Methotrexate-associated lymphoproliferative disorder: A rare pancreatic tumor diagnosed via endoscopic ultrasound-guided fine-needle biopsy

A 73-year-old woman with a history of rheumatoid arthritis treated with methotrexate (MTX) for the last 10 years was referred to our hospital for a pancreatic tumor examination. Contrast-enhanced abdominal computed tomography revealed a 20-mm-diameter hypovascular tumor in the pancreatic tail. A hypoechoic mass with heterogeneous internal echo was found on an endoscopic ultrasound (EUS). An EUS-guided fine-needle biopsy (EUS-FNB) was performed with a 22-gauge Franseen-tip needle. Histologic examination of EUS-FNB specimens from the pancreatic tumor revealed the proliferation of atypical spindle cells. Immunohistochemical staining for CD20 and Ki-67 was positive in the atypical cells. Immunohistochemical staining for CD3 was partially positive in the atypical cells. Epstein-Barr virus-encoded RNA in situ hybridization showed positive staining. MTX-related lymphoproliferative disorder (MTX-LPD) with Epstein-Barr virus infection was diagnosed. MTX treatment was immediately discontinued, and treatment was initiated by a hematologist. However, her condition rapidly deteriorated, and she died of multiple organ failure 4 weeks after diagnosis. MTX-LPD can complicate gastrointestinal lesions. However, most lesions are localized in the stomach and rarely complicate pancreatic lesions. MTX-LPD is classified as an "iatrogenic" LPD. Therefore, immediate action, such as MTX discontinuation, is necessary. In conclusion, endoscopists should be aware that MTX-LPD lesions can occur in the pancreas and gastrointestinal tract. Moreover, EUS-FNB can be useful in the diagnosis of this rare pancreatic tumor.

Successful thoracoscopic operative approach for refractory pneumothorax in interstitial lung disease under local anaesthesia

Refractory pneumothorax associated with interstitial lung disease (ILD) remains a challenging condition due to the patient's tolerability and lung compliance that restrict the feasibility of aggressive interventions. Additionally, many cases recur after improvement with treatment, and reports of successful management for this complicated condition are limited. Herein, we report the case of a 60-year-old man with ILD, utilizing home oxygen therapy, who experienced a successful recovery from a surgical intervention under local anaesthesia for pneumothorax. This case highlights the potential for operative intervention under local anaesthesia as a viable option for patients who do not respond to internal approaches.

Continuous positive airway pressure versus high-flow nasal cannula oxygen therapy for acute hypoxemic respiratory failure: A randomized controlled trial

BACKGROUND AND OBJECTIVE

The relative effectiveness of initial non-invasive respiratory strategies for acute respiratory failure using continuous positive airway pressure (CPAP) or high-flow nasal cannula (HFNC) is unclear.

METHODS

We conducted a multicenter, open-label, parallel-group randomized controlled trial to compare the efficacy of CPAP and HFNC on reducing the risk of meeting the prespecified criteria for intubation and improving clinical outcomes of acute hypoxemic respiratory failure. The primary endpoint was the time taken to meet the prespecified criteria for intubation within 28 days.

RESULTS

Eighty-five patients were randomly assigned to the CPAP or HFNC group. Eleven (28.9%) in the CPAP group and twenty (42.6%) in the HFNC group met the criteria for intubation within 28 days. Compared with HFNC, CPAP reduced the risk of meeting the intubation criteria (hazard ratio [HR], 0.327; 95% CI, 0.148-0.724; p = 0.006). There were no significant between-group differences in the intubation rates, in-hospital and 28-day mortality rates, ventilator-free days, duration of the need for respiratory support, or duration of hospitalization for respiratory illness. Pulmonary oxygenation was significantly better in the CPAP group, with significantly lower pH and higher partial pressure of carbon dioxide, but there were no differences in the respiratory rate between groups. CPAP and HFNC were associated with few possibly causal adverse events.

CONCLUSION

CPAP is more effective than HFNC at reducing the risk of meeting the intubation criteria in patients with acute hypoxemic respiratory failure.

Short-term inhalation of sargramostim with concomitant high-dose steroids does not hasten recovery in moderate COVID-19 pneumonia: a double-blind, randomised, placebo-controlled trial

BACKGROUND

Granulocyte-macrophage colony stimulating factor (GM-CSF) inhalation may alleviate pulmonary inflammation caused by viral pneumonia. To investigate this, we evaluated its efficacy on COVID-19 pneumonia.

METHODS

This double-blind, randomised, placebo-controlled study (ClinicalTrials.gov: NCT04642950) evaluated patients in the first half of 2021 at seven Japanese hospitals. Hospitalised patients with COVID-19 pneumonia with moderate hypoxaemia inhaled sargramostim or placebo for 5 days. The primary endpoint was days to achieve a ≥ 2-category improvement from baseline on a modified 7-category ordinal scale. Secondary endpoints included degree of oxygenation, defined by amount of oxygen supply, and serum CCL17 level.

RESULTS

Seventy-five patients were randomly assigned in a 2:1 ratio to receive sargramostim or placebo, of which 47 and 23 were analysed, respectively. No difference was observed between groups regarding the primary endpoint (8.0 and 7.0 days for sargramostim and placebo, respectively) or in the secondary endpoints, except for CCL17. A post hoc sub-analysis indicated that endpoint assessments were influenced by concomitant corticosteroid therapy. When the cumulative corticosteroid dose was ≤500 mg during Days 1-5, recovery and oxygenation were faster in the sargramostim group than for placebo. Bolus dose corticosteroids were associated with temporarily impaired oxygenation and delayed clinical recovery. The increase in serum CCL17, a candidate prognostic factor, reflected improvement with sargramostim inhalation. The number of adverse events was similar between groups. Two serious adverse events were observed in the sargramostim group without causal relation.

