-year longitudinal cohort study enrolled 3691 community-dwelling older adults (57.2% women; mean age = 74.0 [SD = 5.0] years). Individuals with dementia, stroke, Parkinson disease, depression, low Mini-Mental State Examination scores, dependence on basic activities of daily living, and missing data were excluded. Physical activity and potential confounding factors were investigated as a baseline survey of disability incidence, defined by Japanese long-term care insurance certification, for 2 years in 2 regions. Physical activity data (SB, light-intensity physical activity, and moderate- to vigorous-intensity physical activity [MVPA]) were measured using triaxial accelerometers for 14 days, and daily mean time spent in each physical activity parameter was computed in increments of 10 minutes. The relationship between baseline physical activity and disability incidence adjusted for potential confounders was analyzed using multilevel Cox proportional hazards regression analyses with an isotemporal substitution model.

RESULTS

The disability incidence rate was 3.8%, excluding individuals who could not be followed-up. Replacing 10 minutes of SB per day with MVPA was associated with a decreased disability incidence (hazard ratio = 0.870; 95% CI = 0.766-0.988), whereas no evidence was found for replacing SB with light-intensity physical activity (hazard ratio = 0.980; 95% CI = 0.873-1.10).

CONCLUSIONS

Replacing SB with MVPA was associated with a lower risk of disability. These findings are helpful for establishing disability prevention strategies.

IMPACT

These results suggest that feasible changes in daily behavior, such as replacing 10 minutes of SB with MVPA daily, might have a protective effect on disability incidence. Clarifying these associations is useful for developing disability prevention strategies and may help reduce the incidence of disability in community-dwelling older adults.

Association of Daily Physical Activity with Disability in Community-Dwelling Older Adults With/Without Chronic Kidney Disease

OBJECTIVES

Physical activity is recommended for disability prevention in the older adult population; however, the level of physical activity required for older adults with chronic kidney disease (CKD) remains unknown. This study aimed to examine the associations between daily physical activity and disability incidence in older adults with and without CKD to determine relevant daily physical activity levels.

DESIGN

Prospective observational study.

SETTING AND PARTICIPANTS

3,786 community-dwelling older adults aged ≥65 years.

MEASUREMENTS

Mean daily times spent in light- (LPA) and moderate-to-vigorous physical activity (MVPA) were measured using triaxial accelerometers. CKD was defined by a creatinine estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2. Disability incidence was identified as long-term care insurance certification during a 60-month follow-up period. Associations between physical activity and disability incidence were examined using Cox proportional hazard models stratified by the CKD status. Non-linear and linear associations were tested using the restricted cubic spline.

RESULTS

A total of 1,054 individuals were identified to have CKD. Disability incidence was higher in the CKD group than in the non-CKD group. The adjusted cox proportional hazard models indicated that a 10-minute increase in MVPA time was associated with lower disability incidence in the non-CKD group (hazard ratio [HR], 0.838; 95% confidence interval [CI]: 0.764-0.918) and the CKD group (HR, 0.859; 95% CI: 0.766-0.960). Linear associations were observed in MVPA for the non-CKD and CKD groups.

CONCLUSION

Increasing MVPA was associated with lower disability incidence in older adults with and without CKD. These findings can help devise disability prevention strategies for older CKD patients.

Difference in sarcopenia characteristics associated with physical activity and disability incidences in older adults

BACKGROUND

Deteriorated skeletal muscle condition, including sarcopenia, is a risk factor for disability in older adults. Promoting physical activity is a useful treatment for sarcopenia. However, optimal intensity of physical activity according to sarcopenia characteristics is unclear.

METHODS

This longitudinal cohort study enrolled 2149 community-dwelling older adults (women 55.7%, mean age: 75.5 ± 4.0 years). Five-year disability incidence defined by Japanese long-term care insurance certification and accelerometer-measured physical activities (light-intensity physical activity [LPA] and moderate-to-vigorous intensity physical activity [MVPA]), which were adjusted for potential confounders, was analysed using cox-proportional hazard model stratified by sarcopenia characteristics based on the diagnostic algorithm by the Asian working group for sarcopenia (robust, low physical function, low muscle mass, and sarcopenia). The sarcopenia group was defined as low muscle mass and low physical function (weakness and/or slowness). The low muscle mass and low physical function groups were each defined by these characteristics alone. Muscle mass was analysed via bioelectrical impedance analysis. Each intensity of physical activity times was divided by median values.

