Chronic rhinosinusitis possibly associated with decreased lung function in chronic cough patients.

OBJECTIVES: The purpose of this study is to investigate the lung function in Chronic Rhinosinusitis (CRS) patients with Chronic Cough (CC). METHODS: A total of 1413 CC patients were retrospectively screened and 109 CRS patients with CC were enrolled. Lung function, Lund-Mackay Computed Tomography (CT) score, smoking status, peripheral blood eosinophil count, and immunoglobulin E concentration in serum samples, and Sino-Nasal Outcome Test were examined. Normal control subjects are also recruited. RESULTS: The Forced Expiratory Volume in 1 second (FEV1.0), Percent Predicted FEV1.0, and FEV1.0/Forced Vital Capacity (FVC) ratio in the patients were significantly low as compared with the control subjects. The FEV1.0/FVC ratio was negatively correlated with the Lund-Mackay CT scores of the patients with a high CT score. CONCLUSIONS: The CRS patients with CC should be investigated with lung function. In addition, the multidisciplinary evaluation including a pulmonologist is needed to manage the CRS patients with CC. LEVEL OF EVIDENCE: Level 4.

Lund-Mackay Computed Tomography Score Is Associated With Obstructive Pulmonary Function Changes in Chronic Cough Patients.

BACKGROUND: A remarkable relationship between upper airway conditions and lung diseases has been reported. At the same time, sinonasal findings in chronic cough patients have not been fully examined. OBJECTIVE: The purpose of this study is to show paranasal sinus findings and lung function in chronic cough patients without asthma and chest X-ray abnormalities. METHODS: A total of 1412 patients with persistent cough were enrolled in this study. Of these patients, 376 patients were evaluated for further examination, as the patients with asthma and/or chest X-ray abnormality were excluded from the study. Normal control subjects without any chronic respiratory symptoms were also recruited. Pulmonary function was examined by spirometry. A bronchial obstruction reversibility test was applied. The Lund-Mackay computed tomography (CT) score, peripheral blood eosinophil count, and immunoglobulin E concentration in serum samples were examined. The Sino-Nasal Outcome Test was used to determine the severity of clinical symptoms. RESULTS: The patients with an abnormal soft tissue shadow in the paranasal sinus had significant obstructive lung function. The percent predicted forced expiratory volume in 1 second (FEV1.0) and the FEV1.0/forced vital capacity ratio negatively correlated with Lund-Mackay CT scores both before and after bronchodilator inhalation. There was a statistically significant correlation between pulmonary function and eosinophil count. CONCLUSION: The patients with chronic cough frequently had paranasal sinus abnormalities. The Lund-Mackay CT score may be useful for assessing the condition of the lower airway in chronic cough patients. Upper airway examinations should play a part in the management of chronic cough.

High Detection Rates of Urine Mycobacterium tuberculosis in Patients with Suspected Miliary Tuberculosis.

Objective The utility of detecting Mycobacterium tuberculosis in urine samples from patients with pulmonary tuberculous with diffuse small nodular shadows (suspected miliary tuberculosis (MTB)) is still unclear in Japan. A retrospective cross-sectional study was conducted to investigate the detection rates of M. tuberculosis in urine of patients with suspected MTB. Methods Among 687 hospitalized patients with tuberculosis, 45 with culture-confirmed suspected MTB and the data of culture and polymerase chain reaction (PCR) for M. tuberculosis in urine and sputum samples were investigated. The detection rates of M. tuberculosis in urine using cultures and PCR were calculated. The detection rate of urine was then compared with that of bone marrow aspiration. Results Fourteen patients with suspected MTB were ultimately analyzed. A diagnosis of miliary tuberculosis was suspected in all patients before anti-tuberculosis chemotherapy. Positive results by PCR (11 [78.6%] cases) and culture (8 [57.1%]) were obtained from urine samples. In patients with suspected MTB, there was no significant difference in the detection rates between M. tuberculosis in urine using a combination of PCR and culture (85.6% [12/14 cases]) and bone marrow aspiration (66.7% [8/12 cases]) (p>0.05). Conclusion Using PCR and culture, we demonstrated high detection rates of M. tuberculosis in the urine of patients with suspected MTB. A combination of PCR and culture compared favorably with the detection rates achieved with bone marrow aspiration. We believe that detection of M. tuberculosis from urine and sputum samples may be easy and safe for patients with disseminated tuberculosis infections such as definitive MTB.

