Home High-Flow Nasal Cannula Oxygen Therapy for Stable Hypercapnic COPD: A Randomized Clinical Trial.

Rationale: The long-term effects of using a high-flow nasal cannula for chronic hypercapnic respiratory failure caused by chronic obstructive pulmonary disease remain unclear. Objectives: To assess whether long-term high-flow nasal cannula use reduces the number of exacerbations and improves other physiological parameters in patients with chronic hypercapnic respiratory failure caused by chronic obstructive pulmonary disease. Methods: We enrolled 104 participants (aged ⩾40 yr) with daytime hypercapnia (Global Initiative for Chronic Obstructive Lung Disease stages 2-4) receiving long-term oxygen therapy (⩾16 h/d for ⩾1 mo) and randomly assigned them to high-flow nasal cannula/long-term oxygen therapy and long-term oxygen therapy groups. The primary endpoint was the moderate or severe exacerbation rate. We compared changes from baseline in arterial blood gas values, peripheral oxygen saturation, pulmonary function, health-related quality-of-life scores, and the 6-minute-walk test. Measurements and Main Results: High-flow nasal cannula use significantly reduced the rate of moderate/severe exacerbations (unadjusted mean count 1.0 vs. 2.5, a ratio of the adjusted mean count between groups [95% confidence interval] of 2.85 [1.48-5.47]) and prolonged the duration without moderate or severe exacerbations. The median time to first moderate or severe exacerbation in the long-term oxygen therapy group was 25 (14.1-47.4) weeks; this was not reached in the high-flow nasal cannula/long-term oxygen therapy group. High-flow nasal cannula use significantly improved health-related quality of life scores, peripheral oxygen saturation, and specific pulmonary function parameters. No safety concerns were identified. Conclusions: A high-flow nasal cannula is a reasonable therapeutic option for patients with stable hypercapnic chronic obstructive pulmonary disease and a history of exacerbations. Clinical trial registered with www.umin/ac.jp (UMIN000028581) and www.clinicaltrials.gov (NCT03282019).

Essential role of IL-23 in the development of acute exacerbation of pulmonary fibrosis.

Acute exacerbation of idiopathic pulmonary fibrosis has a poor prognosis associated with neutrophilic inflammation. Interleukin-23 is a proinflammatory cytokine involved in neutrophilic inflammation. However, little is known about its role in acute exacerbation of pulmonary fibrosis. This study was performed to determine the role of interleukin-23 in acute exacerbation of pulmonary fibrosis. For assessment of acute exacerbation of pulmonary fibrosis, mice were intratracheally administered bleomycin followed by lipopolysaccharide. Inflammatory cells, cytokine levels, and morphological morphometry of the lungs were analyzed. Cytokine levels were measured in the bronchoalveolar lavage fluid of idiopathic pulmonary fibrosis patients with or without acute exacerbation. Interleukin-23, -17A, and -22 levels were increased in the airway of mice with acute exacerbation of pulmonary fibrosis. Interleukin-23p19-deficient mice with acute exacerbation of pulmonary fibrosis had markedly reduced airway inflammation and fibrosis associated with decreased levels of interleukin-17A and -22 compared with wild-type mice. Treatment with an anti-interleukin-23 antibody attenuated airway inflammation and fibrosis and reduced interleukin-17A and -22 levels in mice with acute exacerbation of pulmonary fibrosis. T-helper type 17 cells were the predominant source of interleukin-17A in mice with acute exacerbation of pulmonary fibrosis. Interleukin-23 levels in bronchoalveolar lavage fluid tended to be higher in idiopathic pulmonary fibrosis patients with than without acute exacerbation. The data presented here suggest that interleukin-23 is essential for the development of acute exacerbation of pulmonary fibrosis and that blockade of interleukin-23 may be a new therapeutic strategy for acute exacerbation of pulmonary fibrosis.

Impact of bronchoalveolar lavage lymphocytosis on the effects of anti-inflammatory therapy in idiopathic non-specific interstitial pneumonia, idiopathic pleuroparenchymal fibroelastosis, and unclassifiable idiopathic interstitial pneumonia.

