The association between transfer coefficient of the lung and the risk of exacerbation in asthma-COPD overlap: an observational cohort study.

BACKGROUND: Asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) patients experience exacerbations more frequently than those with asthma or COPD alone. Since low diffusing capacity of the lung for carbon monoxide (DLCO) is known as a strong risk factor for severe exacerbation in COPD, DLCO or a transfer coefficient of the lung for carbon monoxide (KCO) is speculated to also be associated with the risk of exacerbations in ACO. METHODS: This study was conducted as an observational cohort survey at the National Hospital Organization Fukuoka National Hospital. DLCO and KCO were measured in 94 patients aged ≥ 40 years with a confirmed diagnosis of ACO. Multivariable-adjusted hazard ratios (HRs) for the exacerbation-free rate over one year were estimated and compared across the levels of DLCO and KCO. RESULTS: Within one year, 33.3% of the cohort experienced exacerbations. After adjustment for potential confounders, low KCO (< 80% per predicted) was positively associated with the incidence of exacerbation (multivariable-adjusted HR = 3.71 (95% confidence interval 1.32-10.4)). The association between low DLCO (< 80% per predicted) and exacerbations showed similar trends, although it failed to reach statistical significance (multivariable-adjusted HR = 1.31 (95% confidence interval 0.55-3.11)). CONCLUSIONS: Low KCO was a significant risk factor for exacerbations among patients with ACO. Clinicians should be aware that ACO patients with impaired KCO are at increased risk of exacerbations and that careful management in such a population is mandatory.

Association of serum antibodies against the Mycobacterium avium complex and hemoptysis: a cross-sectional study.

BACKGROUND: Hemoptysis is very common and can be life threatening in clinical practice for nontuberculous mycobacteria. The serum antibody against the Mycobacterium avium complex (MAC-Ab), the majority of nontuberculous mycobacteria species, is well known to reflect the activity of MAC lung disease; however, there is no study investigating the association between the MAC-Ab and hemoptysis in MAC patients. Therefore, we assessed whether the MAC-Ab is a good biomarker for hemoptysis among subjects with MAC lung disease. METHODS: This study was conducted as a five-year retrospective survey at the National Hospital Organization Fukuoka National Hospital. A total of 155 patients aged ≥20 years with MAC lung disease were enrolled and separated into seropositive and seronegative groups using the cutoff for MAC-Ab levels of 0.7 U/ml. The prevalence of hemoptysis and odds ratios for the presence of hemoptysis were estimated and compared between the groups. To investigate the linear trends in the relationship between MAC-Ab levels and hemoptysis, the subjects were classified into three groups using the tertile distribution of the MAC-Ab. RESULTS: The prevalence of hemoptysis was twice as high in the seropositive group than in the seronegative group (42.2 and 21.7%, respectively, P = 0.02). The multivariable-adjusted risk of hemoptysis was elevated in the seropositive group as compared with the seronegative group (odds ratio = 2.79 (95% confidence interval 1.15-7.44)). Likewise, when categorizing the subjects into three groups, the risk of hemoptysis increased with increasing MAC-Ab levels (P = 0.03 for trend). CONCLUSIONS: A positive MAC-Ab level was a significant risk factor for hemoptysis among patients with MAC lung disease. There were also positive trends in the association between the MAC-Ab titer and the likelihood of hemoptysis. Measuring the MAC-Ab may contribute not only to early detection of the risk of hemoptysis but also to early intervention with anti-NTM therapy and, as a result, to the prevention of hemoptysis in MAC patients.

[The effect of inhaled anticholinergic drugs (tiotropium bromide) on asthma patients with persistent obstructive ventilatory impairment].

AIM: This study investigated the effects of tiotropium bromide on chronic asthma patients with persistent obstructive ventilatory impairment (FEV1/FVC%<70%) like COPD. METHODS AND SUBJECTS: Twenty-four patients (14 males, 10 females, mean age 64.3±10.7 years old) were enrolled. They were all treated with a high dose inhaled steroids and a long-acting ß2-agonist. All patients had bronchial reversibility, normal diffusing capacity (DLCO) and no low attenuation areas in HRCT. This study examined the FEV1 at baseline and after inhalation of short-acting bronchodilators (400 µg salbutamol and 40 µg ipratropium, 15 minutes and 30 minutes after, respectively). Eleven patients agreed to take an additional treatment with tiotropium, and received 18 µg of tiotropium per daily for one year. The usual treatments were continued for 7 patients that did not agree to take tiotropium and for 6 patients who were ineligible for tiotropium due to co-morbidities. The FVC, FEV1, FEV1/FVC%, V50, and IC were compared between the two groups after one year. RESULTS: FEV1 and V50 were significantly elevated after one year in the tiotropium-treated patients in comparison to those in the 13 subjects that did not receive tiotropium bromide, after adjusting for age, smoking and the values determined on enrollment. There was a positive correlation between the change of FEV1 30 min after ipratropium inhalation (short-term effect) and FEV1 one year after tiotropium inhalation (long-term effect). CONCLUSION: Combination treatment with tiotropium, high dose steroids and long-acting ß2 agonist inhalation provides improvement in the expiratory flow limitations of asthma patients with persistent obstructive ventilatory impairment.