What Are the Current Situations and the Challenges of Maternal and Child Malnutrition in Asia?

Changes in lifestyle have led to better nutrition or increasing the risk of NCDs in Asia, while there are still many children and reproductive-aged women (RAW) suffering undernutrition whose lives are at risk in the same region. The MDG of reducing the prevalence of underweight <5 children to half has been achieved already or nearly achieved in many Asian countries, whereas South Asian (SA) countries and several other countries (Cambodia, Laos, East Timor and Yemen) have difficulties in achieving the goal by 2015. In particular, East Timor and Yemen are in a critical situation with undernutrition. There is a strong concern about a rapid increase in overweight and obesity rates in West Asian (WA) and some Central Asian (CA) countries. Iron deficiency is one of the most important risk factors that threaten healthy life among RAW especially in SA, followed by Southeast Asia (SEA) and CA. The same issue is observed among children (1-4 y) in the same regions. Dietary risks (based on DALYS) increase with advancing age in most Asian regions whereas high Body Mass Index is the most important risk factor in WA and some CA countries. High priority should be placed on measures to tackle undernutrition and micronutrient deficiencies including iron deficiency in SA and some countries in SEA and WA; overweight and obesity in WA and CA; and dietary risks among RAW, in most Asian regions.

Evaluation of short-term clinical efficacy of 3-day therapy with azithromycin in comparison with 5-day cefcapene-pivoxyl for acute streptococcal tonsillopharyngitis in primary care.

Group A streptococcal (GAS) tonsillopharyngitis is one of the few conditions for which antibiotics are advocated among common upper respiratory infections. Although a 3-day course of azithromycin is attracting attention as a treatment of choice for the condition, it is not clear if the efficacy of the treatment is comparable with that of treatment with cephalosporins. A prospective, randomized, comparative multicenter study was conducted to compare the efficacy of azithromycin (AZM) given once daily for 3 days with that of cefcapene-pivoxyl (CFPN-PI) divided into three daily doses for 5 days. 88 patients (male: 38, mean age: 16.5) were treated with AZM and 69 (male: 34, mean age: 16.9) with CFPN-PI. The symptoms of all but 5 (2 for AZM and 3 for CFPN-PI) of the patients were resolved by the 8th day of the treatment. By the 4th day of the treatment, criteria for clinical efficacy were fulfilled in 71 (80.7%) subjects who were treated with AZM and in 48 (67.6%) of those treated with CFPN-PI (p = 0.07). The same figures on the 8th day of the treatment were 86 (97.7%) and 68 (95.8%), respectively (p = 0.66), confirming there was no significant difference in clinical efficacy between the two treatments. Mild adverse reactions were reported by two patients treated with AZM and by none treated with CFPN-PI. The clinical efficacy of a 3-day course with AZM was comparable with that of a 5-day course of CFPN-PI for GAS tonsillopharyngitis.

Pulmonary papillary adenoma.

We present a rare case of solitary pulmonary papillary adenoma. A man consulted our hospital because of abnormal chest radiography finding. Chest computed tomography demonstrated a well-defined, homogeneous nodular shadow 11 mm in size at the left lower lobe. The previous physician had considered it to be an old benign inflammatory granuloma and had kept it under observation. This mass was followed through chest radiographs at annual medical checkups for 4 years. In 2006, enlargement and lobulation were noted. We performed thoracoscopic partial resection of the left lower lobe. On postoperative pathology examination, the nodule was found to be a circumscribed nodule consisting of a papillary growth of cuboidal to low-columnar epithelial cells lining the surface of a fibrovascular stroma. The histological features were consistent with pulmonary papillary adenoma. Only 20 cases of pulmonary papillary adenoma have been reported in the literature.

