The pathogenic role of lupus-specific autoantibodies and Interleukin-6 on demyelination of the brainstem and spinal cord in systemic lupus erythematosus.

OBJECTIVES: Demyelinating syndromes that result in brainstem and/or spinal cord lesions similar to those observed in neuromyelitis optica spectrum disorder (NMOSD) as neuropsychiatric syndromes in systemic lupus erythematosus (NPSLE) occasionally develop in patients with SLE. Cerebrospinal fluid (CSF) interleukin (IL)-6 is a known biomarker for NMOSD; however, its application in patients with SLE with brainstem and/or spinal cord lesions is unknown. Additionally, the breakdown of blood-brain barrier (BBB) integrity by autoantibodies is another mechanism of NMOSD; however, it is not elucidated in SLE. Therefore, this study was designed to clarify the use of CSF IL-6 and investigate whether autoantibodies contribute to BBB breaches and the development of brainstem and/or spinal cord lesions. METHODS: Data from patients with NPSLE who had NMOSD-like demyelinating lesions in the central nervous system (CNS), including brainstem and/or spinal cord lesions, were retrospectively analyzed. We retrospectively investigated the interval changes in CSF IL-6 and clinical and serological factors related to BBB permeability using CSF/serum albumin ratio (QAlb). RESULTS: Twelve patients with NPSLE who had demyelinating lesions in the brainstem and/or spinal cord were recruited. Before treatment, CSF IL-6 levels were 29.1 pg/mL and significantly decreased to 3.8 pg/mL by treatment (p = 0.008). Before treatment, CSF IL-6 was significantly correlated with the anti-dsDNA antibody titer (p = 0.027). Furthermore, before treatment, QAlb was significantly correlated with the serum anti-Smith antibody titer. In patients with atypical NMOSD who had specific lesions defined in the NMOSD diagnostic criteria but were negative for antiaquaporin four antibody, a significant correlation was observed between the serum anti-Smith antibody titer and CSF IL-6 (p = 0.025) and QAlb (p = 0.033) values before treatment. CONCLUSION: CSF IL-6 could be a surrogating marker for disease activity, and serum anti-Smith antibody permeabilizes the BBB in patients with NPSLE, supporting the development of NMOSD-like CNS lesions.

Real-world efficacy of belimumab in achieving remission or low-disease activity in systemic lupus erythematosus: A retrospective study.

OBJECTIVES: We investigated the effect of belimumab (BEL) on achieving low disease activity (LDA) and remission as an additive molecular-targeting agent to standard of care (SoC) in patients with SLE. METHODS: Clinical information was retrospectively collected from patients with SLE who received BEL additive to SoC (BEL+SoC), and from patients treated with SoC alone as a control arm. Disease activity was measured by SLE-disease activity score (SLE-DAS). The proportion of patients in LDA and remission at 12 months was compared after propensity score matching. The factors contributing to LDA and remission achievement was identified by Cox proportional hazard model. RESULTS: BEL+SoC significantly reduced SLE-DAS at 6 months, with a significantly higher proportion of patients achieving LDA and remission at 12 months compared to SoC alone. The presence of arthritis at baseline was significantly associated with achieving LDA and remission. Additionally, both treatment groups experienced a significant reduction in daily glucocorticoid dose. CONCLUSIONS: Adding BEL to SoC was beneficial for patients with arthritis, leading to higher proportion of achieving LDA and remission, while also reducing their glucocorticoid dose. Our results indicate the utility of BEL in a treat-to-target approach for SLE patients in a real-world setting.

Evaluation of a carbapenem antimicrobial stewardship program and clinical outcomes in a Japanese hospital.