CONCLUSIONS

Inhaled sargramostim was likely to be effective for COVID-19 pneumonia unless the concomitant corticosteroid dose was high.

Pulmonary tuberculosis presenting with cluster sign and galaxy sign

In a routine medical check-up, a healthy man in his 20s was found to have an upper left lung abnormality. Subsequent chest CT revealed the cluster sign (CS) and galaxy sign (GS). Although tests such as sputum analysis and interferon-gamma assays reduced the likelihood of tuberculosis, these abnormalities remained unchanged. A lung biopsy indicated non-caseating granuloma unrelated to tuberculosis. Initially suspected of sarcoidosis, the patient later developed fever and malaise. Follow-up CT showed CS progressing to a cavitatory shadow and GS intensification. The detection of Mycobacterium tuberculosis (M. tuberculosis) in a subsequent sputum analysis prompted treatment with antitubercular drugs, leading to symptom relief.CS and GS are usually associated with sarcoidosis but can also occur in tuberculosis, connected to slower pathogen growth and lower isolation rates. Furthermore, pulmonary tuberculosis may ultimately be present even when biopsies show non-caseating granulomas that are not typical of M. tuberculosis and sputum culture results are negative for M. tuberculosis Tuberculosis should not be ruled out lightly, and patients should be carefully followed-up.

A multicenter, open-label, phase II trial of pemetrexed plus bevacizumab in elderly patients with previously untreated advanced or recurrent nonsquamous non-small cell lung cancer

BACKGROUND

Although the incidence of lung cancer in elderly individuals has been increasing in recent years, the number of clinical trials designed specifically for elderly patients with advanced non-small cell lung cancer (NSCLC) is still limited. To fulfill this unmet medical need, we conducted a phase II study to elucidate the efficacy of pemetrexed (PEM) plus bevacizumab (Bev) combination chemotherapy in elderly patients with nonsquamous NSCLC.

METHODS

A total of 29 elderly patients (≥75 years old) with nonsquamous NSCLC were enrolled in this multicenter, open-label, phase II study, and 27 patients were finally analyzed. PEM at 500 mg/m2 on day 1 plus Bev at 15 mg/kg on day 1 were administered triweekly. The primary endpoint was the investigator-assessed objective response rate.

RESULTS

The median age at initiating chemotherapy was 80 years old. Almost all patients (92.6%) had adenocarcinoma histology. The median number of cycles administered was 6, and the objective response rate was 40.7%. The median progression-free survival, overall survival and 1-year survival were 8.8 months, 27.2 months and 79%, respectively. The treatment was well-tolerated, and no treatment-related death was observed.

CONCLUSION

Combination chemotherapy with PEM plus Bev in elderly patients with previously untreated advanced non-squamous NSCLC exhibited favorable antitumor activity and tolerability, suggesting that a combination of PEM plus Bev might be a promising treatment option for this population.

Investigating Viral Involvement in Immunocompromised Patients Using Comprehensive Infectious Disease Testing Including FilmArray Respiratory Panel 2.1 on Bronchoscopy: A Retrospective Study

Introduction Reports are rare on the usefulness of the FilmArray Respiratory Panel 2.1 (FARP) using lower respiratory tract specimens. This retrospective study assessed its use, as part of a comprehensive infectious disease panel, to detect the viral causes of pneumonia using bronchoalveolar lavage samples from immunosuppressed patients. Methods This study included immunocompromised patients who underwent bronchoalveolar lavage or bronchial washing by bronchoscopy between April 1, 2021, and April 30, 2022. The collected samples were submitted for comprehensive testing, including FARP test; reverse transcription polymerase chain reaction (RT-PCR) for cytomegalovirus, varicella-zoster virus DNA, and herpes simplex virus; PCR for Pneumocystis jirovecii DNA; antigen testing for Aspergillus and Cryptococcus neoformans; and loop-mediated isothermal amplification method for Legionella. Results Out of 23 patients, 16 (70%) showed bilateral infiltrative shadows on computed tomography and three (13%) were intubated. The most common causes of immunosuppression were anticancer drug use (n=12, 52%) and hematologic tumors (n=11, 48%). Only two (9%) patients tested positive for severe acute respiratory syndrome coronavirus 2 and adenovirus by FARP. Four patients (17%) tested positive for cytomegalovirus by RT-PCR, but no inclusion bodies were identified cytologically. Nine (39%) patients tested positive for Pneumocystis jirovecii by PCR, but cytology confirmed the organism in only one case. Conclusions Comprehensive infectious disease testing, performed using bronchoalveolar lavage samples collected from lung lesions in immunosuppressed patients, showed low positive detection by FARP. The viruses currently detectable by FARP may be less involved in viral pneumonia diagnosed in immunocompromised patients.

Colonic gallstone ileus treated by a transanal ileus tube followed by spontaneous gallstone dislodgement: A case report

A 71‐year‐old obese woman was referred to our hospital with lower left abdominal pain. Computed tomography showed a 46 mm elliptic calcification lodged in the sigmoid‐descending colon junction (SDJ), which had been detected 5 years prior but was not within the gall bladder at presentation. Therefore, we diagnosed colonic gallstone ileus with obstructive colitis caused by a gallstone. Colonoscopy revealed a smooth gallstone impacted at the sigmoid‐descending colon junction, which was not fixed and could be pushed proximally with the endoscope. Dislodgement of the stone was unsuccessful with both a large polypectomy snare and a retrieval basket. Considering the high risk of surgery, we chose a non‐surgical treatment strategy for obstructive colitis. Accordingly, a transanal ileus tube was placed to drain the proximal portion of the gallstone. The drainage of the colon by the ileus tube was satisfactory; the proximal colon was decompressed, ameliorating the obstructive colitis. Five days after tube placement, a colonoscopy revealed spontaneous passage of the gallstone into the rectum where it was finally removed. Cholecystocolonic fistula formation was confirmed by magnetic resonance imaging. We decided to surgically close the cholecystocolonic fistula to prevent future retrograde biliary infections. The surgery used a surgical stapler and was successful, with an uneventful postoperative course. Since radical surgical treatment of colonic gallstones and cholecystoenteric fistulas has a risk of postoperative morbidity and mortality, this case illustrates the importance of thoroughly considering nonsurgical interventions and surgeries for the safe treatment of colonic gallstone ileus.