[Nursing-home-acquired pneumococcal pneumonia--comparison of sputum cultures with Binax NOW Streptococcus pneumoniae urinary antigen assay].

To clarify the clinical significance of Pneumococcal pneumonia in nursing-home-acquired pneumonia, we examined the positive disease rate of using sputum cultures and the Binax NOW Streptococcus pneumoniae urinary antigen assay in 154 nursing-home patients with pneumonia. These included 54 males and 100 females with a mean age of 86.2 years. Bacteriological findings for sputum culture in 130 patients showed Streptococcus pneumoniae to be cultured in 11 cases (8%). In 72 in whom the Streptococcus pneumoniae-urinary antigen test (Binax NOW) was done, the urinary-antigen-positive rate (26/72 ; 36%) was higher than the culture positive rate for S. pneumoniae. Both examinations were done in 64 patients, among whom 5 in whom S. pneumoniae was cultured also had positive results for the urinary antigen test. Almost half of those undergoing percutaneous endoscopic gastroscopy (PEG) tube nutrition had positive results for the urinary antigen test, but not all such patients had positive cultures for S. pneumoniae. Although the culture-positive rate for S. pneumoniae in sputum was low, we concluded that S. pneumoniae was frequently linked to nursing-home-acquired pneumonia, especially in "total-care" patients.

Insufficient level of iodine content in household powder salt in Nepal.

Universal salt iodization (USI) is long term strategy for the control of iodine deficiency disorder (IDD) in Nepal. Standardized periodic testing of the iodine content in salt is a critical part of a salt iodisation programme. To achieve programmatic objective, this study was carried out to estimate the iodine content of household salt in Kavre, Lalitpur and Parsa districts of Nepal. Iodometric titration of 1803 salt samples collected from the households through the students of different schools revealed that 289 (16.0%) had less than 15 ppm iodine. Two hundred forty-one powder salt samples without two children logo (14.3% among total powder salt samples) had iodine below 15 ppm. It includes 25.8% of total salt samples from Parsa district of Terai ecological region. Among total, the largest proportion of the population accounting for almost 93.0% used powder salt. In total 1803 salt samples, mean and median iodine concentration were 31.8 ppm (95.0% CI=31.0-32.6) and 29.5 ppm respectively. The mean and median iodine concentration of phoda (dhike) salt were 22.1 ppm (95.0% CI= 19.2-25.1) and 18.9 ppm; powder salt were 32.6 ppm (95.0% CI= 31.7- 33.4) and 30.6 ppm respectively. In the community level, people are still using the non-iodized salt. To eliminate the IDD more efforts are required at program implementation and monitoring level.

[Comparison of ciprofloxacin with biapenem in patients with moderate or severe pneumonia].

We conducted the comparative study to clarify the clinical efficacy and features of ciprofloxacin (CPFX) and biapenem (BIPM) in the treatment of moderate or severe pneumonia. Among 209 patients enrolled, 173 patients (CPFX; 87, BIPM; 86) complying with the protocol were evaluated for safety and 171 (CPFX; 85, BIPM; 86) for efficacy. No significant difference was noted between groups in patient profiles. Both groups were similar in efficacy, as evaluated by the following variables: fever, WBC, CRP, and chest X ray score. The incidence of adverse drug reactions was 16.1% (14/87 patients) in the CPFX group and 16.3% (14/86 patients) in the BIPM group. Phlebitis occasionally occurred in the CPFX group and drug eruption and liver function disorder occasionally in the BIPM group. In conclusion, both CPFX and BIPM were useful in treating moderate or severe pneumonia and no difference was seen between groups in efficacy. Some differences were noted in adverse reactions, however.

[Comparison of nursing home-acquired pneumonia with community-acquired elderly pneumonia].