INTRODUCTION: Microorganisms can evolve and become resistant to antimicrobials, and this is known as antimicrobial resistance (AMR). Inappropriate use of antibiotics contributes to AMR, and antimicrobial stewardship programs have been developed to mitigate AMR. The Appropriate Use of Carbapenems Program was implemented in March 2019 in a university hospital and its effect was evaluated. METHODS: We conducted a prospective audit and feedback on carbapenems at the time of prescription daily. Additionally, we compared a monthly survey of the total days of therapy (DOTs) per 1000 patient-days for carbapenems, piperacillin/tazobactam, and fluoroquinolones. The susceptibility of Pseudomonas aeruginosa to meropenem, piperacillin/tazobactam, and levofloxacin was tested before (January 2018 to February 2019) and after (March 2019 to December 2020) the intervention. RESULTS: The monthly median DOTs of carbapenem usage decreased after the intervention; carbapenem use immediately declined during the intervention period. The monthly median DOTs of piperacillin/tazobactam and fluoroquinolones also decreased and continued to decline significantly after the intervention. Susceptibility of P. aeruginosa to meropenem, piperacillin/tazobactam, and levofloxacin did not change significantly during the study. CONCLUSION: The implementation of the Appropriate Use of Carbapenems Program was effective in reducing the use of broad-spectrum antibiotics and maintaining the antibiotic susceptibility of P. aeruginosa.

Clinical feasibility of remote intermittently scanned continuous glucose monitoring in coronavirus disease 2019 patients with and without diabetes during dexamethasone therapy.

The clinical utility of intermittently scanned continuous glucose monitoring (isCGM) in patients with coronavirus disease 2019 (COVID-19) is unclear. Hence, we investigated the accuracy of isCGM in COVID-19 patients during dexamethasone therapy. We evaluated the accuracy of the FreeStyle Libre via smartphone isCGM device compared to point-of-care (POC) fingerstick glucose level monitoring in 16 patients with COVID-19 (10 with and 6 without diabetes, 13 men; HbA1c 6.9 ± 1.0%). Overall, isCGM correlated well with POC measurements (46.2% and 53.8% within areas A and B of the Parkes error grid, respectively). The overall mean absolute relative difference (MARD) for isCGM compared to POC measurements was 19.4%. The MARDs were 19.8% and 19.7% for POC blood glucose measurements ranging from 70 to 180 mg/dL and >180 mg/dL, respectively. When divided according to the presence and absence of diabetes, both groups of paired glucose measurements showed a good correlation (56.3% and 43.7%, and 27.1% and 72.9% within the A and B areas in patients with and without diabetes, respectively), but the MARD was not significant but higher in patients without diabetes (16.5% and 24.2% in patients with and without diabetes). In conclusion, although isCGM may not be as accurate as traditional blood glucose monitoring, it has good reliability in COVID-19 patients with and without diabetes during dexamethasone therapy.

Analysis of the Time-To-Onset and Factors Affecting Clinical Outcomes of Immune Reconstitution Inflammatory Syndrome in People Living with HIV Using Data from the Japanese Spontaneous Reporting Database.

PURPOSE: Data on immune reconstitution inflammatory syndrome (IRIS), despite being a widely recognized complication of antiretroviral therapy, remain limited. The objective of the present study was to evaluate the time-to-onset and factors affecting clinical outcomes of IRIS in people living with HIV (PLWH) using data from the Japanese Adverse Drug Event Report (JADER) database. METHODS: Data of PLWH who developed IRIS as an adverse event were extracted from the JADER database. Cases with the data of both the start date of anti-HIV drug therapy and date of IRIS onset were included in the study. The survey items included sex, age, anti-HIV drug use, IRIS-compatible events, time-to-onset of IRIS, and clinical outcome. The time-to-onset of IRIS was evaluated in relation to anchor drug use. Overall, 79 cases were included in the analysis. RESULTS: The median (range) time-to-onset of IRIS was 29 (1-365) days, and it differed significantly between IRIS-compatible events (P = 0.029). In particular, the time-to-onset of Pneumocystis pneumonia-IRIS was the shortest among the IRIS-compatible events (median [range]: 12 [5-301] days). Age ≥ 50 years at IRIS onset appeared to be related to the poor clinical outcomes of IRIS in PLWH (P = 0.048). The use of integrase strand transfer inhibitors did not affect the time-to-onset of IRIS or clinical outcome of IRIS in PLWH. CONCLUSION: This analysis based on the data from the JADER database revealed that IRIS-compatible events were related to the time-to-onset of IRIS and that patients older than 50 years had poorer clinical outcomes of IRIS. This finding will be useful for healthcare professionals when considering medications for patients with HIV infection/AIDS and for the management of IRIS.