β-Delayed One and Two Neutron Emission Probabilities Southeast of ^{132}Sn and the Odd-Even Systematics in r-Process Nuclide Abundances

The β-delayed one- and two-neutron emission probabilities (P_{1n} and P_{2n}) of 20 neutron-rich nuclei with N≥82 have been measured at the RIBF facility of the RIKEN Nishina Center. P_{1n} of ^{130,131}Ag, ^{133,134}Cd, ^{135,136}In, and ^{138,139}Sn were determined for the first time, and stringent upper limits were placed on P_{2n} for nearly all cases. β-delayed two-neutron emission (β2n) was unambiguously identified in ^{133}Cd and ^{135,136}In, and their P_{2n} were measured. Weak β2n was also detected from ^{137,138}Sn. Our results highlight the effect of the N=82 and Z=50 shell closures on β-delayed neutron emission probability and provide stringent benchmarks for newly developed macroscopic-microscopic and self-consistent global models with the inclusion of a statistical treatment of neutron and γ emission. The impact of our measurements on r-process nucleosynthesis was studied in a neutron star merger scenario. Our P_{1n} and P_{2n} have a direct impact on the odd-even staggering of the final abundance, improving the agreement between calculated and observed Solar System abundances. The odd isotope fraction of Ba in r-process-enhanced (r-II) stars is also better reproduced using our new data.

A case of a thoracic mass negative on thoracentesis diagnosed by cryobiopsy from the visceral pleura

Thoracoscopy under local anaesthesia is recommended for malignant tumours with negative pleural effusion cytology. Cryobiopsy from the visceral pleura by thoracoscopy under local anaesthesia can provide more diagnostic options for patients with thoracentesis‐negative malignant effusions. Here we present the first case in which this technique was used. The patient had a pleural metastasis that could not be diagnosed even with rapid cytology of the parietal pleura biopsy. Indications, technical pitfalls, and safety tips are discussed.

A Case of Nonsmall-Cell Lung Cancer with Anaphylaxis after 41 Courses of Pembrolizumab along with Adrenal Insufficiency as an Immune-Related Adverse Event

In this report, we present a case of nonsmall-cell lung cancer with anaphylaxis after 41 courses of pembrolizumab along with adrenal insufficiency as an immune-related adverse event (irAE). A 73-year-old man with no allergic disease started pembrolizumab for postoperative recurrence of lung cancer. After four courses, tumor shrinkage was observed and maintained thereafter. After the 39th course, his serum sodium level and random serum cortisol level decreased. Adrenal insufficiency was considered; however, the patient was asymptomatic. Furthermore, his serum sodium level improved spontaneously; therefore, he was followed up. At the end of the 40th course, rhinorrhea and pharyngeal discomfort were noted; however, they were mild and resolved spontaneously. Immediately after administration of the 41st course, he developed pembrolizumab-induced anaphylaxis with percutaneous oxygen saturation decreased. The symptoms quickly improved after intramuscular adrenaline were administered and did not recur. Three months after discharge, the patient was urgently examined for vomiting and anorexia. His serum sodium levels decreased to 119 mEq/L, and an adrenocorticotropic hormone stimulation test was performed. It showed a low response, and the patient was diagnosed with secondary adrenal insufficiency as an irAE of pembrolizumab and treated with hydrocortisone, which quickly improved his serum sodium levels and symptoms. When adrenal insufficiency develops due to irAEs, patients may be susceptible to allergic reactions.

Elevated plasma levels of Krebs von den Lungen-6 and geographic appearance on high-resolution computed tomography are associated with diffuse alveolar damage in autopsy cases of acute respiratory distress syndrome: a retrospective study

Background

Although diffuse alveolar damage (DAD) is a histopathological hallmark of acute respiratory distress syndrome (ARDS), its detection without lung biopsy is challenging. In patients with ARDS, the specificity of the Berlin definition to diagnose DAD as a reference standard is not adequately high, making it difficult to adequately diagnose DAD. The purpose of this study was to investigate the relationship between DAD and clinical findings, including KL-6 and geographic appearance, in ARDS patients and to identify more specific diagnostic criteria for DAD.

Methods

Among all adult autopsy cases at a tertiary hospital in Japan between January 2006 and March 2021, patients with ARDS who met the Berlin definition criteria were included. The patients’ conditions were classified according to histopathological patterns as DAD or non-DAD, and clinical characteristics, laboratory data, and high-resolution computed tomography (HRCT) findings were compared between the two groups.

Results

During the study period, 27 met the Berlin definition (median age: 79 years, 19 men), of whom 18 (67%) had DAD and 9 (33%) did not. In the non-DAD group, histopathologic findings revealed organizing pneumonia in seven patients and pulmonary hemorrhage in two patients. On HRCT at onset, patients with DAD had more geographic appearance than those without DAD (89% vs. 44%). In patients with geographic appearance and elevated KL-6 (> 500 U/mL), the sensitivity and specificity for DAD diagnosis were 56% and 100%, respectively. All three patients with no geographic appearance and normal KL-6 did not have DAD.