To clarify whether the environment of a nursing home affects the clinical features of patients with pneumonia, we compared the characteristics of 103 patients (nursing home group) who suffered from pneumonia at a nursing home with 153 elderly patients with the same background (community group) who lived in their own home. Although there were no significant differences in CRP, WBC, and body temperature at admission and duration of hospitalization, the degree of independency of the nursing home group was significantly lower than the community group. As the degree of independency became worse, the length of hospitalization extended and mortality increased. Bacteriological findings of sputum culture showed that methicillin-resistant Staphylococcus aureus (MRSA) was cultured in 20 cases (19%) of the nursing home group and 18 cases (13%) of the community group. In isolated analysis of total care cases, MRSA positive rates were similar in the nursing home group (17/58; 29%) and the community group (8/30; 27%). Only 1 case with penicillin-susceptible Streptococcus pneumoniae (PSSP) was found in the nursing home group, however 7 species of PSSP were cultured in the community group, including 5 self-help cases. Pseudomonas aeruginosa was cultured in 8 patients of each group, and most of them were total care cases. We concluded that the difference in frequency and species of bacteria depended on the condition of patients, rather than the environment, and differences in conditions might lead to differences in clinical features.

Assessment of IDD problem by estimation of urinary iodine among school children.

Iodine deficiency disorder (IDD) is a major micronutrient deficiency problem in Nepal. Urinary iodine estimation has been the gold standard employed for the assessment of iodine status and of IDD. This study was conducted with objective to assess the urinary iodine among the school children of Kavre, Lalitpur and Parsa districts. Attempts were made to relate urinary iodine with salt use and other sociodemographic variables. Altogether 190 urine samples (74 samples from Kavre, 89 from Parsa and 27 from Lalitpur district) were collected from school children aged 5-13 years. The urinary iodine was analyzed by using urinary iodine assay kit (Bioclone Australia Pvt Limited). It was found that 3.2% children had urine iodine concentration below 20 microg/l. Similarly, the percentage of children with urine iodine concentration 21-50 microg/l, 51-99 microg/l, 100-299 microg/l and above 300 microg/l were 14.2%, 10.5%, 43.7% and 28.4% respectively. Iodine deficient population of school children was 39.2% of Kavre, 19.1% of Parsa and 25.9% of Lalitpur. Overall, it was found that 27.9% children had urine iodine level less than the normal WHO levels. The median urine iodine level was 139.0 microg/l of Kavre, 266.7 microg/l of Parsa and 244.4 microg/l of Lalitpur school children. Urinary iodine excretion (UIE) median value among male students was 211.9 microg/l, among female students was 190.2 microg/l and the difference was statistically insignificant (P > 0.05). There was no significant correlation between consumed salt iodine level and urine iodine excretion level (P > 0.05). Short-term iodine supplementation programs should be arranged for iodine deficient children in the study districts. This study shows that IDD continues to be prevalent in the country as a major public health problem, which requires strengthening effective intervention program and other preventive measures.

Prevalence of previously undiagnosed airflow limitation in patients who underwent preoperative pulmonary function test.

Although being a rapidly expanding socioeconomical burden worldwide, chronic obstructive pulmonary disease (COPD) is often overlooked because of its insidious progression. Since spirometry is the primary tool for the diagnosis of COPD, physicians should be aware of the disease in any situation where interpreting spirometry. This study was to estimate the prevalence of undiagnosed COPD among patients who underwent spirometry as a preoperative evaluation for elective surgeries. Patients aged 40 years or older who completed routine spirometry as a preoperative evaluation for elective surgeries between January to December, 2000. Medical records were reviewed for medical history, clinical findings, smoking status, and discharge diagnoses for patients who demonstrated airflow limitation (AL), defined as FEV(1)/FVC<70% on spirometry. Of the 1031 patients who qualified for the study, 263 (26%) presented AL. Sixty-nine of these patients with AL (26%) had underlying conditions that could account for AL, such as asthma and previously diagnosed COPD. The remaining 194 patients with AL (74%) were suspected to have undiagnosed COPD, 90% of which was mild in severity. Only 30 (15%) of these patients appeared to be diagnosed have received a diagnosed as COPD by physician on this occasion. This study testifies that COPD is often unnoticed, and demonstrates that every spirometry, such as in preoperative evaluation, gives a clue to identify affected individuals, for which awareness of the disease is essential.

Effects of economic status and education level on the height and weight of community adolescents in Nepal.