BACKGROUND: Idiopathic non-specific interstitial pneumonia (iNSIP), idiopathic pleuroparenchymal fibroelastosis (iPPFE), and unclassifiable idiopathic interstitial pneumonia (IIP) are IIPs with chronic fibrotic phenotypes, and unlike idiopathic pulmonary fibrosis, they have often been treated with anti-inflammatory drugs, including corticosteroids and immunosuppressants. However, the impact of bronchoalveolar lavage (BAL) lymphocytosis on the effects of anti-inflammatory therapy has never been evaluated. This study aimed to elucidate whether BAL lymphocytosis can be used to predict the efficacy of anti-inflammatory drugs for iNSIP, iPPFE, and unclassifiable IIP. METHODS: Japanese patients diagnosed with iNSIP, iPPFE, and unclassifiable IIP by multidisciplinary discussion were identified using the nationwide registry. Eligible patients were stratified into four groups with and without BAL lymphocytosis and anti-inflammatory therapy to compare overall survival (OS) and changes in lung function. BAL lymphocytosis was defined as a lymphocyte differential count > 15%, and the cut-off was corroborated by survival classification and regression tree analysis. RESULTS: Overall, 186 patients (37 iNSIP, 16 iPPFE, and 133 unclassifiable IIP) were analyzed. Limited to patients treated with anti-inflammatory drugs (n = 123), patients with BAL lymphocytosis had a better prognosis [hazard ratio (HR), 0.26; 95% confidence interval (CI), 0.11-0.63; P = 0.003], higher slope of forced vital capacity (FVC) % predicted for 2 years, and longer OS (log-rank test, P = 0.012) than those without BAL lymphocytosis. On multivariate analysis, BAL lymphocytosis (HR 0.31; 95% CI 0.13-0.75; P = 0.009) was a prognostic factor for OS, along with age and FVC % predicted. Conversely, for patients managed without anti-inflammatory therapy (n = 63), the presence or absence of BAL lymphocytosis had no prognostic value. CONCLUSIONS: BAL lymphocytosis is associated with good outcomes in patients treated with anti-inflammatory drugs, but has no prognostic value when anti-inflammatory drugs are not used. BAL lymphocytosis may provide a predictive biomarker for identifying patients with iNSIP, iPPFE and unclassifiable IIP who are likely to benefit from anti-inflammatory drugs.

Usefulness of ß-lactam and macrolide combination therapy for treating community-acquired pneumonia patients hospitalized in the intensive care unit: Propensity score analysis of a prospective cohort study.

INTRODUCTION: Whether ß-lactam and macrolide combination therapy reduces mortality in severe community-acquired pneumonia (SCAP) patients hospitalized in the intensive care unit (ICU) is controversial. The aim of the present study was to evaluate the usefulness of ß-lactam and macrolide combination therapy for SCAP patients hospitalized in the ICU. METHODS: A prospective, observational, cohort study of hospitalized pneumonia patients was performed. Hospitalized SCAP patients admitted to the ICU within 24 h between October 2010 and October 2017 were included for analysis. The primary outcome was 30-day mortality, and secondary outcomes were 14-day mortality and ICU mortality. Inverse probability of treatment weighting (IPTW) analysis as a propensity score analysis was used to reduce biases, including six covariates: age, sex, C-reactive protein, albumin, Pneumonia Severity Index score, and APACHE II score. RESULTS: A total of 78 patients were included, with 48 patients in the non-macrolide-containing ß-lactam therapy group and 30 patients in the macrolide combination therapy group. ß-lactam and macrolide combination therapy significantly decreased 30-day mortality (16.7% vs. 43.8%; P = 0.015) and 14-day mortality (6.7% vs. 31.3%; P = 0.020), but not ICU mortality (10% vs 27.1%, P = 0.08) compared with non-macrolide-containing ß-lactam therapy. After adjusting by IPTW, macrolide combination therapy also decreased 30-day mortality (odds ratio, 0.29; 95%CI, 0.09-0.96; P = 0.04) and 14-day mortality (odds ratio, 0.19; 95%CI, 0.04-0.92; P = 0.04), but not ICU mortality (odds ratio, 0.34; 95%CI, 0.08-1.36; P = 0.13). CONCLUSIONS: Combination therapy with ß-lactam and macrolides significantly improved the prognosis of SCAP patients hospitalized in the ICU compared with a non-macrolide-containing ß-lactam regimen.

Therapeutic plasma exchange for clinically amyopathic dermatomyositis (CADM) associated with rapidly progressive interstitial pneumonia.