Conclusions

Geographic appearance on HRCT combined with KL-6 levels may predict the presence of DAD in patients with ARDS.

Findings of virtual bronchoscopic navigation can predict the diagnostic rate of primary lung cancer by bronchoscopy in patients with peripheral lung lesions

BACKGROUND

Despite being minimally invasive, bronchoscopy does not always result in pathological specimens being obtained. Therefore, we investigated whether virtual bronchoscopic navigation (VBN) findings were associated with the rate of diagnosis of primary lung cancer by bronchoscopy in patients with peripheral lung lesions.

METHODS

This study included patients with suspected malignant peripheral lung lesions who underwent bronchoscopy at St. Luke's International Hospital between October 2013 and March 2020. Patients diagnosed with primary lung cancer were grouped according to whether their pathology could be diagnosed by bronchoscopy, and their clinical factors were compared. In addition, the distance between the edge of the lesion and the nearest branch ("distance by VBN") was calculated. The distance by VBN and various clinical factors were compared with the diagnostic rates of primary lung cancer.

RESULTS

The study included 523 patients with 578 lesions. After excluding 55 patients who underwent multiple bronchoscopies, 381 patients were diagnosed with primary lung cancer. The diagnostic rate by bronchoscopy was 71.1% (271/381). Multivariate analysis revealed that the lesion diameter (odds ratio [OR] 1.107), distance by VBN (OR 0.94) and lesion structure (solid lesion or ground-glass nodule; OR 2.988) influenced the risk of a lung cancer diagnosis. The area under the receiver operating characteristic curve for diagnosis based on lesion diameter and distance by VBN was 0.810.

CONCLUSION

The distance by VBN and lesion diameter were predictive of the diagnostic rates of primary lung cancer by bronchoscopy in patients with peripheral lung lesions.

Progressive pulmonary fibrosis due to diffuse alveolar damage in a COVID ‐19‐infected autopsy case

We encountered a patient with severe coronavirus disease 2019 (COVID‐19)‐related pneumonia, who died of progressive respiratory acidosis after 2 months of treatment with mechanical ventilation. The autopsy revealed diffuse alveolar damage (DAD) without any active signs of fungal or bacterial infections, suggesting prolonged and over‐activated immune responses against COVID‐19 infection. When COVID‐19 patients develop acute respiratory distress syndrome, it is essential to remember that the infection can progress to DAD a few months after the disease onset.

Combined treatment with endobronchial Watanabe spigot and N ‐butyl‐2‐cyanoacrylate for refractory pneumothorax in COVID ‐19

Coronavirus disease 2019 (COVID‐19) causes pneumothorax or mediastinal emphysema in approximately 1% of patients. According to the British Thoracic Society guidelines, the next treatment option for patients with persistent pneumothorax despite chest drainage is pleurodesis or surgery. In fact, there are reports of autologous blood pleurodesis or surgery for the treatment of pneumothorax caused by COVID‐19. However, elderly patients or patients in poor general condition may not be able to tolerate surgical invasion. In this report, we present two patients who did not respond to chest drainage or pleurodesis and who were not suitable for surgery because of their poor general condition. These patients were successfully treated with an endobronchial Watanabe spigot and N‐butyl‐2‐cyanoacrylate. This method may be an option for the treatment of refractory pneumothorax in COVID‐19.

Bronchoscopy for the diagnosis of nontuberculous mycobacterial pulmonary disease: Specificity and diagnostic yield in a retrospective cohort study

BACKGROUND

Bronchoscopy is a recognized method for obtaining specimens for the diagnosis of nontuberculous mycobacterial pulmonary disease (NTM-PD). However, its diagnostic properties remain to be elucidated. The aim of this study was to determine the specificity of bronchoscopy for the diagnosis of NTM-PD, and to examine the diagnostic yield of bronchoscopy for detecting nontuberculous mycobacteria (NTM) when patients cannot expectorate sputum with NTM.

METHODS

This retrospective cohort study included 2657 patients who underwent bronchoscopy and mycobacterial culture between January 2004 and June 2018 in a tertiary care center in Tokyo, Japan. To examine the specificity of bronchoscopy, the first cohort comprised patients who underwent bronchoscopy for the diagnosis of lung cancer and mycobacterial culture. To investigate the diagnostic yield, patients with nodular bronchiectasis who underwent bronchoscopy for the diagnosis of NTM-PD were enrolled into the second cohort.

RESULTS

In total, 919 patients were diagnosed with lung cancer, 19 patients showed positive culture for NTM, and 14 patients showed findings for NTM-PD. Accordingly, the specificity was calculated as 900/905 (99.4%). In addition, NTM-PD was suspected before bronchoscopy in 199 patients; the diagnostic yield was 105/199 (52.8%). Four factors were associated with NTM-PD: upper lobe examination, absence of specific bacteria, absence of connective tissue disease, and a higher total computed tomography score.

CONCLUSIONS

Bronchoscopy has a high specificity for the diagnosis of NTM-PD. In addition, even when NTM is undetected in sputum, bronchoscopy may detect mycobacteria in approximately half of the patients suspected of having NTM-PD.

Results of the 𝚵− atomic X-ray measurement in J-PARC E07

Ξ− atomic X-ray spectroscopy is one of the most useful methods for investigation of the Ξ-nucleus strong interaction. A serious problem in the measurement is the significant background coming from in-flight Ξ− decay. For the first Ξ− atomic X-ray spectroscopy experiment, a novel method of identifying stopped Ξ− events using nuclear emulsion was developed to reject background photons from in-flight Ξ− decay. We succeeded in reducing the background to 1/170 by this method employing coincidence measurements using the nuclear emulsion and X-ray detectors.