There is scarce information on the relative importance of socio-economic factors in determining the adolescent anthropometric measurements. The objective of this study was to examine the effects of economic status, education level, and food consumption on the height and weight of community adolescents in Nepal. The study was done in the communities of the Kathmandu Valley area in Nepal. All together 426 unmarried adolescent girls aged 14-19 y were selected. The adolescents were interviewed regarding socioeconomic background (education, occupation and property possessions) and frequency of foods consumption. Height and weight were determined and BMI was calculated. Z-scores of height-for-age and weight-for-age were calculated based on the WHO/NCHS standard to avoid bias by age. The adolescents participating in the survey were categorized into three groups using the various indicators of economic status: Low Economic Status (LES) group, Middle Economic Status (MES) group and High Economic Status (HES) group. The Z-scores of height and weight were significantly lower in the LES group than in the MES and HES groups (p<0.05). The Z-score of height was significantly increased with education level even under the condition of controlling economic level (p<0.05). Since the frequency of milk consumption was significantly related not only with height (p<0.05), but also with economic (chi2=31.6, df=4, p<0.001) and education levels (chi2=22.4, df=6, p<0.01), the increased height in the groups of the better economic status or the better education level was interpreted to be due to the outcome of the higher frequency of milk consumption. This study indicated that education was a more important factor affecting the height of the adolescents via improved food habits even under adverse economic conditions.

Chronic pulmonary scedosporiosis simulating aspergillosis.

Scedosporium apiospermum, a ubiquitously distributed saprophyte, is emerging as an important pathogen in immunocompromised patients. We describe a 72-year-old patient with chronic S. apiospermum infection of the lung simulating aspergilloma. His medical history was unremarkable except that he had undergone partial lung resection as a treatment for pulmonary tuberculosis several decades previously. He had no underlying immunosuppressive conditions. This patient illustrates that pulmonary scedosporiosis is not confined to immunocompromised patients and that the clinical presentation may be indistinguishable from that of aspergilloma.

Helicobacter pylori infection rate in patients with nontuberculous mycobacteriosis who are on longterm combination chemotherapy of clarithromycin and rifampicin.

Clarithromycin resistance in Helicobacter pylori has increased the incidence of eradication failure. Clarithromycin is a key drug in the current treatment regimens for H. pylori infection, and it is also used for nontuberculous mycobacteriosis (NTM). The rate of H. pylori infection in 15 patients with NTM who were on longterm clarithromycin, rifampicin, and other drug therapy was examined, using the [(13)C] urea breath test. H. pylori was detected in 5 of the 15 patients (33.3%), which was significantly lower than the prevalence of H. pyloriin subjects who had routine upper gastrointestinal endoscopy in Japan (P = 0.0006). Thus, H. pylori resistance to clarithromycin is suggested to be low in patients with longterm administration, and the possibility exists of a combination of clarithromycin and rifampicin as a second-line therapy for the eradiation of H. pylori.

[Successful treatment with micafungin in a case of candidemia associated with pneumonia].

A 63-year-old woman was admitted to our hospital with fever and cough. Candidemia was diagnosed by blood culture and culture of IVH catheter. Although, the patient was treated with fluconazole, clinical symptoms and chest radiographic findings worsened. After micafungin was replaced with fluconazole, her symptoms, chest radiographic findings improved and stabilized. It is suggested that micafungin is useful for the treatment of candidemia associated with Candida parapsilosis.

Clinical utility of lipoarabinomannan antibody in pleural fluid for the diagnosis of tuberculous pleurisy.

We studied the clinical utility of the detection of lipoarabinomannan antibody, using MycoDot, in pleural fluid for the diagnosis of tuberculous pleurisy. Nine patients with active tuberculous pleurisy, 1 patient with chronic tuberculous empyema, and 16 patients with nontuberculous pleural effusions were studied. The results were positive in 5 patients with tuberculous pleural disease. Sensitivity was 50% (5 of 10; including the 1 patient with chronic tuberculous empyema) and specificity was 93.8% (15 of 16). Detection of lipoarabinomannan antibody using MycoDot in pleural fluid is a specific diagnostic tool for tuberculous pleurisy; furthermore, this diagnostic method is simple, rapid, and cost-effective.