RESULTS

The disability incidence rate was 15.4%, excluding those who could not be followed up. Mean LPA times were 43.8 ± 18.0, 45.6 ± 17.5, 45.4 ± 16.6, 40.8 ± 18.6, and 41.4 ± 18.5 min/day and MVPA times were 24.6 ± 17.6, 26.3 ± 18.3, 27.2 ± 17.3, 21.6 ± 16.3, and 21.5 ± 16.4 min/day in all participants, the robust, low muscle mass, low physical function, and sarcopenia groups, respectively. For all participants, higher MVPA was associated with disability incidence [hazard ratios (HR), 0.63; 95% confidence interval (95% CI), 0.49-0.81; P < 0.001], whereas higher LPA showed no association (HR, 0.86; 95% CI, 0.68-1.10; P = 0.22). Higher LPA was associated in the sarcopenia group (HR, 0.35; 95% CI, 0.15-0.85; P = 0.019), and MVPA was associated in the robust (HR, 0.58; 95% CI, 0.39-0.87; P = 0.008) and low physical function (HR, 0.66; 95% CI, 0.45-0.98; P = 0.040) groups. Both LPA and MVPA showed no association in the low muscle mass group. The P values for interactions between sarcopenia characteristics and physical activity were 0.017 for LPA and 0.014 for MVPA.

CONCLUSIONS

The LPA was associated with a lower risk of disability in older adults with sarcopenia, whereas MVPA was associated in subjects with robust and low physical function. Our findings indicate a need for individualized approaches to prevent disability based on muscle condition.

Screening prefrailty in Japanese community-dwelling older adults with daily gait speed and number of steps via tri-axial accelerometers

Prefrailty is an intermediate stage between non-frailty and frailty. It is associated with an increased risk of progression to frailty, which makes it important to screen older adults for prefrailty at an early stage. This study verified whether daily gait speed and number of steps measured using a tri-axial accelerometer could be used to identify prefrailty. In total, 1692 Japanese community-dwelling older adults were divided into robust (n = 1032) and prefrail (n = 660) groups based on the Kihon Checklist, which is a self-administered questionnaire. Both daily gait speed and number of steps were measured for two weeks using tri-axial accelerometers. We also calculated the area under the ROC curve and the cut-off values for these parameters. Our results showed that the cut-off value for daily gait speed was 106.3 cm/s, while that for number of steps was 6342.2. In addition, we found that the combined assessment of both cut-off values was a more effective way to screen older adults with prefrailty status compared to either parameter alone. This is also considered an effective way to reduce national expenditures for daily care assistance.

Effects of promoting daily physical activity on physical and mental health in older individuals

[Purpose] A trial was conducted to examine the effects of promoting daily physical activity, tailored to specific living situations, on physical and mental health indicators in older adults. [Participants and Methods] Participants in the ‘Intervention’ group (N=21) wore accelerometers during the 12-week trial period, and for one week during preliminary and follow-up surveys. Based on their physical activity levels as measured by accelerometers, participants were given instructions to increase their daily physical activity. Participants in the ‘Control’ group (N=18) wore the accelerometer only during the preliminary and follow-up survey. [Results] Number of steps increased significantly in the intervention group and a significant decrease in light physical activity time was observed in the control group. No such decrease was observed in the intervention group. With regard to health-related quality of life, significant interactions were observed between groups based on the 36-Item Short-Form Health Survey Mental Component Summary score, and some sub-items. A combined analysis of both groups found a significant positive correlation between the change in light physical activity time and the Mental Component Summary score. [Conclusion] An increase in daily physical activity was considered to have a sustained bolstering effect on mental health.

Foot pressure analysis of gait pattern in older Japanese females requiring different personal care support levels

[Purpose] This study evaluated gait parameters and foot pressure in two regions of the feet among older females with different personal care support needs to analyze factors that contribute to higher support requirements. [Subjects and Methods] Thirty-two older females were divided into support-need and care-need level groups. Gait parameters (speed, cadence, step length, step width, gait angle, toe angle, double support phase, swing phase, and stance phase) and foot pressure during a 5-m walk were measured and analyzed in the two groups. [Results] The percentage of the double support phase on both feet and the right stance phase were significantly higher in the care-need level group, while that of the right swing phase was significantly lower than that of the support-need level group. Additionally, the phase showing peak pressure on the left rear foot was significantly delayed and the left forefoot pressure in the terminal stance was significantly lower in the care-need level group than in the support-need level group. [Conclusion] These findings show that the temporal duration parameters and foot pressure on a particular side were significantly different between the two groups and suggest that these differences were associated with a higher care level.

Lung diseases directly associated with rheumatoid arthritis and their relationship to outcome

The outcome and cause of death of each lung disease directly associated with rheumatoid arthritis (RA-LD) have been poorly investigated. A retrospective study was conducted of 144 patients with RA-LD, in whom the median follow-up period after the initial visit for a respiratory examination was 4.5 yrs. A total of 57 patients were identified with usual interstitial pneumonia (UIP), 31 with bronchiectasis, 16 with nonspecific interstitial pneumonia (NSIP), 11 with bronchiolitis, five with organising pneumonia (OP), five with diffuse alveolar damage (DAD) and 19 with combined disease. The 5-yr survival rates were 36.6% in the UIP group, 87.1% in the bronchiectasis group, 93.8% in the NSIP group, 88.9% in the bronchiolitis group, 60.0% in the OP group and 20.0% in the DAD group. Survival of patients with DAD was worse than that of patients with UIP. Overall, survival of patients with UIP was worse than that of patients with bronchiectasis, NSIP or bronchiolitis. Of the 144 patients, 71 (49.3%) died, of whom 58 (81.7%) died due to respiratory lesions. Of patients with RA-LD, patients with DAD experienced the highest mortality, and the survival of patients with UIP was worse than that of patients with NSIP.