Bereaved Family Members' Perceived Care at the End of Life for Patients with Noncancerous Respiratory Diseases

Background: Data regarding the quality of end-of-life care for patients with noncancerous illnesses are lacking.

Objective: This study aimed to evaluate end-of-life care for patients with noncancerous respiratory disease from the perspective of bereaved family members and explore the factors associated with the quality of patient death and care.

Design: This cross-sectional study included patients who had died of noncancerous respiratory disease in general wards of pulmonary department in Japan between 2014 and 2016 and conducted an anonymous self-report questionnaire survey for the patients' bereaved family members.

Measurements: We evaluated overall satisfaction with care and the quality of death and end-of-life care using the Good Death Inventory (GDI) and Care Evaluation Scale (CES), respectively. A multiple linear regression analysis was performed to explore the factors associated with these outcomes.

Results: In total, 130 questionnaires were distributed, and the effective response rate was 38% and 50 patients were included (median age: 82 [range 58–101] years; 37 men [74%]). Primary diagnoses at death included 29 cases of pneumonia (58%), 15 interstitial lung disease (30%), and 3 chronic obstructive pulmonary disease (6%). Of the bereaved family members, 26 (52%) were spouses, and 19 (38%) were children (median age [range]: 68 [33–102] years, 15 men [30%]). The overall CES and GDI scores (mean ± standard deviation) were 77 ± 15 and 79 ± 15, respectively. The presence of dementia was an independent factor associated with high CES and GDI scores in the multiple linear regression analysis.

Conclusions: In patients who died of noncancerous respiratory disease, the presence of dementia could be associated with the higher quality of patient death and care. In dementia, an understanding of the terminal nature of this condition may lead to an appropriate end-of-life care.

High-resolution computed tomography for the prediction of mortality in acute respiratory distress syndrome: A retrospective cohort study

BACKGROUND AND AIMS

Acute respiratory distress syndrome (ARDS) demonstrates several image patterns on high-resolution computed tomography (HRCT). The purpose of this study was to investigate the relationship between specific HRCT findings and the prognosis of ARDS.

METHODS

This was a retrospective cohort study performed in a single hospital in Japan. We categorized HRCT findings into three distribution patterns: diffuse, subpleural sparing, and dorsal patterns. All patterns were assessed at three levels of each lung. Multivariable logistic regression analysis was used to identify parameters associated with in-hospital mortality.

RESULTS

A total of 144 patients with ARDS (age: 72 ± 16 years, 112 men) were included in the study. The in-hospital mortality rate was 42% (survivors, n = 83; nonsurvivors, n = 61). Nonsurvivors were significantly older (70 ± 17 vs 76 ± 13, P = 0.01) and had lower serum albumin levels (P = 0.01), more traction bronchiectasis (P = 0.02), and more diffuse pattern (P < 0.001) than survivors. The presence of diffuse patterns was an independent adverse prognostic factor for predicting mortality (odds ratio, 1.32; 95% confidence interval [CI]: 1.08-1.61, P = 0.007).

CONCLUSIONS

HRCT distribution patterns may predict mortality in ARDS patients.

First Direct Measurement of an Astrophysical p-Process Reaction Cross Section Using a Radioactive Ion Beam

We have performed the first direct measurement of the ^{83}Rb(p,γ) radiative capture reaction cross section in inverse kinematics using a radioactive beam of ^{83}Rb at incident energies of 2.4 and 2.7A  MeV. The measured cross section at an effective relative kinetic energy of E_{cm}=2.393  MeV, which lies within the relevant energy window for core collapse supernovae, is smaller than the prediction of statistical model calculations. This leads to the abundance of ^{84}Sr produced in the astrophysical p process being higher than previously calculated. Moreover, the discrepancy of the present data with theoretical predictions indicates that further experimental investigation of p-process reactions involving unstable projectiles is clearly warranted.

Gravity-Induced Lower-Leg Swelling Can Be Ameliorated by Ingestion of α-Glucosyl Hesperidin Beverage

The most likely cause of lower-leg swelling is prolonged sitting, which sometimes induces deep vein thrombosis, also known as, economy class syndrome. We aimed to clarify the influence of intake of 4^G-α-glucopyranosyl hesperidin (G-Hsp) beverage on the lower-leg swelling caused by 6 h of sitting in six healthy women. All subjects ingested 100 mL of G-Hsp or Placebo beverages with 100 mL of mineral water after 10 min of rest in a chair. Subsequently, subjects were requested to sit in the chair in a relaxed position for 6 h with two breaks to walk for urination. Calf water content measured by impedance plethysmography, calf circumference, and calf skin temperature by infrared thermography were measured, along with assessment of calf swelling sensation on a visual analog scale. Increase in ankle % circumference was significantly less after the G-Hsp ingestion (101.8 ± 1.5%) than after placebo (103.3 ± 0.8%; P = 0.004). A significant difference was found between percent circumference after the G-Hsp and the placebo, that is, the calf swelling after the placebo was significantly larger (P = 0.043). A gradual increase in skin temperature at the lower limb was observed after G-Hsp ingestion, while there was no change after placebo. Gravity-induced calf and ankle swelling resulted by prolonged sitting can be ameliorated by oral ingestion of hesperidin-derived G-Hsp through production of nitric oxide. It might be helpful in preventing economy-class syndrome caused by enforced sitting for a long duration.

Steroid resistance and rebound phenomena in patients with COVID-19

Background

In patients with coronavirus disease (COVID-19) pneumonia, corticosteroids reduce progression to respiratory failure and death. Some patients, however, remain unresponsive to this treatment, or experience a rebound after termination.

Methods

This retrospective cohort study included COVID-19 patients treated with systemic corticosteroids in a Japanese hospital between June 1, 2020, and January 17, 2021. Patients were categorized into three groups: success, rebound, and refractory, and clinical characteristics and outcomes were compared.