[Antifungal susceptibility of Candida species causing candidemia in Kurume University Hospital and Shaiseikai Hutukaichi Hospital].

Prevention of candidemia has been difficult and empirical therapy may eventually reduce morbidity and mortality. Successful empirical therapies depend on understanding of fungal features and antifungal agents. Susceptibility to amphotericin B (AMPH-B), flucytosine (5-FC), fluconazole (FLCZ), itraconazole (ITCZ), miconazole (MCZ), and micafungin (MCFG) of 41 Candida species isolated from blood were determined. Candida albicans was the most common species (23 species), followed by C. parapsilosis (5 species), C. tropicalis (4 species), C. glabrata (3 species), C. guilliermondii (2 species), C. krusei (1 specie), and Candida spp (3 species). The isolation rates of the drug-resistant (DR) fungi were 5% for 5-FC. The rates of DR and susceptible dose dependent (S-DD) fungi were 0% and 2% for FLCZ, respectively. The rates of DR and S-DD fungi were 0% and 17% for ITCZ, respectively. No shift to resistant species in C. albicans occurred in our hospitals. All C. albicans were susceptible for the antifungal agents examined.

Endobronchial tuberculosis.

Endobronchial tuberculosis is defined as tuberculous infection of the tracheobronchial tree. Although clinical features differ between various types and stages of endobronchial tuberculosis, common symptoms are cough, hemoptysis, sputum production, wheezing, chest pain, fever and dyspnea. Endobronchial tuberculosis is difficult to diagnose, because the lesion is not evident in the chest radiograph. Computerized tomography is very useful in evaluating bronchial lesions such as stenosis or obstruction. The most important goal of treatment in active endobronchial tuberculosis is the eradication of tubercle bacilli. The second most important goal is prevention of bronchial stenosis. Corticosteroid therapy for prevention of bronchial stenosis in endobronchial tuberculosis remains controversial, but the best results are associated with minimal delay in the initiation of steroid treatment. In inactive disease, treatment to restore full patency is appropriate. As steroids or other medication are unable to reverse stenosis from fibrous disease, airway patency must be restored mechanically by surgery or endobronchial intervention. Aerosol therapy with streptomycin and corticosteroids is useful in treatment against active endobronchial tuberculosis. Time to healing of ulcerous lesions is shorter, and bronchial stenosis is less severe in patients on aerosol therapy. Progression to bronchial stenosis may be prevented if the therapy is initiated as soon as possible.

Enhanced expression of interleukin-18 and its receptor in idiopathic pulmonary fibrosis.

Idiopathic pulmonary fibrosis (IPF)/usual interstitial pneumonia (UIP) is a major interstitial lung disease (ILD). Recently, we established a new mouse model for ILD in which daily administration of interleukin (IL)-18 with IL-2 induces lethal lung injury, suggesting that IL-18 is involved in the pathogenesis of ILD. Here, utilizing immunohistochemistry, we have analyzed IL-18 and IL-18 receptor (IL-18R) alpha expression in the lungs of 18 patients with IPF/UIP and 13 control subjects by using monoclonal anti-IL-18 antibodies and a new monoclonal antibody for IL-18Ralpha (H44). IL-18 was expressed in bronchoalveolar epithelium, alveolar macrophages, and the endothelium of small vessels in control subjects, and was abundantly expressed in the majority of pulmonary cells in patients with IPF. IL-18Ralpha was expressed in bronchoalveolar epithelium and alveolar macrophages in control subjects, and was strongly expressed in interstitial cells in patients with IPF, especially in the fibroblastic foci (FF). Interestingly, IL-18Ralpha expression was only weakly observed in areas showing established fibrosis. Semiquantitative analysis revealed that the histologic FF score was significantly correlated with the IL-18Ralpha expression level in FF lesions. Moreover, IL-18 levels in the serum and bronchoalveolar lavage fluid of patients with IPF were significantly higher than those in control subjects. Our findings suggest IL-18 and IL-18R are involved in the pathogenesis of IPF/UIP.