Smoking-related changes in the background lung of specimens resected for lung cancer: a semiquantitative study with correlation to postoperative course

AIMS

To assess the pathological findings in lobectomy specimens, to correlate them with smoking history and postoperative course and to compare the findings with those in smoking-related interstitial lung disease.

METHODS AND RESULTS

Patients who had undergone lobectomy for lung cancer were reviewed. Subjects included 230 non-smokers and 587 smokers, of whom 572 had a known smoking index (SI). They were classified into mild, moderate and heavy smokers. Centrilobular emphysema (CLE), respiratory bronchiolitis, airspace enlargement with fibrosis (AEF), the presence of foci resembling usual interstitial pneumonia pattern (UIP/P) and the rate of postoperative respiratory failure were assessed. The incidence of AEF was 6.5% in mild smokers, and 17.7% in moderate smokers (P < 0.01) with lower lobe predominance. There were significant correlations (P < 0.01) between AEF and CLE and AEF and UIP/P. The rate of respiratory failure after lobectomy was 6%, and 10% in patients having UIP/P with or without AEF, but was not seen in patients with AEF alone (P < 0.01).

CONCLUSIONS

AEF is an important smoking-related change in the lung that appears to correlate with the smoking history, and its distinction from UIP/P may be important.

Ulcerative colitis after autologous peripheral blood stem cell transplantation for non-Hodgkin's lymphoma

A 54-year-old woman with peripheral T cell lymphoma in second complete remission (CR) received an autologous peripheral blood stem cell transplant (PBSCT). Antibiotic-resistant bloody diarrhea, and fever developed 110 days after transplant. Blood and stool cultures were negative. Skin rash was not observed. Barium enema and colonoscopy showed typical features of pancolonic-type ulcerative colitis (UC). Endoscopic biopsies confirmed the diagnosis of UC. Mesalazine and immunosuppressive therapy improved symptoms dramatically. We detected serum antibodies against synthetic tropomyosin (TM) peptide when UC was diagnosed. We postulate that autoimmunity including autoreactive anti-TM antibodies may be involved in the pathogenesis of UC after autologous PBSCT in this patient.

Successful living donor liver transplantation for polycystic liver in a patient with autosomal-dominant polycystic kidney disease

Orthotopic liver transplantation has been recommended for patients with disabling polycystic liver disease (PCLD). Because of the shortage of cadaveric donors, living donor liver transplantation (LDLT) has been developed as an alternative. We describe the case of a woman with PCLD as an extrarenal manifestation of autosomal-dominant polycystic kidney disease (ADPKD) who was successfully palliated by LDLT. The patient was a 48-year-old woman with abdominal distention. Computed tomography showed a massively enlarged liver containing innumerable cysts, as well as bilateral kidney cysts. Hepatic and renal functions were well preserved. Genetic analysis of the family did not exclude linkage to the PKD1 locus. Two and a half years after the first examination, the patient reported severely disabling symptoms caused by the PCLD. Living donor liver transplantation was performed using a right-lobe graft. The recipient and donor were both well 8 months after the transplantation. The excised liver weighed 7.4 kg, and the histopathology revealed multiple cysts and von Meyenburg complexes in the portal areas.

[Invasive pulmonary aspergillosis following influenza A infection]

A 55-year-old man with arc welder's pneumoconiosis who presented with bilateral pneumonia was admitted to our hospital. Streptococcus pneumoniae and Aspergillus fumigatus were cultured from sputum on admission. The patient was treated with antibiotics and an anti-fungal agent, but his chest radiograph shadows became exacerbated, and he died of respiratory failure on the fourth day of hospitalization. Histological examination of postmortem lung tissue revealed necrotizing aspergillous pneumonia. The results of hemagglutination inhibition tests for influenza A (H3 N2) were x16 in September 1999, and x512 on the third day of hospitalization. We diagnosed this patient's condition as invasive pulmonary aspergillosis associated with influenza A viral infection. The suppression of cellular immunity, lymphocytopenia, and destruction of airways-mucociliary transport induced by influenza A viral infection were suspected to have predisposed him to aspergillus superinfection.

Chronic bronchiolitis with associated eosinophilic lung disease (eosinophilic bronchiolitis)

We encountered an adult patient with dyspnea, eosinophilia and bronchiolitis. He was diagnosed as having diffuse panbronchiolitis, and was treated with erythromycin for 3 years, but his symptoms had gradually worsened. Bronchoalveolar lavage showed marked eosinophilia, and video-assisted thoracoscopic lung biopsy revealed chronic bronchiolitis with associated eosinophilic lung disease (eosinophilic bronchiolitis). To our knowledge, no case of eosinophilic bronchiolitis has been reported in the literature.