BACKGROUND: Patients with clinically amyopathic dermatomyositis (CADM) with anti-melanoma differentiation-associated gene 5 antibody (anti-MDA5 Ab) frequently develop rapidly progressive interstitial pneumonia (RPIP), often with fatal outcomes. Therapeutic plasma exchange (TPE) has been reported as effective against CADM-RPIP refractory to conventional immunosuppressive therapy. However, the detailed mechanisms by which TPE improves disease activity of CADM-RPIP remain unclear. AIM: To elucidate the clinical and demographic characteristics of patients with anti-MDA5 Ab-positive CADM-RPIP treated with TPE and to analyze changes in laboratory findings before, during, and after TPE. MATERIALS & METHODS: Patients hospitalized for CADM-RPIP and treated with TPE in 2017 and 2018 were analyzed retrospectively. RESULTS: Three patients were successfully treated with TPE, with good tolerance. Anti-MDA5 Ab titers decreased significantly over the course of TPE. CONCLUSION: We emphasize that TPE could represent an effective treatment option for CADM-RPIP refractory to traditional therapy. Removal of anti-MDA5 Ab and other pathogenic factors may facilitate favorable outcomes.

Radiological fibrosis score is strongly associated with worse survival in rheumatoid arthritis-related interstitial lung disease.

OBJECTIVES: High-resolution computed tomography (HRCT) parenchymal patterns have been used to predict prognosis in patients with interstitial lung disease (ILD). In idiopathic pulmonary fibrosis, the fibrosis score (i.e. the combined extent of reticulation and honeycombing) has been associated with worse survival. This study aimed to identify HRCT patterns and patient characteristics that can predict poor prognosis in rheumatoid arthritis-related ILD (RA-ILD). METHODS: We retrospectively analysed 65 patients with newly diagnosed RA-ILD from 2007 to 2016 at Kurashiki Central hospital. Using univariate and bivariate Cox regression analysis, associations with mortality, were identified. RESULTS: During a median follow-up of 56.5 months, 16/65 (24.6%) patients died. Univariate analysis identified six significant poor prognostic factors: lower baseline % predicted forced vital capacity, total interstitial disease score, reticulation score, traction bronchiectasis score, fibrosis score, and definite UIP pattern. Fibrosis score remained to be an independently significant poor prognostic factor of survival on bivariate analysis. Patients with a fibrosis score >20% had higher mortality (HR, 9.019; 95% CI, 2.87-28.35; p < .05). CONCLUSION: This study showed that fibrosis score is strongly associated with worse survival in RA-ILD, and patients with fibrosis score >20% had a 9.019-fold increased risk of mortality.

Radiographic fibrosis score predicts survival in systemic sclerosis-associated interstitial lung disease.

BACKGROUND AND OBJECTIVE: Interstitial lung disease (ILD) is a common pulmonary manifestation of systemic sclerosis (SSc). It is unknown whether radiographic fibrosis score predicts mortality in SSc-associated ILD (SSc-ILD). We retrospectively analysed patients with SSc-ILD to evaluate whether radiographic fibrosis score was a useful predictor of mortality. METHODS: We identified SSc-ILD patients evaluated at Kurashiki Central Hospital (Japan) from 2006 to 2016, and radiographic fibrosis scores based on the extent of reticulation and honeycombing on high-resolution computed tomography (HRCT) scanning were calculated by manually tracing around each fibrotic area. Independent predictors of overall survival were determined using the Cox proportional hazards model. RESULTS: The study included 48 patients, of whom 19 had usual interstitial pneumonia on HRCT. The median follow-up period was 56.6 months, and over the follow-up period 15 patients died. The 5-year survival was 72.4%. In the multivariate analysis, radiographic fibrosis score, age, being male and forced vital capacity were independently associated with an increased risk of death, while HRCT pattern was not. CONCLUSION: A high radiographic fibrosis score was a poor prognostic factor in SSc-ILD. More widespread fibrosis was associated with an increased risk of death, independent of HRCT pattern.

Risk factors for drug-resistant pathogens in immunocompetent patients with pneumonia: Evaluation of PES pathogens.