First report in Japan of a delivery of a woman with the 2019 novel coronavirus disease.

On April 2, 2020, we received a maternal transport from a local city hospital of a pregnant woman (38 weeks and 0 days of gestation) in her 20s, who had the 2019 novel coronavirus disease (COVID-19). We performed an emergency cesarean section with spinal anesthesia because of an abnormal fetal heart rate pattern. A healthy 3106-g male baby was delivered. All the severe acute respiratory syndrome coronavirus 2 polymerase chain reaction tests of nasal and oral discharges, anal swabs and blood samples of the neonate at 9 h, 30 h and 4 days after birth were negative. Because the mother was diagnosed as having COVID-19 pneumonia, the neonate was given formula milk. The mother's nasal discharge samples at 20 and 21 days were negative. The mother first held her baby in her arms on the 22nd day after birth, and they were discharged on the following day. To the best of our knowledge, this is the first report in Japan of a delivery of a baby from a woman infected with COVID-19.

Detection of Streptococcus agalactiae by immunochromatography with group B streptococcus-specific surface immunogenic protein in pregnant women.

BACKGROUND: Infection with Streptococcus agalactiae (Group B streptococcus: GBS) is a significant cause of morbidity and mortality in neonates. Screening for GBS is mainly done by culture-based methods, but a reliable result may take several days to obtain and culture is difficult to perform at institutions without a laboratory. We evaluated an immunochromatography method for rapid detection of GBS-specific surface immunogenic protein (Sip) using anti-Sip monoclonal antibodies. MATERIALS AND METHODS: A total of 377 cervical and vaginal swabs collected during weeks 35-37 of gestation were inoculated into GBS medium F and incubated. Growth of microorganisms and production of red/orange pigment were assessed by observation. Then culture extracts were subjected to immunochromatography and were also inoculated onto chromID Strepto B (STRB) medium, after which isolates were serotyped and characterized by PCR. RESULTS: Of the 377 samples, 54 (14.3%) were positive for GBS by immunochromatography after incubation in GBS medium F. On the other hand, GBS was isolated from 58 (15.4%) of the 377 samples by culture with GBS medium F and STRB medium. Ten of the 58 isolates were non-pigmented and 4 of these were not detected by immunochromatography. The sensitivity, specificity, positive predictive value, and negative predictive value of immunochromatography were 93.1% (54/58), 100% (319/319), 100% (54/54), and 98.8% (319/323), respectively. CONCLUSIONS: Immunochromatography was comparable to culture on STRB medium for detecting GBS, indicating that this method could be used clinically for GBS screening in pregnant women even at small institutions.

Transverse myelitis extended to disseminated encephalitis in systemic lupus erythematosus: Histological evidence for vasculitis.

A 42-year-old woman was admitted due to systemic lupus erythematosus complicated with glomerulonephritis and pulmonary hypertension. During the treatment for these complications, she presented motor paresis and sensory loss caused by transverse myelitis. In spite of methyl prednisolone pulse therapy, she further developed acute confusional state due to disseminated encephalitis and fell into respiratory arrest. On laboratory examination, elevation of anti-NR2 antibodies in serum as well as in cerebrospinal fluid was noted. Although she recovered from the disseminated encephalitis after extensive treatment with high doses of corticosteroid and intravenous cyclophosphamide, she suddenly died of pulmonary hypertension. Autopsy findings confirmed the presence of liquefaction necrosis in the entire circumference of the whole spinal cord along with intimal hyperplasia and obliteration of the small arteries, accompanied by mononuclear cell infiltration and disruption of internal elastic lamina. It is therefore most likely that our patient developed longitudinal transverse myelitis through spinal cord vasculitis, which extended to brainstem and brain parenchyma, leading to the development of disseminated encephalitis.

Evaluation of the efficacy and safety of changes in antiretroviral regimens for HIV-infected patients.