[Pathologic findings both before and after steroid therapy in a case of desquamative interstitial pneumonia]

A 62-year-old man was admitted to our hospital because of dyspnea on effort. Histological findings from video-assisted thoracoscopic surgical biopsy were desquamative interstitial pneumonia (DIP). Two months after the introduction of steroid therapy, the patient underwent right middle lobe lobectomy for primary lung cancer. The histologic findings in this lobe revealed non-specific interstitial pneumonia, not characteristic of DIP. This case was the first in which histologic examination revealed DIP both before and after steroid therapy.

[A case of pulmonary lymphangioleiomyomatosis in an elderly woman]

We encountered a postmenopausal woman in whom pulmonary lymphangioleiomyomatosis was pathologically diagnosed. Cases of pulmonary lymphangioleiomyomatosis are rare in postmenopausal women. The patient was the oldest in whom such a case was reported in the literature. Pulmonary lymphangioleiomyomatosis should be on the list of differential diagnoses for cases of pulmonary cystic lesions, even in postmenopausal women.

Spontaneous ruptured middle colic artery aneurysm with concurrent renal cell carcinoma

We present the first reported case of spontaneous ruptured middle colic artery aneurysm in a patient who has concurrent hypervascular tumor which has a potential for rupturing. A 68-year-old Japanese man was admitted with abdominal pain and hypervascular renal tumor which developed in the subcapsular cortex and protruded outward. The next morning after admission, anemia rapidly progressed and severe abdominal pain developed. Emergency laparotomy was performed for a preliminary diagnosis of ruptured hypervascular renal tumor. However, the renal tumor was not ruptured but a ruptured middle colic artery aneurysm was found. The aneurysm measured 3.0 x 2.0 cm in greatest diameter and was resected. Three weeks later, nephrectomy for hypervascular renal tumor was electively performed. Histologically, the tumor was clear cell carcinoma. In the present case, the diagnosis of ruptured middle colic artery was extremely difficult.

[A case of drug-induced interstitial pneumonitis in rheumatoid arthritis treated with bucillamine]

We report a case of bucillamine-induced interstitial pneumonitis in a 57-year-old woman. Rheumatoid arthritis was diagnosed in May 1999, and she was treated with bucillamine from June 1999, with a favorable outcome. After complaining of cough, fever, and dyspnea in October, she was admitted to this hospital. Blood gas analysis showed severe hypoxemia. The chest CT revealed both bilateral diffuse ground-glass opacity along the bronchovascular bundles, and thickening of the interlobular septa. We suspected bucillamine-induced interstitial pneumonitis from the findings of the CT scan, BALF and TBLB, and also from the improvement of PaO2 after the withdrawal of bucillamine. We treated the patient with prednisolone, and a favorable response was noted. A lymphocyte stimulation test using bucillamine was positive. A video-assisted thoracic surgery lung biopsy showed findings compatible with acute interstitial pneumonia without the association of hyaline membrane formation. A focal fibrosis was also observed. We believe that this is the only reported case of pathologically proven bucillamine-induced interstitial pneumonitis, in which a surgical lung biopsy was performed.

[Familial summer-type hypersensitivity pneumonitis in a grandfather and his two-and-a-half-year-old grandson]

We encountered a family in which two of the six members, the grandfather and his grandson, had summer-type hypersensitivity pneumonitis in late summer. Chest computed tomography of these patients showed small, diffuse nodular shadows in both lung fields, with mosaic-like opacities in the grandfather and ground glass opacity of both lung fields in the grandson. Bronchoalveolar lavage fluid from the grandfather disclosed high total cell counts, high percentages of lymphocytes, and a low ratio of CD 4+ cells to CD 8+ cells. Transbronchial lung biopsy specimens obtained from the same patient revealed alveolitis with non-caseous epithelioid cell granulomas in the interstitium and Masson bodies in the alveolar septa. These two patients recovered spontaneously after hospital admission. They had positive results in provocation tests for their home and were positive for serum anti-Trichosporon cutaneum (T. asahii, T. mucoides) antibodies. Both cases were accordingly diagnosed as summer-type hypersensitivity pneumonitis.

[A questionnaire survey of surgical lung biopsy in patients with diffuse lung diseases]

A nationwide questionnaire survey was conducted to investigate the indications, diagnostic yield, complications, outcome, and benefit of surgical lung biopsy for diffuse lung diseases. Surgical lung biopsies were performed in 410 patients at 132 institutes in 1998, 94% of them as video-assisted thoracoscopic surgery (VATS). Interstitial lung diseases of unknown etiology formed the largest diagnostic group, and consisted of 194 patients. The clinical diagnosis prior to lung biopsy was inconsistent with the final diagnosis in 32.8%. Complications were seen in 32 patients, and mortality was 1.2%. Acute exacerbation of the underlying disease was seen in 9 patients, four of whom died. Patients with nonspecific interstitial pneumonia and even usual interstitial pneumonia who were treated following biopsy showed better outcomes than those untreated. The physician in charge judged that 82.2% of the patients received clinical benefits from the biopsy procedure. We concluded that VATS lung biopsies are indicated in more cases to confirm diagnoses and as a reference for treatments in patients with diffuse lung disease.