RATIONALE: The new acronym, PES pathogens (Pseudomonas aeruginosa, Enterobacteriaceae extended-spectrum beta-lactamase-positive, and methicillin-resistant Staphylococcus aureus), was recently proposed to identify drug-resistant pathogens associated with community-acquired pneumonia. OBJECTIVES: To evaluate the risk factors for antimicrobial-resistant pathogens in immunocompetent patients with pneumonia and to validate the role of PES pathogens. METHODS: A retrospective analysis of a prospective observational study of immunocompetent patients with pneumonia between March 2009 and June 2015 was conducted. We clarified the risk factors for PES pathogens. RESULTS: Of the total 1559 patients, an etiological diagnosis was made in 705 (45.2%) patients. PES pathogens were identified in 51 (7.2%) patients, with 53 PES pathogens (P. aeruginosa, 34; ESBL-positive Enterobacteriaceae, 6; and MRSA, 13). Patients with PES pathogens had tendencies toward initial treatment failure, readmission within 30 days, and a prolonged hospital stay. Using multivariate analysis, female sex (adjusted odds ratio [AOR] 1.998, 95% confidence interval [CI] 1.047-3.810), admission within 90 days (AOR 2.827, 95% CI 1.250-6.397), poor performance status (AOR 2.380, 95% CI 1.047-5.413), and enteral feeding (AOR 5.808, 95% CI 1.813-18.613) were independent risk factors for infection with PES pathogens. The area under the receiver operating characteristics curve for the risk factors was 0.66 (95% CI 0.577-0.744). CONCLUSIONS: We believe the definition of PES pathogens is an appropriate description of drug-resistant pathogens associated with pneumonia in immunocompetent patients. The frequency of PES pathogens is quite low. However, recognition is critical because they can cause refractory pneumonia and different antimicrobial treatment is required.

Impact of lymphocyte differential count > 15% in BALF on the mortality of patients with acute exacerbation of chronic fibrosing idiopathic interstitial pneumonia.

BACKGROUND: Chronic fibrosing idiopathic interstitial pneumonia (CFIIP) has a potential risk of acute exacerbation (AE). However, the usefulness of cellular analysis of bronchoalveolar lavage fluid (BALF) has never been evaluated. This study aimed to evaluate the impact of the lymphocyte differential count > 15% in BALF on the mortality of patients with AE of CFIIP. METHODS: We retrospectively analysed 37 patients with AE of CFIIP who underwent BAL on admission. Patients were divided into two groups: one group consisting of those with a lymphocyte differential count > 15% and the other consisting of those with a lymphocyte differential count ≤ 15%. We compared the 90-day mortality between the two groups as the primary outcome, using the two-tailed log-rank test. RESULTS: The median follow-up duration was 6.9 months. Twenty-four patients had a lymphocyte differential count > 15%. The 90-day mortality was significantly higher in the group with a lymphocyte differential count ≤ 15% than in the group with a lymphocyte differential count > 15% (long rank test, p = 0.003). In the multivariate analysis a lymphocyte differential count > 15% was shown to be an independent favourable prognostic factor for 90-day mortality (HR: 0.125; 95% CI: 0.0247-0.589; p = 0.009). CONCLUSIONS: A lymphocyte differential count > 15% in BALF may be associated with favourable outcomes in patients with AE of CFIIP.

Serological and morphological prognostic factors in patients with interstitial pneumonia with autoimmune features.

BACKGROUND: To identify the prognostic factors for survival in patients with interstitial pneumonia with autoimmune features (IPAF) who meet the serological domain of the IPAF criteria. METHODS: We retrospectively analysed 99 IPAF patients who met the serological domain and were hospitalised at the Respiratory Medicine Unit of Kurashiki Central Hospital from 1999 to 2015. The high-resolution computed tomography findings were usual interstitial pneumonia (UIP; n = 1), non-specific interstitial pneumonia (NSIP; n = 63), NSIP with organizing pneumonia (OP) overlap (n = 15), and OP (n = 20). One patient who had radiological UIP pattern, and met the serological and clinical domains was excluded. The clinical characteristics, radiological findings, administered therapy, and prognosis of the remaining 98 IPAF patients who met the serological and morphological domains were analysed. RESULTS: The median age of the 98 IPAF patients was 68 years, and 41 (41.8%) of them were men. Twelve (12.2%) of the 98 IPAF patients developed other characteristics and were diagnosed with connective tissue disease (CTD) later during the median follow-up of 4.5 years. Univariate Cox analysis revealed systemic sclerosis (SSc)-specific and SSc-associated antibodies (ANA nucleolar pattern, ANA centromere pattern, anti-ribonucleoprotein and anti-Scl-70) positive IPAF, radiological NSIP pattern, bronchoalveolar lavage fluid lymphocytes >15%, and age as significant prognostic factors for survival. Multivariate Cox analysis revealed radiological NSIP pattern (hazard ratio [HR], 4.48; 95% confidence interval [CI], 1.28-15.77, p = 0.02) and age (HR, 1.07; 95% CI, 1.02-1.11, p = 0.01) were significantly associated with worse survival. CONCLUSIONS: We confirmed that radiological NSIP pattern and age are poor prognostic factors for the survival of IPAF patients. This study suggested that the autoantibodies that are highly specific for certain connective tissue diseases might be less important for the prognosis of IPAF compared with the radiological-pathological patterns. The relatively high proportion of IPAF patients who developed CTD later suggests the importance of careful observation for evolution to CTD in IPAF.