Results

A total of 319 COVID-19 patients were admitted to our hospital and 113 patients met inclusion criteria. The success group had 83 patients (73.5%), the rebound group had nine patients (8.0%), and the refractory group had 21 patients (18.6%). Compared with the success group, the rebound group received corticosteroids earlier, for a shorter duration, and stopped them sooner. The median time from symptom onset to rebound was 12 days. There was no rebound after 20 days. Compared with the success group, the hazard ratio for the number of days from corticosteroid onset to an improvement of two points on a seven-point ordinal scale was 0.29 (95% confidence interval [CI], 0.14–0.60, P < .001) for the rebound group versus 0.13 (95% CI, 0.07–0.25, P < .001) for the refractory group.

Conclusions

COVID-19 patients treated with corticosteroids were classified into three response groups: success, rebound, and refractory, between which recovery time and prognosis differed. It was found that corticosteroid administration may prevent rebound phenomena if administered at least two weeks from symptom onset.

Ultrasonic humidifier lung as a mimic of COVID-19

Chest computed tomography (CT) has been used to complement coronavirus disease 2019 (COVID-19) diagnosis due to its high sensitivity. However, owing to the low specificity of CT findings, differential diagnosis is essential. The typical CT findings of COVID-19 include ground-glass opacifications and consolidations with predominant distribution in bilateral, peripheral, and subpleural parts of the lung. These imaging findings are non-specific and may resemble other lung conditions, including ultrasonic humidifier lung, which is a condition that develops on inhaling aerosols generated by ultrasonic humidifiers. We present two patients with initial symptoms similar to COVID-19. CT examination revealed centrilobular nodules and consolidations with upper lobe-predominant distribution, although atypical for COVID-19, but key findings for ultrasonic humidifier lung. Therefore, ultrasonic humidifier lung could be a differential diagnosis for COVID-19 in dry environments. Characteristic CT findings and a history of ultrasonic humidifier use are critical to the final diagnosis.

Corticosteroids for hospitalized patients with mild to critically-ill COVID-19: a multicenter, retrospective, propensity score-matched study

Corticosteroids use in coronavirus disease 2019 (COVID-19) is controversial, especially in mild to severe patients who do not require invasive/noninvasive ventilation. Moreover, many factors remain unclear regarding the appropriate use of corticosteroids for COVID-19. In this context, this multicenter, retrospective, propensity score-matched study was launched to evaluate the efficacy of systemic corticosteroid administration for hospitalized patients with COVID-19 ranging in the degree of severity from mild to critically-ill disease. This multicenter, retrospective study enrolled consecutive hospitalized COVID-19 patients diagnosed January-April 2020 across 30 institutions in Japan. Clinical outcomes were compared for COVID-19 patients who received or did not receive corticosteroids, after adjusting for propensity scores. The primary endpoint was the odds ratio (OR) for improvement on a 7-point ordinal score on Day 15. Of 1092 COVID-19 patients analyzed, 118 patients were assigned to either the corticosteroid and non-corticosteroid group, after propensity score matching. At baseline, most patients did not require invasive/noninvasive ventilation (85.6% corticosteroid group vs. 89.8% non-corticosteroid group). The odds of improvement in a 7-point ordinal score on Day 15 was significantly lower for the corticosteroid versus non-corticosteroid group (OR, 0.611; 95% confidence interval [CI], 0.388-0.962; p = 0.034). The time to improvement in radiological findings was significantly shorter in the corticosteroid versus non-corticosteroid group (hazard ratio [HR], 1.758; 95% CI, 1.323-2.337; p < 0.001), regardless of baseline clinical status. The duration of invasive mechanical ventilation was shorter in corticosteroid versus non-corticosteroid group (HR, 1.466; 95% CI, 0.841-2.554; p = 0.177). Of the 106 patients who received methylprednisolone, the duration of invasive mechanical ventilation was significantly shorter in the pulse/semi-pulse versus standard dose group (HR, 2.831; 95% CI, 1.347-5.950; p = 0.006). In conclusion, corticosteroids for hospitalized patients with COVID-19 did not improve clinical status on Day 15, but reduced the time to improvement in radiological findings for all patients regardless of disease severity and also reduced the duration of invasive mechanical ventilation in patients who required intubation.Trial registration: This study was registered in the University hospital Medical Information Network Clinical Trials Registry on April 21, 2020 (ID: UMIN000040211).

Reproducibility of peripheral branches in virtual bronchoscopic navigation using VINCENT and LungPoint software for peripheral lung lesions

BACKGROUND

Recently, virtual bronchoscopic navigation (VBN) has become frequently used for the pathological specimen collection of peripheral lung lesions using various VBN software packages. Herein, we examined the reproducibility of peripheral branches in VBN software using LungPoint and VINCENT versions 4.0 and 5.5.

METHODS

This study included patients suspected of malignant peripheral lung lesions who underwent bronchoscopy at our hospital from February 2016 to April 2017. Computed tomography was taken at a thickness of 1.25 mm in all cases, and VB images were created based on the computed tomography data using LungPoint, or VINCENT version 4.0 or 5.5. One observer read the program-generated VB images and compared how many branches could be visualized with the lobe bronchus as the primary branch.

RESULTS

A total of 129 patients (n = 131 lesions) underwent bronchoscopy, with 82 cases of primary lung cancer. Pathological bronchoscopic diagnosis was done in 63 cases, resulting to a diagnostic rate of 76.8%. VB images generated by LungPoint, and VINCENT versions 4.0 and 5.5 reproduced an average of 4.3, 3.47, and 5.12 branches, respectively, with significant differences (p < 0.05) between them.