Autoantibodies against the specific epitope of human tropomyosin(s) detected by a peptide based enzyme immunoassay in sera of patients with ulcerative colitis show antibody dependent cell mediated cytotoxicity against HLA-DPw9 transfected L cells

BACKGROUND AND AIMS

Recent studies suggest that tropomyosin (TM) may act as a putative autoantigen in ulcerative colitis (UC). Recently, we identified, by computer homology analysis, a specific peptide (HIAEDADRK) in human TM that can bind to HLA-DPw9. The aim of this study was to investigate the presence of autoantibodies against this peptide in UC.

METHODS

Antibodies were measured by ELISA with a synthetic peptide in 20 healthy volunteers, 48 patients with UC, 26 with Crohn's disease (CD), eight with primary sclerosing cholangitis (PSC), and six with primary biliary cirrhosis (PBC). The functional significance of antibodies was investigated by antibody dependent cell mediated cytotoxicity (ADCC) against DPw9 transfected L cells using a standard (51)Cr release assay.

RESULTS

Optical density values (mean (SD)) of sera from patients with UC (1.40 (0. 52)) and PSC (1.65 (0.12)) were significantly higher than those from healthy volunteers (0.32 (0.28)) (p<0.05), CD (0.50 (0.34)) (p<0.05) and PBC (0.14 (0.09)) (p<0.05). Values in UC decreased with clinical improvement. The ADCC activity of UC sera correlated well with antibody titre against this synthetic peptide.

CONCLUSIONS

Anti-TM antibody was detected in UC sera by a specific peptide based ELISA with high reproducibility. This peptide may be an antigenic epitope of TM involved in the immunopathogenesis of UC and, perhaps, PSC.

[Tricuspid valve replacement in a patient with idiopathic tricuspid regurgitation]

Tricuspid regurgitation is often seen but is rarely categorized as "idiopathic". A 66-year-old man suspected of idiopathic tricuspid regurgitation underwent tricuspid valve replacement. With right heart failure over twenty years, his CTR increased to eighty six (86) per cent. During operation, no abnormal findings were observed except for the dilated tricuspid valve ring. Then a stented porcine xenograft (Carpentier-Edwards 33 mm) was inserted in the tricuspid valve annulus. Seven years after replacement, he died. Autopsy demonstrated myocardial hypertrophy of the right ventricle and dilatation of the right heart, supporting the diagnosis of idiopathic tricuspid regurgitation.

A case of malignant lymphoma producing autoantibody against platelet glycoprotein Ib

A 61-year-old woman was referred to our hospital for refractory thrombocytopenia (3 x 10(3)/microliter) and massive melena. Bone marrow aspiration revealed normal cellularity and increased megakaryocytes (250/microliter). An abdominal computerized axial tomography scan showed isodensity masses on both adrenal glands. 67 Ga-scintigraphy exhibited strong uptake into the bilateral adrenal tumor and mediastinal region. IgM-type antibody against platelet glycoprotein Ib (GpIb) was detected in the patient's serum. A needle biopsy of the right adrenal tumor was performed, and histology was non-Hodgkin's lymphoma (NHL), diffuse large B-cell type. Following the diagnosis of autoimmune thrombocytopenia associated with lymphoma, administration of corticosteroid (predonisolone 60 mg/day) and high-dose intravenous globulin (15 g/day x 4 days) was carried out, but neither was effective in normalizing the thrombocytopenia. Immunosuppressive therapy (cyclophosphamide 500 mg and 1 mg of vincristine) markedly restored the platelet counts to 7.2 x 10(4)/microliter and ceased the melena; furthermore, the size of adrenal tumors decreased by more than 60% after therapy. We cultured the lymphoma cells drawn by needle biopsy with IL-6 in vitro and found that the lymphoma cells produced IgM-type antiplatelet antibodies against platelet GpIb in the culture supernatant. Thus this is a rare case of NHL in which the production of antiplatelet antibody from lymphoma cells was confirmed in vitro.

[A case of sleeve resection of the left main bronchus for tuberculous bronchial lesion]

A 31-year-old woman was admitted to our center with left chest pain and dyspnea after treatment of pulmonary tuberculosis. Chest X-ray film showed atelectasis of left lower lobe and left deviation of the mediastium. Bronchofiberscopy revealed obstruction of the left main bronchus. Chest MRI showed intermediate intensity at the left main bronchus and very high intensity at the peripheral bronchus. We performed sleeve resection of the left main bronchus and anastomosed end to end with absorbable monofilament sutures. Postoperative course was uneventful. Bronchoplasty for tuberculous obstructive lesion is a useful procedure.