Clinical characteristics of pneumonia in bedridden patients receiving home care: a 3-year prospective observational study.

BACKGROUND: The aim of the study was to describe the epidemiology, clinical features, antimicrobial treatment, and outcomes of bedridden pneumonia patients receiving home healthcare. METHODS: A 3-year prospective observational study of poor performance status (PS) 3-4 patients receiving long-term home healthcare and hospitalized at a single center with pneumonia between October 2010 and September 2013 was conducted, and their clinical characteristics were compared with non-bedridden community-acquired pneumonia (CAP) patients. RESULTS: A total of 131 CAP patients with PS 3-4, and 400 CAP patients with PS 0-2 were evaluated. The PS 3-4 patients were older, and exhibited a higher frequency of underlying diseases. Aspiration was thought to be associated with pneumonia in 77.1% of the PS 3-4 patients. Streptococcus pneumoniae was the leading pathogen in both groups, whereas the frequency of streptococci and polymicrobial infections was higher in the PS 3-4 group. The incidence of multidrug-resistant pathogens such as methicillin-resistant Staphylococcus aureus (MRSA) or Pseudomonas aeruginosa was lower than in previous healthcare-associated pneumonia reports. The in-hospital mortality and recurrence rates were significantly higher in the PS 3-4 group than in the good PS group (17.6% vs. 6.0%, p < 0.001 and 15.3% vs. 7.5%, p = 0.008, respectively). CONCLUSIONS: The clinical characteristics of pneumonia in poor PS patients were similar to healthcare-associated pneumonia (HCAP), except for the frequency of drug-resistant pathogens. Hence, it might be beneficial to categorize pneumonia in home residents with poor PS separately from pneumonia in CAP patients who were previously healthy or experienced mild comorbidities.

Interstitial lung disease in clinically amyopathic dermatomyositis with and without anti-MDA-5 antibody: to lump or split?

BACKGROUND: Interstitial lung disease (ILD) associated with clinically amyopathic dermatomyositis (CADM-ILD) is often refractory and rapidly progressive. Although the anti-melanoma differentiation-associated gene 5 (anti-MDA-5) antibody is associated with rapidly progressive ILD (RP-ILD), differences in clinical features and prognosis of anti-MDA-5 antibody-positive and -negative CADM-ILD remain unclear. METHODS: To clarify the differences in the clinical features and prognosis between anti-MDA-5 antibody-positive and -negative cases, we retrospectively reviewed the medical records of patients diagnosed with CADM-ILD with and without anti-MDA-5 antibody at Kurashiki Central Hospital from January 2005 to September 2014. RESULTS: Anti-MDA-5 antibody was found in 10 of 16 patients (63%). The levels of Krebs von den Lungen-6 (KL-6) and surfactant protein D (SP-D) at the first visit were significantly lower in positive patients than in negative patients, whereas the levels of aspartate aminotransferase (AST), γ-glutamyl transpeptidase (γ-GTP), and the CD4(+)/CD8(+) ratio in the bronchoalveolar lavage (BAL) fluid were significantly higher in positive patients than negative patients. Subpleural ground-glass opacity (GGO) or irregular linear opacity was predominant in positive patients. Peribronchovascular consolidation was predominant in negative patients. Positive patients had significantly lower survival rates than negative patients, with all six fatal cases occurring in positive patients who died of refractory ILD within 92 days from the first visit despite intensive treatment. CONCLUSIONS: There are clear differences in the clinical features and prognosis of anti-MDA-5 antibody-positive and -negative CADM-ILD. Low serum KL-6 and SP-D levels, high serum AST and γ-GTP levels, high CD4(+)/CD8(+) ratio in BAL fluid, and predominance of subpleural GGO or irregular linear opacity in HRCT may help to discriminate anti-MDA-5 antibody-positive CADM-ILD with poor prognosis.