CONCLUSIONS

VINCENT version 5.5 exhibits better reproducibility of peripheral branches than LungPoint for VBN.

Identification of patients with COVID-19 who are optimal for methylprednisolone pulse therapy

BACKGROUND

Corticosteroids have been reported to reduce the mortality rates in patients with coronavirus disease 2019 (COVID-19). Additionally, the role of high-dose methylprednisolone pulse therapy in reducing mortality in critically ill patients has also been documented. The purpose of this study is to identify patients with COVID-19 who are suitable for methylprednisolone pulse therapy.

METHODS

This was a retrospective study that included patients with COVID-19 receiving methylprednisolone pulse therapy (≥250 mg/day for 3 days) with subsequent tapering doses at our hospital between June 2020 and January 2021. We examined the differences in background clinical factors between the surviving group and the deceased group.

RESULTS

Out of 156 patients who received steroid therapy, 17 received methylprednisolone pulse therapy. Ten patients recovered (surviving group) and seven patients died (deceased group). The median age of the surviving and deceased groups was 64.5 years (range, 57-85) and 79 years (73-90), respectively, with a significant difference (p=0.004). Five of the deceased patients (71%) had developed serious complications associated with the cause of death, including pneumothorax, pneumomediastinum, COVID-19-associated pulmonary aspergillosis, cytomegalovirus infection, and bacteremia. On the other hand, out of the 10 survivors, only one elderly person had cytomegalovirus infection and the rest recovered without complications.

CONCLUSION

Administration of methylprednisolone pulse therapy with subsequent tapering may be an effective treatment in patients with COVID-19 up to the age of early 70s; however, severe complications may be seen in elderly patients.

A surgically treated case of severe upper gastrointestinal hemorrhage with gastritis cystica polyposa

Background

Gastritis cystica polyposa (GCP) is a recently recognized entity histologically characterized by hyperplasia and cystic dilatation of the gastric glands spreading through the submucosal layer. Its symptoms include those affecting the upper gastrointestinal tract, such as upper abdominal pain, nausea, and anorexia, although some patients might be asymptomatic. GCP rarely causes severe hemorrhage. Recently, we encountered a GCP case that exhibited severe hemorrhage.

Case presentation

A 53 year-old man visited the emergency department complaining of hematemesis. He underwent distal gastrectomy and Billroth II reconstruction for duodenal ulcers 32 years ago. Upper gastrointestinal endoscopy detected bleeding from the reddened mucosa at the anastomosis; thus, tentative endoscopic hemostasis was conducted. Despite medical treatment with transfusion, melena with significant hemodynamic impairment persisted. He was treated again with endoscopic hemostasis and interventional radiology (IVR) but remained unresponsive to these procedures. He eventually underwent partial resection of the anastomosis site with Roux-en-Y reconstruction and finally achieved excellent postoperative recovery. Histopathological examination of the resected specimen suggested a GCP bleeding.

Conclusions

GCP can indeed cause severe hemorrhage. Hemorrhage caused by GCP may not respond to endoscopic hemostasis or IVR; therefore, surgical treatment should be decided without delay.

Individual response of humans to ionising radiation: governing factors and importance for radiological protection

Tissue reactions and stochastic effects after exposure to ionising radiation are variable between individuals but the factors and mechanisms governing individual responses are not well understood. Individual responses can be measured at different levels of biological organization and using different endpoints following varying doses of radiation, including: cancers, non-cancer diseases and mortality in the whole organism; normal tissue reactions after exposures; and, cellular endpoints such as chromosomal damage and molecular alterations. There is no doubt that many factors influence the responses of people to radiation to different degrees. In addition to the obvious general factors of radiation quality, dose, dose rate and the tissue (sub)volume irradiated, recognized and potential determining factors include age, sex, life style (e.g., smoking, diet, possibly body mass index), environmental factors, genetics and epigenetics, stochastic distribution of cellular events, and systemic comorbidities such as diabetes or viral infections. Genetic factors are commonly thought to be a substantial contributor to individual response to radiation. Apart from a small number of rare monogenic diseases such as ataxia telangiectasia, the inheritance of an abnormally responsive phenotype among a population of healthy individuals does not follow a classical Mendelian inheritance pattern. Rather it is considered to be a multi-factorial, complex trait.

Thymic epithelial tumor treatment in Japan: analysis of hospital cancer registry and insurance claims data, 2012-2014

INTRODUCTION

Thymic epithelial tumors are a rare type of neoplasm. Accordingly, it is difficult to perform phase III trials in patients with thymic epithelial tumors, and thus, no standard treatment has been established for these tumors. In this study, we aimed to investigate the current status of thymic epithelial tumor treatment in Japan.

METHODS

This retrospective observational study enrolled patients with thymic epithelial tumor whose data were recorded in a nationwide Hospital-based Cancer Registry that was linked with health insurance claims data for the registered patients between 2012 and 2014. The patients' treatment details were obtained from a health insurance claims database.

RESULTS

A total of 813 patients with thymoma and 547 with thymic carcinoma were included in the analysis. Overall, 549 (67.5%) thymoma patients underwent surgical resection alone. Among patients with thymic carcinoma, 230 (42.0%) underwent initial surgery, and 124 (53.9%) received subsequent radiotherapy and chemotherapy. Chemotherapy regimens varied across the hospitals; overall, 21 and 22 regimens were used to treat thymoma and thymic carcinoma, respectively. Platinum-based combination regimens were predominantly selected for both diseases.

CONCLUSIONS

This study revealed the real-world patterns of thymic epithelial tumor treatment in Japan. Although the nature of this study did not enable the determination of optimal treatment strategies, the simultaneous analysis of nationwide registry, insurance, efficacy and prognostic data may contribute to the establishment of a standard treatment strategy for rarely occurring cancers such as thymic epithelial tumor.