[Immunoblastic lymphadenopathy-like T cell lymphoma with high levels of serum interleukin-6, cold agglutinin disease, and immune thrombocytopenia]

An 88-year-old woman was admitted with generalized lymphadenopathy, anemia, and thrombocytopenia. On admission, a peripheral blood examination showed a red blood cell count of 146 x 10(6)/microliter, a hemoglobin concentration of 6.9 g/dl, and a platelet count of 5.0 x 10(4)/microliter. Blood examination detected polyclonal hypergammaglobulinemia; the results of the direct/indirect Coombs' test were positive; and an elevated cold agglutinin titer and high platelet associated IgG (PA-IgG) level indicated the existence of autoantibodies. Serum cytokine measurements disclosed an elevated level of interleukin-6 (IL-6). Immunoblastic lymphadenopathy-like T cell lymphoma was diagnosed on the basis of lymph node biopsy specimens. VP-16 and steroid therapy alleviated the patient's lymphadenopathy, anemia, thrombocytopenia, and hypergammaglobulinemia. These findings suggest that tumor cells with a T cell phenotype produced IL-6 in large quantities, thus provoking B-cell and plasmacytic histologic changes and humoral disease manifestations, including hypergammaglobulinemia.

Synthesis of dipeptide-type human immunodeficiency virus (HIV) protease inhibitors with a binding unit to gp120

Some dipeptide-type human immunodeficiency virus (HIV) protease inhibitors derived from KNI-102, with a N-carbomethoxycarbonylprolyl-phenylalanine benzyl ester (CPF) moiety as a binding site to gp120, were synthesized. Compounds 11a showed 7--100 times higher HIV protease-inhibitory activity (11a; IC50 = 0.90 microgram/ml, 1.1 microM) than the standard compound 3 or 4 (3; IC50 = 3.7 micrograms/ml, 7.7 microM, 4; IC50 = 75 micrograms/ml, 155 microM). Generally, the compounds substituted at the o-position of the phenoxyacetyl group 7a, 11a, 16a and 21a showed several times higher inhibitory activity than 3.

[A case of gastric cancer with peritonitis carcinomatosa and malignant biliary stenosis treated by intraperitoneal CDDP and MMC with UFT therapy]

A 55-year-old man, who complained of vomiting, was diagnosed as having a Borrmann type 3 gastric cancer (T3N3P2H0M0: Stage IVb). He was treated by distal gastrectomy. After four months, PTCD was applied for malignant biliary stenosis due to lymphnode metastasis. Since ascites due to peritonitis carcinomatosa developed about six months after operation, UFT therapy combined with CDDP 50 mg and MMC 10 mg intraperitoneally were performed. The patient became gradually less aware of subjective symptoms after chemotherapy. Three months later, he enjoyed a good general condition and all of the fixed tubes were removed. This chemotherapy seemed effective to support his quality of life.

Suppression of HIV-1 replication in peripheral blood mononuclear cells by fasudil

Fasudil is a potent inhibitor for various protein kinases such as myosin light chain kinase and protein kinase C. It has been used as a drug for improvement of intracranial vasospasm and following ischaemic diseases. In this report, we demonstrate that fasudil suppressed the replication of human immunodeficiency virus type 1 (HIV-1) in mitogen-activated peripheral blood mononuclear cells. Our finding shows that fasudil may be useful as a new and distinct chemotherapeutic agent against HIV-1 infection.

[A case of Sairei-to-induced pneumonitis diagnosed by lymphocyte stimulation test of bronchoalveolar lavage fluid]

A 51-year-old woman was admitted with fever, cough and dyspnea. She had been taking Sairei-to, a traditional Chinese medicine, for 2 months. On admission, chest X-ray revealed a ground-glass appearance in the lung fields bilaterally and serum LDH was elevated. A differential cell count of the bronchoalveolar lavage fluid (BALF) showed that lymphocytes were increased, with a decreased ratio of CD4/CD8 cells. A lymphocyte stimulation test (LST) for Sairei-to using the lymphocytes in BALF was a positive, although a test of peripheral blood was negative. Sairei-to-induced pneumonitis was diagnosed based on the clinical course, laboratory findings, BALF cell analysis and LST of BALF. Only 4 cases of pneumonitis due to Sairei-to have been reported. This case suggests that LST of BALF is useful for diagnosing drug-induced pneumonitis.

[A case of advanced colon cancer with marked response to combination chemotherapy with 5-FU, low dose CDDP, and leucovorin]

We encountered an elderly patient with advanced colon cancer who responded marked by to combination chemotherapy with 5-fluorouracil (5-FU), low-dose cisplatin (CDDP), and leucovorin (LV). The 86-year-old man was admitted for advanced transverse colon cancer with liver and lung metastasis. Combination chemotherapy with 5-FU, low dose CDDP, and LV was given for a total of 12 weeks. After this chemotherapeutic regimen, diagnostic CT scan revealed the metastatic lesions had disappeared, and a pathological analysis of primary tumor confirmed that the patient had achieved a complete remission (CR). During chemotherapy, there was no severe side effect, apart from mild nausea (WHO: Grade 1). The patient is presently enjoying a good general condition and has been rehabilitated for discharge.

Syndrome of the sea-blue histiocyte

A 39-year-old male was admitted with fever, systemic lymph node swelling, liver dysfunction and mild splenomegaly. Liver biopsy specimen showed histiocytic aggregation in portal areas. These histiocytes were closely packed with granules, dyed sea-blue with May-Giemsa staining. Further microscopical examination of lymph nodes, gastro-intestinal tract and bone marrow also revealed the accumulation of sea-blue histiocytes. Activities of lipid metabolic enzymes were normal and hematopoietic diseases which are sometimes accompanied by secondary sea-blue histiocytosis were ruled out. We diagnosed this case as syndrome of the sea-blue histiocyte.