PURPOSE: Antiretroviral therapy is now available for HIV-infected patients, and so-called highly active antiretroviral therapy (HAART) now makes it possible to strongly suppress viral proliferation and restore immunity. However, the development of new drugs and regimens for HAART is still in progress, with the aim of overcoming a number of associated problems. For this purpose, changes in the prescribed anti-HIV drugs are often made. In the present study, we attempted to clarify the actual effects of such treatment modifications in patients who had been started on HAART. METHODS: We retrospectively investigated HIV-infected patients who had been started on HAART at Kitasato University Hospital between April 1997 and March 2013. The patients' backgrounds, characteristics and laboratory data were established from the hospital medical records. RESULTS: The total follow-up time was 447.3 person-years. The patients remained on their initial regimen for a median period of 2040 days, and 39 patients took a second regimen for a median of 2714 days. There was no treatment failure due to regimen change. The reason for the regimen change was adverse effects in 49 cases, poor adherence/virological failure in 4, immunological failure in 3, patient request in 2, and proposals made by health care workers, or for simplification, in 11. The number of patients who required regimen change due to renal dysfunction showed a gradual increase. The number of times anti-HIV drugs were taken per day was not altered when the regimen changed, being mainly once or twice a day. CONCLUSION: In the present study, there were no instances of treatment failure due to regimen change. Through appropriate regimen change, it is possible to avoid serious adverse effects, and to improve patient adherence. Further adverse effects associated with long-term antiretroviral therapy, and reduction of adherence through medication fatigue should be considered. Drug selection and regimen change should be considered in relation to long-term prognosis.

IgG4-related disease complicated with diffuse and chronic gastrointestinal inflammation leading to small intestinal perforation.

Immunoglobulin (Ig) G4-related disease (IgG4-RD) is a systemic inflammatory disease characterised by elevated serum IgG4, IgG4+ cell infiltration, storiform fibrosis, and obliterative phlebitis. While IgG4-RD can affect various organs, gastrointestinal tract involvement is less common. Here, we report a 70-year-old female with IgG4-RD complicated with diffuse and chronic gastrointestinal inflammation, which led to small intestinal perforation. She had been suffering from anorexia, abdominal pain, vomiting, and diarrhoea and hospitalised due to recurrent ileus. Consequently, she was referred due to small intestinal perforation required for surgical intervention. Pathology revealed acute and chronic inflammation with massive IgG4+ plasmacyte infiltration into mucosa of the small intestine and ischaemic change secondarily caused by chronic inflammation. Random biopsies from the mucosa of stomach, duodenum, ileum, and colon also revealed diffuse and massive IgG4+ plasmacyte infiltration in stomach, duodenum, small intestine, and colon. She was diagnosed with IgG4-RD based on the pathological findings and elevated serum IgG4 levels. Glucocorticoid rapidly ameliorated the symptoms. IgG4-RD may cause gastrointestinal manifestations, and histopathological assessment should be considered, even in the absence of specific characteristics of IgG4-RD.

Evaluation of renal adverse effects of combination anti-retroviral therapy including tenofovir in HIV-infected patients.

PURPOSE: In order to maintain plasma HIV-RNA concentration in HIV-infected patients, below the detection limit combination anti-retroviral therapy (cART) are used. Although the nucleoside/nucleotide reverse transcriptase inhibitor, tenofovir disoproxil fumarate (TDF) is a first-line drug commonly used, it is associated with renal dysfunction. Nevertheless, only few clinical studies have focused on TDF in combination with new anti-HIV drugs, including the protease inhibitor (PI) darunavir (DRV), or the integrase strand transfer inhibitor (INSTI) raltegravir (RAL). Here we report the influence of such cART involving TDF on renal function. METHODS: We retrospectively investigated 68 patients under cART that included TDF between November 2004 and May 2012. We used hospital records to establish each patient's background and characteristics, CD4 cell count, plasma HIV-RNA concentration, drug combinations, renal function, and anti-retrovial therapy history. RESULTS: In all patients who had received cART, the plasma HIV-RNA concentration had fallen to less than 40 copies/mL by week 24 after the start of the therapy, and an increase in the CD4 cell count was observed. For each drug used in combination with TDF, the plasma HIV-RNA concentration and CD4 cell count showed a similar trend. After week 12, the estimated glomerular filtration rate (eGFR) had significantly decreased in all patients. The eGFR was significantly lower in those received PI on week 24 and in those received INSTI on week 12. The eGFR was significantly reduced in PI group who received atazanavir + ritonavir (ATV/RTV) on week 60. The eGFR in the DRV/RTV group tended to decrease. The eGFR in the PI and ATV/RTV group was significantly lower than in the efavirenz (EFV) group on week 96. CONCLUSION: It selecting drugs to include in combination therapy of HIV-infected patients, consideration should be given to the risk of renal dysfunction. There is a need to monitor renal function when TDF is combined with ATV/RTV, DRV/RTV or RAL.