[A Study on the Clinical Course and Antimicrobial Susceptibility of Mycoplasma pneumoniae in a Community Hospital].

Recently, reports of macrolide-resistant strains of Mycoplasma pneumoniae have been increasing. We examined the antimicrobial susceptibility and clinical significance in patients with M. pneumoniae. Seventy patients in whom M. pneumoniae was detected from 2008 to 2012 were included in the study, and compared with patients between 2003 and 2006. There were no macrolide-resistant strains detected in the 38 strains from 2003 to 2006, but from 2008 to 2012, out of the 70 strains 46 (65.7%) were positive for the macrolide-resistant 23SrRNA gene mutant (A2063G), which is consistent with recent trends. Comparison between cases of macrolide resistant strains and those with macrolide sensitive strains did not reveal a significant difference in the hospitalization period. The approximate duration of fever was 7 days; for both cases: those who received effective antimicrobials as the initial therapy, and for those with macrolide sensitive strains. It seems that the duration of fever depends on susceptibility to the initial antimicrobials regardless of macrolide resistance. There were some patients that improved without use of quinolone or minocycline, though macrolide-resistant strains were detected. These patients did not reveal extension of the hospital stay nor aggravation of pneumonia. This suggests that a macrolide drug might be the first choice drug for M. pneumoniae even now, and a change of drug should be considered when fever duration is long.

Clinical characteristics of severe community-acquired pneumonia among younger patients: an analysis of 18 years at a community hospital.

Unlike elderly patients with community-acquired pneumonia whose outcomes are markedly affected by their background characteristics, it appears that the severity of the infection itself contributes to outcomes in younger patients with community-acquired pneumonia. In order to identify clinical characteristics of severe community-acquired pneumonia in younger patients under 60 years old, among such cases prospectively collected at our hospital over a period of 18 years, those meeting the criteria for severe community-acquired pneumonia, as defined in the Infectious Diseases Society of America/American Thoracic Society Guidelines for community-acquired pneumonia, were retrospectively examined and compared to elderly patients with severe community-acquired pneumonia. Younger patients with severe pneumonia accounted for 12.9% of younger hospitalized patients. Although the incidence of severe pneumonia in younger patients was lower than that in elderly patients, its severity may be underestimated by severity assessment based on the conventional guidelines. Thus, attention is required. While Streptococcus pneumoniae and Legionella species were important causative pathogens, atypical pathogens and viruses were also frequently detected. There were only 11 deaths over a period of 18 years. Based on multivariate analysis, the risk factors for aggravation of community-acquired pneumonia among younger patients were age 50 years or older, diabetes mellitus, chronic liver disease, and Legionella pneumonia. Although the mortality rate from community-acquired pneumonia is extremely low in previously healthy younger patients, outcomes might be poor for patients with underlying diseases and those with rapid progression. Multimodal treatments including respiratory management may be appropriate.

Feasibility of continued treatment with dupilumab in patients with type 2 inflammatory disease who developed eosinophilic pneumonia: 3 case reports.

Several reports have described dupilumab-induced eosinophilic pneumonia (EP) after treatment with dupilumab in patients with type 2 inflammatory disease. Other reports have suggested the efficacy of dupilumab for chronic EP (CEP). Whether dupilumab can be continued in patients with type 2 inflammatory disease who develop EP during dupilumab treatment remains unclear. We present herein three cases with different clinical presentations involving dupilumab and EP. In Case 1, dupilumab was discontinued because of dupilumab-induced EP during the treatment of asthma. In Case 2, although pre-existing idiopathic EP worsened during the treatment of eosinophilic chronic rhinosinusitis (ECRS), dupilumab was continued. In Case 3, CEP and ECRS were successfully treated with dupilumab and corticosteroids were discontinued. In conclusion, treatment with dupilumab in patients with type 2 inflammatory disease and idiopathic EP is worth considering if the benefits are deemed to outweigh the risks and careful attention is given to the clinical course.