[Clinical study of ten cases with acute abdomen after eating raw firefly squid (Watasenia scintillans, Hotaruika), which are probably due to type X larvae of the suborder spirurina]

We studied ten cases with abdominal pain after eating raw firefly squid, Watasenia scintillans, Hotaruika. Characteristic clinical features were abdominal pain, nausea, vomiting, diarrhea, creeping eruption and ileus with ascites. In ten patients, there were all cases with abdominal pain, nine with nausea and vomiting, four with diarrhea, one with creeping eruption, six with ileus. Laboratory examination revealed eosinophilia on peripheral blood in ten cases and high serum IgE value in nine cases. The infection rate of type X lavae of the suborder spirurina in Watasenia scintillans is almost 3%, so we measured the antibody to type X larvae of the suborder spirurina in nine patients by indirect fluorescent antibody method and the antibody titer was positive in seven cases. Most patients recovered in several days from first visit. But one patient was diagnosed peritonitis and operated with partial ileectomy. Pathological finding of resected specimen showed an erosion in the mucosal layer and an inflammation with marked eosinophilia in the submucosal layer. These results suggest that abdominal complaints after eating Watasenia scintillans are due to type X larvae of the suborder spirurina.

Immunohistochemical study of hepatic angiomyolipoma

An immunohistochemical study was performed on nine hepatic angiomyolipomas (AML) found in eight patients. Histologically, the tumors were fundamentally composed of the three heterogeneous tissue components of blood vessels, smooth muscle cells (SMC), and fat cells, although the proportions and distributions were quite variable from tumor to tumor and from area to area in the same tumor. Additionally, cellular pleomorphism and atypia with occasional bizarre giant cells were found in the SMC component. This histologic feature might lead to a mistaken diagnosis of malignant neoplasm, and pathologists should therefore be aware of the broad histologic spectrum of hepatic AML. However, the immunostaining patterns were basically the same in all nine tumors. All tumor components were negative for epithelial membrane antigen (EMA) and for cytokeratin. The spindle-shaped SMC component of the tumor was occasionally positive for vimentin, desmin and alpha-smooth muscle actin, whereas epithelioid SMC were negative for all three. Both the epithelioid and spindle-shaped SMC were occasionally positive for S-100 and neuron-specific enolase. All types of SMC in the tumor, whether spindle, epithelioid, intermediate or pleomorphic SMC, were strongly positive for HMB-45, a melanoma-specific monoclonal antibody. Fat cells were occasionally positive for S-100. Endothelial cells were positive for factor VIII-associated antigen. Among hepatic tumors HMB-45 reactivity is, so far as we know, found exclusively in the SMC of AML, and the HMB-45 reactivity of a hepatic tumor is thus clearly an important piece of information in the diagnosis of AML.

[Remission and relapse of acute eosinophilic pneumonia]

A 46-year-old man presented with progressive dyspnea of acute onset, nonproductive coughing, and a high fever. He had been in his usual good health until symptoms began on the previous day. The chest roentgenogram revealed Kerley A and B lines, perivascular cuffing, hilar haze, and bilateral pleural effusins. Body temperature was 37 degrees C and PaO2 was 42 Torr. All clinical and radiographic signs improved. On the 12th hospital day, dyspnea and diffuse infiltration shadows on the chest roentgenogram suddenly occurred again. Acute eosinophilic pneumonia was strongly suspected because of increasing peripheral eosinophilia, and from the results of histologic examination of a specimen obtained by transbronchial lung biopsy. Without steroid treatment, the patient's condition gradually improved. Most cases of eosinophilic pneumonia have been diagnosed as pulmonary infiltration with eosinophilia (PIE). However, this patient did not have PIE syndrome, but instead was given a diagnosis of acute eosinophilic pneumonia, which was first described in 1990. This case may help establish criteria for the diagnosis and steroid treatment of acute eosinophilic pneumonia.

Immunoblastic lymphadenopathy-like T-cell lymphoma displaying rearrangement of both IgH and TCR beta genes after 4-year follow-up of idiopathic eosinophilia

Immunoblastic lymphadenopathy (IBL)-like T-cell lymphoma (IBL-T) occurred in a 60-year-old female after a 4-year follow-up of idiopathic eosinophilia and upper pharyngeal inflammatory tumor with infiltration of mature eosinophils. Gene analysis of tumor cells revealed rearrangement of both IgH and TCR beta genes. The patient died of lymphoma seven months after the onset of the illness, in spite of chemotherapy against lymphoma. The relationship between eosinophilia and the pathogenesis of IBL-T, as well as the significance of the rearrangement of both IgH and TCR beta genes are discussed.