[An adult case of acute pericarditis and glomerulonephritis associated with human parvovirus B19 infection].

We report herein on a 52-year-old Japanese woman with acute pericarditis and glomerulonephritis associated with human parvovirus B19 infection, who had no significant medical history. The patient was admitted for progressive edema and upper abdominal pain. On physical examination, she had hypertension, generalized edema and upper abdominal tenderness. Urinalysis revealed protein (1+), and occult blood (+/-), with cellular casts. Echocardiography revealed pericardial effusion measuring 3-9mm in diameter. A serological test showed elevation of serum IgM antibodies for parvovirus B19. At the end of two weeks, generalized edema and glomerulonephritis improved spontaneously, and pericardial effusion was resolved three weeks after admission. This case would appear to be a very rare case indicating a direct relationship between human parvovirus B19 infection and acute pericarditis in a healthy adult patient.

The relation between habitual sleep duration and blood pressure values in Japanese male subjects.

BACKGROUND: Previous studies have demonstrated that sleep duration is closely associated with metabolic risk factors. However, the relationship between habitual sleep duration and blood pressure values in Japanese population has not been fully established. METHODS: We performed a cross-sectional study of 1,670 Japanese male subjects to clarify the relationship between habitual sleep duration and blood pressure values. The study subjects were divided into four groups (<6, 6-, 7-, and ≥8 h) according to their nightly habitual sleep duration. RESULTS: The rate of subjects with <6, 6-, 7-, and ≥8 h sleep duration was 12.0, 37.6, 38.2, and 12.2 %, respectively. Compared with the group with 7-h sleep duration (referent), the <6 and ≥8 h groups had significantly greater systolic and diastolic blood pressure values. The rate of hypertensive subjects, defined as systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg, with sleep duration of <6, 6-, 7-, and ≥8 h was 13.4, 5.7, 7.5, and 13.8 %, respectively. Compared with the group with 7-h sleep duration (referent), the multivariate odds ratios (95 % confidence interval) of the groups with <6 and ≥8 h for hypertension was 2.43 (1.40-4.20, P < 0.01) and 2.28 (1.31-3.95, P < 0.01), respectively, adjusted for conventional cardiovascular risk factors. CONCLUSION: The present study demonstrates that both long and short habitual sleep duration were significantly associated with high blood pressure values and hypertension occurrence in Japanese male subjects.

A Case in Which Breast Cancer Developed at the Same Time As Dermatomyositis, and the Onset of New Cancer Was Able to Be Predicted by the Exacerbating Skin Symptoms and Parallel Increase in the Anti-TIF1-γ Antibody Levels.

Dermatomyositis (DM) is an idiopathic inflammatory myopathy. The incidence of malignancy in DM patients is quite high. Anti-transcription intermediary factor 1-γ (anti-TIF1-γ) antibody is more prevalent in DM patients with malignancy than in those without malignancy. A 70-year-old woman developed hoarseness and difficulty swallowing. A physical examination revealed skin abnormalities. Breast cancer was found in her right breast. She was positive for anti-TIF1-γ antibody. Chemotherapy reduced the tumor size, decreased the anti-TIF1-γ antibody level, and improved her symptoms. About 2.5 years later, however, her skin symptoms worsened, and anti-TIF1-γ antibody levels increased again, and colorectal cancer was found. Treatment with endoscopic mucosal resection (EMR) improved her symptoms again. Our case suggests that the exacerbating skin symptoms and parallel increase in the anti-TIF1-γ antibody level led to the detection of a second cancer after treatment of the first cancer in this case of DM.