Clinical evaluation of a new rapid immunochromatographic test for detection of Bordetella pertussis antigen.

A more rapid and less complicated test to diagnose pertussis is required in clinical settings. We need to detect Bordetella pertussis, which mainly causes pertussis, as early as possible, because pertussis is more likely to become severe in infants, and people around them can easily become a source of infection due to its strong infectivity. Nevertheless, methods that can detect B. pertussis rapidly and efficiently are lacking. Therefore, we developed a new immunochromatographic antigen kit (ICkit) for the early diagnosis of pertussis. The ICkit detects B. pertussis antigens in a nasopharyngeal swab without equipment and provides the result in about 15 min with a simple procedure. Additionally, a prospective study to evaluate the ICkit was conducted in 11 medical institutions, involving 195 cases with suspected pertussis. Compared with the real-time polymerase chain reaction (rPCR), the sensitivity and specificity of the ICkit were 86.4% (19/22) and 97.1% (168/173), respectively. The ICkit detected the antigen in both children and adults. Furthermore, the ICkit detected the antigen until the 25th day from the onset of cough, when rPCR detected the antigen. Thus, the ICkit demonstrated a high correlation with rPCR and would help diagnose pertussis more rapidly and efficiently.

[Pulmonary disorders in indium-processing workers].

The production of indium-tin oxide has increased during the past decade, owing to the increased manufacture of liquid-crystal panels, especially in Japan. We carried out a medical checkup including high resolution CT (HRCT), pulmonary function test, KL-6, SP-D and serum indium concentration, for 40 men (mean age 40.4 +/- 12.4 years old) working in an indium plant. Four workers who were all smokers had emphysematous changes on HRCT and one subject (non-smoker) had lung cancer. There were no findings of interstitial changes on HRCT. Serum KL-6 was significantly elevated (over 500U/ml) in 9 subjects (22.5%). Subjects with a high concentration of serum indium (3ng/ml<) had significantly longer exposure periods, higher KL-6 and SP-D levels compared with those with a low concentration (3ng/ml>). The serum indium concentration positively correlated with the KL-6 level. These results suggest that inhaled indium compounds can cause pulmonary disorders such as interstitial changes.

[A case of inflammatory granuloma secondary to a foreign body (Cryptomeria) mimicking a bronchial tumor].

This report documents a case of inflammatory granuloma overcoming secondary to a foreign body (Cryptomeria) mimicking a bronchial tumor. A 45-year-old man was referred to the hospital because of hemoptysis and a chronic cough. He had had a chronic cough before visiting the hospital, but had left it untreated for months. A computed tomography (CT) scan showed bronchiectasis in the right lower lobe with evidence of mediastinal lymphadenopathy. Fiberoptic bronchoscopic examinations revealed a tumor with an uneven surface at the orifice of the right B10(b+c), bronchus. The cytological findings of the bronchial tumor showed no malignancy but a predominance of neutrophils. Antibiotics were administered intravenously because of a suspected respiratory infection. After treatment, the abnormal shadows on the chest CT improved. Fiberoptic bronchoscopic examinations showed the bronchial tumor to have disappeared, and a bronchial foreign body was found lodged in the right. B10(b+c) bronchus and it was removed. Pathological examinations and a detailed history revealed that the patient had aspirated a foreign body (Cryptomeria). The tumor was thought to be an inflammatory granuloma secondary to the aspiration of the foreign body. This case highlights the need to search aggressively for foreign bodies in case of clinical symptoms, such as chronic cough, hemoptysis, or findings such as respiratory infection, and bronchial occlusion.

A 63-Year-Old Woman With Progressive Dyspnea After Remission of Lymphoma.

CASE PRESENTAION: A 63-year-old woman visited our hospital for a further evaluation of progressive dyspnea. She had developed a progressive airflow obstruction after 3 years' remission of non-Hodgkin's lymphoma (follicular mixed cell type), which had been treated with chemotherapy (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone). The patient's primary care physician had diagnosed her as having COPD and bronchial asthma and had treated her with medications including inhaled corticosteroids, tiotropium, and oral erythromycin. Her dyspnea had gradually worsened, however, and she had a score of 4 on the modified Medical Research Council dyspnea scale at the time of admission to our hospital.

Hypoalbuminemia, influenza vaccination and other factors related to the development of pneumonia acquired outside hospitals in southern Japan: A case-control study.