Multiple angiomyolipoma of the liver

Angiomyolipoma (AML) of the liver is extremely rare; we believe only about 60 cases, all solitary, have been reported. We present here the first reported case, to our knowledge, of multiple AMLs in the liver. Two masses were found in the liver of a 43-year-old Japanese woman complaining of abdominal discomfort by ultrasonography and computed tomography. With a preoperative diagnosis of hepatocellular carcinoma, a tumor in the right lobe 4.0 cm in largest diameter and one in the left lobe measuring 2.4 cm were resected. Histologically, both tumors were composed of smooth-muscle cells, fat cells, and blood vessels, and contained foci of extramedullary hematopoiesis. Although the smooth-muscle cell component was predominant and both tumors exhibited some pleomorphism, no mitosis was found. These histologic findings are consistent with the diagnosis of AML.

[A case of a synchronous triple primary lung cancer with hamartoma]

We present a case of synchronous triple primary lung cancer. 69-year-old male admitted after mass examination with the tumor shadows on right S3, left S4 and left S8. Further examinations confirmed as squamous cell carcinoma of right S3 and left S8 and as benign tumor of left S4 with right hillar lymph nodal swelling. In addition to these lesion, bronchofiberscopy revealed the squamous cell carcinoma of left basal bronchus. The secondlook operation was planned for bilateral primary lung cancer. At first, patient underwent right S3 segmentectomy with regional lymph nodes dissection. Two month later, left thoractomy was performed, followed by left lower lobectomy. Histopathological examination defined as well differentiated squamous cell carcinoma, moderately differentiated squamous cell carcinoma, squamous cell carcinoma in situ and hamartoma for right S3, left S8, left basal bronchus and left S4, respectively. Lymph node metastasis was found only in #121. Although tumors were resected with good curability, respiratory function was depressed and performance status deteriorated. It is important to attention to the preservation of respiratory function for the surgical treatment to multiple lesions and the combined therapy with radiation, chemotherapy and/or laser may be considered.

[A case of multiple nodular pulmonary amyloidosis associated with Sjögren's syndrome]

A 58-year-old female, who had complained of dryness of the conjunctiva and mouth for nine years, was admitted to our hospital because chest X-ray films revealed increases in both the size and the number of pulmonary nodules in comparison to four years earlier. Histological findings of the salivary gland biopsy confirmed a diagnosis of Sjögren's syndrome. An open lung biopsy was performed. Histologically, the pulmonary nodules consisted of homogeneous, acellular eosinophilic materials, which were identified as amyloid by Congo red staining. Immunohistochemical examination showed the amyloid to be composed of AA protein. There were no deposits in other organs. Peribronchial lymphocytic infiltration associated with Sjögren's syndrome was present. Nodular pulmonary amyloidosis with Sjögren's syndrome is very rare condition. To our knowledge, this case is only the ninth to be reported in the literature.

[Virus-associated hemophagocytic syndrome with interstitial pneumonia in adults and a review of literature in Japan]

A 21-year-old man was admitted with fever, jaundice, abdominal pain and general fatigue. Other clinical manifestations revealed liver dysfunction, hepatosplenomegaly, pancytopenia and disseminated intravascular coagulation. Anti-EB virus (EA-DR-IgG) was initially elevated on admission and was decreased after that, furthermore anti EBNA was elevated in the late period of his clinical course, which indicated primary infection or secondary alteration of EBV immunity. Bone marrow examination revealed hemophagocytosis by mature histiocytes. Therefore, he was diagnosed as Virus-associated hemophagocytic syndrome (VAHS). An arterial blood gas analysis on admission showed hypoxemia and findings of interstitial pneumonia (IP) were distinctly observed on chest CT scan. Steroid therapy was then initiated and the patient responded very well. The clinical findings and laboratory data including IP, were improved. The 20 adult cases of VAHS in Japan were clinically studied and a review of the complication of VAHS with IP was also made.

Intrahepatic cholangiocarcinomas associated with nonbiliary cirrhosis. A clinicopathologic study

To determine the prevalence and clinicopathologic features of cholangiocarcinoma (CC) associated with nonbiliary cirrhosis, we performed a clinicopathologic study. Among the 5,563 autopsies in our laboratories during the past 14 years, 85 (1.5%) were CCs. Four (4.7%) were associated with cirrhosis, due to hepatitis B virus in one case and cryptogenic (probably non-A non-B hepatitis virus) in the remaining three. Clinically, patients with CC and cirrhosis were characterized by male preponderance, lower age, past history of liver injury, and elevated values of zinc sulfate and thymol turbidity tests. Pathologically, all CCs with cirrhosis were basically adenocarcinoma; other histologic features included adenocarcinoma resembling bile ductules without mucin (one case), adenocarcinoma with broad areas of signet ring cell carcinoma (one case), adenocarcinoma with extensive sarcomatoid transformation (one case), and adenocarcinoma associated with hepatoliths (one case). Immunohistochemically, immunophenotypes of carcinoma cells of CC with cirrhosis were not different from those of CC without cirrhosis. Carcinoembryonic antigens, CA19-9, DU-PAN-2, and biliary-type cytokeratins were positive and alpha-fetoprotein was negative, suggesting that our CCs are not hepatocellular neoplasms but true CCs. It must be stressed that there are actual CCs arising in nonbiliary cirrhotic livers.