Involvement of the complement system in immune thrombocytopenia: review of the literature.

Immune thrombocytopenia (ITP) is a thrombocytopenic condition induced by autoimmune mechanisms and includes secondary ITP with underlying diseases such as connective tissue diseases (CTD). In recent years, it has been elucidated that the subsets of the ITP are associated with complement abnormalities but much remains unclear. To perform a literature review and identify the characteristics of complement abnormalities in ITP. PUBMED was used to collect the literature published up to June 2022 related to ITP and complement abnormalities. Primary and secondary ITP (CTD-related) were examined. Out of the collected articles, 17 were extracted. Eight articles were related to primary ITP (pITP) and 9 to CTD-related ITP. Analysis of the literature revealed that the ITP severity was inversely correlated with serum C3, C4 levels in both ITP subgroups. In pITP, a wide range of complement abnormalities was reported, including abnormalities of initial proteins, complement regulatory proteins, or the end products. In CTD-related ITP, reported complement abnormalities were limited to the initial proteins. Activation of the early complement system, mainly through activation of C3 and its precursor protein C4, was reported for both ITPs. On the other hand, more extensive complement activation has been reported in pITP.

Efficacy and safety of single-dose ivermectin in mild-to-moderate COVID-19: the double-blind, randomized, placebo-controlled CORVETTE-01 trial.

Background: To investigate whether ivermectin inhibits SARS-CoV-2 proliferation in patients with mild-to-moderate COVID-19 using time to a negative COVID-19 reverse transcription-polymerase chain reaction (RT-PCR) test. Methods: CORVETTE-01 was a double-blind, randomized, placebo-controlled study (August 2020-October 2021) conducted in Japan. Overall, 248 patients diagnosed with COVID-19 using RT-PCR were assessed for eligibility. A single oral dose of ivermectin (200 µg/kg) or placebo was administered under fasting. The primary outcome was time to a negative COVID-19 RT-PCR test result for SARS-CoV-2 nucleic acid, assessed using stratified log-rank test and Cox regression models. Results: Overall, 112 and 109 patients were randomized to ivermectin and placebo, respectively; 106 patients from each group were included in the full analysis set (male [%], mean age: 68.9%, 47.9 years [ivermectin]; 62.3%, 47.5 years [placebo]). No significant difference was observed in the occurrence of negative RT-PCR tests between the groups (hazard ratio, 0.96; 95% confidence interval [CI] 0.70-1.32; p = 0.785). Median (95% CI) time to a negative RT-PCR test was 14.0 (13.0-16.0) and 14.0 (12.0-16.0) days for ivermectin and placebo, respectively; 82.1% and 84% of patients achieved negative RT-PCR tests, respectively. Conclusion: In patients with COVID-19, single-dose ivermectin was ineffective in decreasing the time to a negative RT-PCR test. Clinical Trial Registration: ClinicalTrials.gov, NCT04703205.

Pre-Vaccination Anti-Severe Acute Respiratory Syndrome Coronavirus 2 Antibody Seroprevalence in Workers at Three Japanese Hospitals.