AIM: Pneumonia is the third largest cause of death in Japan. Pneumonia continues to be one of the most common causes of morbidity, hospitalization and mortality, especially in the elderly. The aim of the present study was to evaluate the factors related to the development of pneumonia acquired outside hospitals among the Japanese elderly. METHODS: We carried out a hospital-based, case-control study. Cases were patients who had been newly diagnosed with pneumonia acquired outside hospitals. For each case, one to three controls were defined as outpatients with other diseases (not pneumonia) at the same hospitals. All participants (i.e. 50 cases and 110 controls) were aged 65 years and older. RESULTS: Compared with control participants, hypoalbuminemia (<3.5 g/dL) and low body mass index (<18.0) were more common in pneumonia patients, whereas the proportion of those who could go out by themselves (i.e. self-support in activities of daily living) and the vaccination rate of seasonal influenza were lower in patients with pneumonia than control participants. Even after controlling for age, sex, hospital and aforementioned four factors, hypoalbuminemia (OR 9.19, 95% CI 3.70-22.81) increased the risk of pneumonia, whereas seasonal influenza vaccination (OR 0.37, 95% CI 0.16-0.85) reduced the risk. Even after excluding those who lived in a nursing home, hypoalbuminemina (OR 12.19, 95% CI 4.29-34.63) increased the risk of pneumonia. CONCLUSIONS: Hypoalbuminemia might be a risk factor for pneumonia among the elderly living in the community.

Breath Sound Intensity during Tidal Breathing in COPD Patients.

OBJECTIVE: There is a discrepancy in the intensity of breath sounds in chronic obstructive pulmonary disease (COPD) patients between subjective studies, which have reported a diminished intensity, and objective studies using airflow-standardized measurements, which have not demonstrated a diminished intensity. We herein evaluated the breath sound intensity in COPD patients during tidal breathing in order to obtain clinically relevant results. METHODS: The subjects included 20 stable COPD patients and 20 normal controls. Microphones were attached to six sites on the chest wall, and breath sounds at the chest wall and airflow in the mouth were measured during resting tidal and deep tidal breathing. The octave-band power values of the breath sounds were subsequently calculated. RESULTS: 1. During resting breathing, the intensity of breath sounds during both inspiration and expiration was significantly greater in the COPD group than in the control group; the difference was prominent at higher frequency bands (>400 Hz). In addition, the power of the high frequency bands tended to be positively correlated with the CT visual emphysema scores but not the forced expiratory volume in one second, The airflow during resting breathing did not differ between the two groups. 2. During deep breathing, the intensity of inspiratory breath sounds at the dominant frequency band (200-400 Hz) was diminished over the upper and middle lung fields in the COPD group compared to that observed in the control group, while the intensity during expiration was not. The airflow during deep breathing was lower in the COPD group than in the control group. CONCLUSION: In the present study, the breath sound intensity in the COPD patients was diminished during deep inspiration due to a reduced airflow and increased during both resting inspiration and expiration.

[A case of tuberculosis pleuritis with high serum soluble IL-2 receptor].

A 56-year-old man was admitted to our hospital because of bilateral pleural effusion. Computed tomography revealed solitary mediastinal lymphadenopathy, splenomegaly and a small amount of ascites. No lung parenchymal lesion was seen. Although lymphocyte predominance without atypia and a high adenocine deaminase concentration in the pleural fluid were compatible with tuberculous pleurisy, no mycobacteria could be detected either with Ziehl-Nielsen stain or with PCR. Because the serum soluble interleukin 2 receptor (sIL-2 R) level was unexpectedly high (> 8,000 U/ml), and a level not previously reported in benign diseases, we performed thoracoscopy- and mediastinoscopy-assisted biopsies, both of which eventually confirmed the diagnosis of tuberculosis. After a 4-drug anti-tuberculous regimen was initiated, pleural effusion and ascites subsided, with a marked decrease in the sIL-2R level. This case indicates that in tuberculous pleurisy, serum sIL-2R can rise to a level suggestive of hematological malignancies, it and also illustrates the validity of thoracoscopy-assisted pleural biopsy in such situations.

Exhaled nitric oxide as a simple assessment of airway hyperresponsiveness in bronchial asthma and chronic cough patients.

Exhaled nitric oxide (NO) has been suggested to be a marker of airway inflammation. The aim of this study was to evaluate the role of exhaled NO in bronchial asthma and chronic cough patients to predict bronchial hyperresponsiveness (BHR). We measured the exhaled NO concentration using the chemiluminescence method in 52 asthma patients (group I consisting of 24 without prior inhaled corticosteroid (ICS) use, and group II consisting of 28 previously on ICS and 16 chronic cough patients in group III). In addition to regular examinations, spirometry and methacholine inhalation tests using the Astograph were done. In group I, a significantly negative correlation was observed regarding the exhaled NO concentration with FEV1/FVC%, V50, and BHR that was assessed as Dmin and PD35-Grs, and a positive correlation with peripheral blood eosinophils. In group III, a significantly negative correlation was seen regarding the exhaled NO concentration with BHR. We thus concluded that measuring exhaled NO concentration appears to be a useful noninvasive method to predict the BHR, airway obstruction, and inflammation in asthma and chronic cough patients.