Remission of hypersensitivity pneumonitis after allogeneic hematopoietic stem cell transplantation.

A 50-year-old man was diagnosed with hypersensitivity pneumonitis caused by the environment of his bar owing to worsening symptoms, laboratory test results, and computed tomography images after an environmental inhalation challenge test. His hypersensitivity pneumonitis exacerbated despite receiving prednisolone 20 mg/day. The patient underwent allogeneic hematopoietic stem cell transplantation (HSCT) from a human leukocyte antigen-matched unrelated donor for myelodysplastic syndrome. No exacerbation of hypersensitivity pneumonitis was observed after HSCT. An environmental inhalation challenge test involving exposure to his bar confirmed the remission of hypersensitivity pneumonitis after HSCT. This case demonstrates that hypersensitivity pneumonitis can be remitted by HSCT.

[A case of lung disease and spondylitis due to Mycobacterium intracellulare in a immunocompetent patient].

A 73-year-old immunocompetent woman was diagnosed with pulmonary nontuberculous mycobacterial (NTM) infection and followed up without treatment. She developed lumbago and consulted a physician. Spinal magnetic resonance imaging (MRI) indicated pyogenic spondylitis and she was admitted to the orthopedics department at our hospital 4 months after developing lumbago. Spinal MRI on admission revealed spondylitis in L5/S1 and thus antibiotic agents were administered. However, the antibiotics were ineffective and she underwent surgery. Mycobacterium avium complex (MAC) was identified from cultures of surgical specimens, and the histopathological findings revealed epithelioid cell granuloma with necrosis. Spondylitis due to MAC was diagnosed and the patient was administered with rifampicin, ethambutol, clarithromycin and streptomycin. She was discharged on hospital day 113 with a good outcome. Recently, the number of spondylitis due to NTM infection in immunocompetent patients have been increasing. We should take it into consideration that not only bacteria and Mycobacterium tuberculosis but also NTM infection can cause infectious spondylitis.

Frequency and clinical features of radiographic head injury caused by inpatient falls: a single-centre retrospective cohort study.

OBJECTIVES: The lack of clear criteria makes it difficult for clinicians to determine which patients should be imaged after an inpatient fall. This study identified the clinical characteristics of patients who required a head CT scan following an inpatient fall. DESIGN: This was a retrospective cohort study conducted from January 2016 to December 2018. We obtained the data from our safety surveillance database, which record all cases of inpatient falls in our hospital. SETTING: Single-centre, tertiary, secondary care hospital. PARTICIPANTS: We included all consecutive patients who claimed to have fallen and bruised their heads as well as patients who were confirmed to have a bruise on the head but were unavailable to be interviewed about the fall. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was radiographic head injury revealed on head CT after a fall. RESULTS: Overall, 834 adult patients (662 confirmed and 172 suspected cases) were included. The median age was 76 years, and 62% were men. Patients with radiographic head injury were more likely to have a lower platelet count, consciousness disturbance and new vomiting episodes compared with those without radiographic head injury (all p<0.05). The use of anticoagulants or antiplatelets was not different between patients with and without radiographic head injury. Among the 15 (1.8%) patients with a radiographic head injury, 13 with intracranial haemorrhage had at least one of the following characteristics: received anticoagulant or antiplatelet agents, platelet count of <2.0×109/L, consciousness disturbance or new vomiting episodes. There were no deaths among patients with radiographic head injuries. CONCLUSIONS: The incidence of radiographic head injury due to falls in adult inpatients with suspected or confirmed head injuries was 1.8%. Only patients with risk factors had radiographic head injuries, which might help reduce the number of unnecessary CT scans in inpatient falls. TRIAL REGISTRATION NUMBER: Study protocol (Kurashiki Central Hospital, Medical ethical committee. IRB no. 3750).

Acute onset systemic lupus erythematosus interstitial lung disease: A case report.

A 40-year-old Japanese man was diagnosed with systemic lupus erythematosus. Chest computed tomography showed patchy consolidation in both lungs. A cryobiopsy and bronchoalveolar lavage showed organizing pneumonia, not acute lupus pneumonia or diffuse alveolar hemorrhage. This case demonstrates the usefulness of cryobiopsy for the management of systemic lupus erythematosus interstitial lung disease.