Bilateral Pleuritis as the Initial Symptom of Systemic Lupus Erythematosus: A Case Series and Literature Review

We documented four cases of systemic lupus erythematosus (SLE) presenting with pleuritis as the initial disease manifestation. The diagnosis was challenging because, atypically, all patients were elderly and 3 of the 4 patients were men. Furthermore, SLE pleuritis, characterized by lymphocytic pleural effusion and high ADA activity, is difficult to differentiate from tuberculous pleurisy. A detailed physical examination, blood tests, and urinalysis are therefore indispensable to ensure an accurate diagnosis. We also reviewed the previously published case reports on SLE patients presenting with pleuritis and discussed the relevant findings.

Primary Synovial Sarcoma of the Mediastinum with Long-term Follow-up

Chest radiography showed a right posterior mass on the mediastinum of an 84-year-old woman. The mass had been growing gradually for four years. Surgical excision was performed, and a pathological examination found the mass to be consistent with primary synovial sarcoma (SS) of the mediastinum. To our knowledge, this is a rare case in which follow-up imaging was able to be performed over a period of four years. This disease is aggressive, and its early diagnosis is key to achieving a cure. It is important to consider primary SS in the differential diagnosis of a primary intra-thoracic tumor, even if the tumor grows slowly.

Effects of catechin-enriched ion beverage intake on thermoregulatory function in a hot environment

We examined the effect of intake of a catechin-enriched ion beverage (Cat-I) on the thermoregulatory response in a hot environment. Eight healthy men were exposed to a hot environment for 90 min at an ambient temperature of 35 °C (relative humidity: 75%) combined with lower leg water immersion at 40 °C. At that time, either Cat-I, an ion beverage (Ion), or mineral water (Placebo) was consumed at three points: (1) at the start of lower leg immersion, (2) at 30 min after immersion, and (3) at 60 min after immersion. In all conditions, tympanic temperature (Tty) increased gradually during lower leg water immersion. However, the rate of increase of Tty tended to be suppressed after 30 min. The effect of drinking Cat-I had a limited detection period of approximately 60-70 min, and the rate of sweating was clearly increased with Cat-I compared with Ion and Placebo. Cat-I also tended to decrease the body temperature threshold at which sweating was induced compared with Ion or Placebo. These findings suggest that Cat-I efficiently suppressed the increase of body temperature in a hot environment.

Effect of spraying of fine water particles on facial skin moisture and viscoelasticity in adult women

BACKGROUND/PURPOSE

It is known that the elderly and adult women with reduction in sebum secretion have reduced skin barrier function, drying of the skin in a low humidity environment is accompanied by physiological distress. As our hypothesis, when fine water particles are sprayed on the skin, the water content of the corneal layer is significantly increased. In the present study, we examined the ability of fine water particles to improve facial skin moisture levels in adult women.

METHODS

We examined skin conductance, transepidermal water loss (TEWL), and skin elasticity as an index of skin barrier function at the cheek in 17 healthy adult women in the spraying of fine water particles, in the environment temperature at 24°C and 34.5% relative humidity.

RESULTS

The skin conductance of stratum corneum after 120 minute of spraying, A condition (peak particle size below 0.5 μm) was 119.7 ± 25.1%, B condition (peak particle size 1.8 μm) was 100.4 ± 31.7%, C condition (peak particle size 5.4 μm) was 110.1 ± 25.0%, and the A condition was significantly higher than the B condition. Also, skin elasticity in the A condition tended to be higher value than in the other conditions. Transepidermal water loss (TEWL) after 120 minute of spraying showed a lower value in the A condition than in the other conditions. In the A condition, the skin conductance steadily maintained their initial levels up to 360 minute after spraying.

CONCLUSION

Especially, by spraying smallest fine water particles, skin barrier function at the cheek was improved. These data indicated that non-charged fine water particles played an important role on moisten skin in a low humidity environment.

The clinical practice of high-flow nasal cannula oxygen therapy in adults: A Japanese cross-sectional multicenter survey

BACKGROUND

High-flow nasal cannula oxygen therapy (HFNC) is widely used mainly in the acute care setting, but limited data are available on real-world practice in adults. The objective of this study was to describe HFNC practices in Japanese adults.

METHODS

A retrospective cross-sectional multicenter survey of adult patients receiving HFNC from January through March 2015 was conducted in 33 participating hospitals in Japan.

RESULTS

We obtained information on 321 patients (median age, 76; 218 men, 103 women; median estimated PaO₂/F_IO_2, 178 mm Hg) from 22 hospitals. Do-not-intubate status was determined in 37.4% of patients. Prior to HFNC, 57.9% of patients received conventional oxygen therapy; 25.9%, noninvasive ventilation; and 15.0%, invasive mechanical ventilation. The common indications for HFNC were acute hypoxemic respiratory failure (ARF) (65.4%), postoperative respiratory support (15.9%), and post-extubation respiratory support (11.2%). The underlying etiology of ARF included interstitial lung disease, pneumonia, and cardiogenic pulmonary edema. HFNC was administered mostly in intensive care units or intermittent care units (60.7%) and general wards (36.1%). Median duration of HFNC was 4 days; median total flow rate, 40 L/min; and median F_IO₂, 50%. HFNC significantly improved PaO₂, PaCO₂, SpO₂ and respiratory rate from baseline. Two-thirds of patients finally survived to be discharged or transferred.

CONCLUSIONS

We documented patient demographics, clinical indications, and settings of HFNC use in the real world. We also demonstrated positive effects of HFNC on respiratory parameters. Further studies are urgently needed regarding the efficacy and safety of HFNC in populations outside of previous clinical trials.