BACKGROUND: Antibody testing is essential for accurately estimating the number of people infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This study aimed to investigate the influence of background factors on seroprevalence by testing for anti-SARS-CoV-2 antibodies in blood samples obtained from the staff of three hospitals. METHODS: This cross-sectional observational study was conducted from June 8 to July 4, 2020, as part of a mandatory health examination. Leftover blood samples collected during the health examinations at each hospital were used to test for the presence of anti-SARS-CoV-2 antibodies. The Elecsys Anti-SARS-CoV-2 RUO assay was used for antibody detection. The relationship between staff age, gender, body mass index, blood pressure, work environments with different exposure risks, place of residence, and campus location and seroprevalence was investigated. The data were anonymized prior to analysis. RESULTS: A total of 3,677 individuals were included in the study, comprising 2,554 females (69.5%) and 1,123 males (30.5%). Anti-SARS-CoV-2 antibody (immunoglobulin G) was detected in 13 participants (0.35%). Seroprevalence was slightly higher in males than females (0.62% vs. 0.23%, P=0.08). By occupation, anti-SARS-CoV-2 antibodies were found in 6 (0.75%) physicians, 6 (0.31%) nurses, and one individual (0.11%) in the medical personnel group, with slightly higher levels in physicians. No significant difference was noted in the seroprevalence in terms of all background factors. CONCLUSIONS: Our study shows that the background factors do not impact seropositivity rates. Thorough daily infection control and adherence to recommended health guidelines were found to reduce infection risk.

Cross-sectional area of erector spinae muscles is associated with activities of daily living at discharge in middle- to older-aged patients with coronavirus disease 2019.

OBJECTIVES: Measurement of skeletal muscle wasting using computed tomography (CT) is widely known to be useful in predicting prognosis. Although some reports have been found in patients with coronavirus disease 2019 (COVID-19), few reports have focused on the ability to perform activities of daily living (ADLs). This study retrospectively investigated the relationship between the erector spinae muscle area measured from CT images and ADL at the time of hospital discharge in patients with COVID-19. METHODS: Among patients aged 40 years or older, 271 patients (median age, 65 years; 180/271 male patients) who had CT cross-sectional images of the 12th thoracic vertebral level on admission were included. The Katz index was used to assess ADLs, and patients who were not completely independent were defined as dependent. Multivariable logistic and Poisson regression analyses were applied to examine the relationship between the cross-sectional area of the erector spinae muscles and the onset of ADL dependence at discharge. RESULTS: A total of 75 (27.7%) patients became dependent on ADL at the time of hospital discharge. Decreased erector spinae muscle area was significantly related to dependent ADL at discharge (adjusted odds ratio: 0.886, 95% confidence interval: 0.805-0.975). In addition, the erector spinae muscle area was significantly related to the number of ADL items for which independence was not achieved (adjusted incidence rate ratio: 0.959, P < 0.001). CONCLUSIONS: The cross-sectional area of the erector spinae muscles from the thoracic CT image was associated with the ability to perform basic ADL at hospital discharge.

Tracheal Tube Obstruction Due to Hemoptysis Associated With Pulmonary Infarction in a Patient With Severe COVID-19 Pneumonia.

The incidence of thrombotic complications is extremely high among severe coronavirus disease 2019 (COVID-19) patients in the intensive care unit. Various factors such as a cytokine storm due to an excessive immune response to inflammation, hypoxemia, and disseminated intravascular coagulation are considered predisposing factors for thrombotic complications. A 55-year-old Japanese man intubated eight days previously was referred to our hospital because of a severe COVID-19 pneumonia diagnosis after his pharyngeal swab tested positive for severe acute respiratory syndrome coronavirus 2 using reverse transcription-polymerase chain reaction. The patient continued to remain hypoxic (PaO2/FiO2 ratio <100 mmHg) at the referring hospital. On admission, we initiated veno-venous extracorporeal membrane oxygenation (VV-ECMO). Unfractionated heparin and nafamostat mesylate were used as anticoagulants during VV-ECMO. Despite adequate anticoagulant therapy, he developed pulmonary infarction due to pulmonary embolism followed by hemoptysis. On day 10 following admission, his oxygen saturation dropped from 95% to 88%, with a marked decrease in his ventilator tidal volume, accompanied by an inability to ventilate the patient. Thereafter, we increased the VV-ECMO flow and exchanged his endotracheal tube. The lumen of the removed tracheal tube was found to be occluded by a large-sized blood coagulum. There was no further episode of tube occlusion. The patient was discharged in a walkable state on day 39 following admission. Endotracheal tube obstruction secondary to hemoptysis should be suggested in patients with COVID-19 requiring ventilator support, as they are unable to perform frequent endotracheal tube suctions owing to the risk of infection.