Japanese Guideline for Adult Asthma 2014.

Adult bronchial asthma (hereinafter, asthma) is characterized by chronic airway inflammation, reversible airway narrowing, and airway hyperresponsiveness. Long-standing asthma induces airway remodeling to cause intractable asthma. The number of patients with asthma has increased, and that of patients who die from asthma has decreased (1.5 per 100,000 patients in 2012). The aim of asthma treatment is to enable patients with asthma to lead a normal life without any symptoms. A good relationship between physicians and patients is indispensable for appropriate treatment. Long-term management with antiasthmatic agents and elimination of the causes and risk factors of asthma are fundamental to its treatment. Four steps in pharmacotherapy differentiate between mild and intensive treatments; each step includes an appropriate daily dose of an inhaled corticosteroid, varying from low to high. Long-acting ß2-agonists, leukotriene receptor antagonists, and sustained-release theophylline are recommended as concomitant drugs, while anti-immunoglobulin E antibody therapy has been recently developed for the most severe and persistent asthma involving allergic reactions. Inhaled ß2-agonists, aminophylline, corticosteroids, adrenaline, oxygen therapy, and others are used as needed in acute exacerbations by choosing treatment steps for asthma exacerbations depending on the severity of attacks. Allergic rhinitis, chronic obstructive pulmonary disease, aspirin-induced asthma, pregnancy, asthma in athletes, and cough-variant asthma are also important issues that need to be considered.

[Clinical pathway based on evidence-based medicine (EBM) for chemotherapy for lung cancer].

Recently, combination treatment with cisplatin has been recommended as chemotherapy for lung cancer. However, no clinical pathway for safe and efficient use of anticancer agents has been established. We devised a clinical pathway satisfying evidence-based medicine (EBM) criteria by analyzing case records and the relevant literature. We analyzed 73 case records of hospitalized patients who had undergone chemotherapy for lung cancer on the internal medicine ward of the Showa University Hospital. Grade 3 or higher toxicities of leukopenia, thrombocytopenia, anemia, vomiting, and diarrhea occurred in 30%, 51%, 14%, 5%, 8%, and 1% of patients, respectively. Therefore the checklists for these toxicities were included in the clinical pathway. The National Cancer Institute Common Toxicity Criteria were used for the evaluation of toxicities. According to the guidelines of the American Society of Clinical Oncology and the US Infection Society, the indicated agents and criteria for their use were chosen for supportive cancer treatment. Pharmacists, physicians, and nurses collaborated in making the clinical pathway safe and sufficiently easy for practical use. The final version of the clinical pathway is compatible with EBM and includes items required for safe chemotherapy, which could be helpful in risk management.

[Case of interstitial pneumonitis induced by a Chinese herbal medicine, bofu-tsusho-san].

The patient was a 64-year-old woman. She had complained of dyspnea during exercise, productive cough, and pyrexia for two months after treatment to reduce her body weight with a Chinese herbal medicine, bofu-tsusho-san. This symptom worsened gradually, and she was admitted to our hospital for the examination and therapy. Chest radiography and CT scanning on admission showed ground-glass-attenuation with partial consolidation. Replacement of the medicine with treatment with oxygen and few medications for two weeks, made her condition well. The result of DLST for the herbal medicine, Bofu-tsusho-san was negative, but we strongly think it induced pneumonitis. The Chinese herbs ogon and kanzo which are ingredients of bofu-tsusho-san, can cause drug-induced pneumonitis. In conclusion, care should be taken if side effects, hypersensitivity, lung disease, liver injury, or other morbid conditions arise during the use of herbal medicines, because these disorders may lead to serious illness.

Inhibitory effect of catechin against the superantigen staphylococcal enterotoxin B (SEB).

Staphylococcal superantigens (SsAgs) have gained attention as one of the factors aggravating atopic dermatitis (AD) and several potential mechanisms of AD aggravation by SsAgs have been reported. Tea catechin has been found to have many unique antimicrobiological activities such as antibacterial, antiviral, antifungal and antitoxic effects. In the present study, we investigated the inhibitory effect of the green tea catechin extract, Polyphenon, and (-)-epigallocatechin gallate (EGCg) on staphylococcal enterotoxin B (SEB) and its mechanisms of action, and we also discuss the possibility of therapeutic benefits for AD patients of tea catechin. Polyphenon inhibited the lethal toxicity of SEB and the SEB-induced production of TNF-alpha, IFN-gamma and IL-4 following its intraperitoneal administration to BALB/c mice. Although Polyphenon is composed of several isomers among which EGCg is approximately 50% of the total, we considered that most of the inhibitory effect of Polyphenon in mice could be attributed to EGCg. EGCg was immediately bound to SEB molecules and neutralized SEB in a dose- and incubation time-dependent manner without molecular weight alteration of the SEB molecule. Furthermore, EGCg inhibited SEB-induced TNF-alpha and IFN- gamma production and IL-2, IFN-gamma, IL-10 and IL-12 p40 mRNA expression in human PBMCs from normal donors in a dose-dependent manner. Inhibition of SsAg-induced T-cell activation by catechin was observed in both in vivo and in vitro studies, suggesting that catechin may be useful in the treatment of AD.

Cross-over comparison between respiratory muscle stretch gymnastics and inspiratory muscle training.

OBJECTIVES: To compare the effect of respiratory muscle stretch gymnastics (RMSG), proposed as a possible additional form of rehabilitation for patients with chronic obstructive pulmonary disease (COPD), with that of inspiratory muscle training (IMT). PATIENTS: Twelve naive outpatients with COPD at a university hospital. METHOD: The patients performed IMT (2 sessions of 10 minutes of training at 30% of PImax, daily) for 4 weeks and RMSG (3 sessions of 5 RMSG patterns 4 times each, daily) for 4 weeks, in randomized order, with a 4-week washout period between the two interventions. MEASUREMENTS AND RESULTS: PImax increased with IMT (mean 66.1 to 79.1 cmH2O), but not with RMSG (mean 66.0 to 69.4 cmH2O). RMSG and IMT similarly increased maximum chest wall expansion. FRC was significantly decreased by 158 ml with RMSG, but not with IMT. There were no significant changes in VC, FEV1, or PEF nor in arterial blood gases with either form of rehabilitation. Six-minute walking distance was more significantly increased with RMSG (mean 383 to 430 m), than with IMT (mean 386 to 412 m). CONCLUSIONS: RMSG may have clinically significant benefits, which may be somewhat different from the benefits of IMT, in patients with COPD.

[Japanese cedar pollinosis is a risk factor for bronchial asthma in Japanese adult asthmatics].

It is well known that allergic rhinitis and asthma often coexist in the same patients. Here, we investigated the influence of Japanese cedar pollinosis on the exacerbation of asthma investigated by questionnaire, daily asthma diary, and peak expiratory flow (PEF) monitoring. Furthermore, airway responsiveness to histamine before pollen season was also investigated in some patients. 333 adult patients with asthma were enrolled into the study and 116 patients (34.8%) were suffering from Japanese cedar pollinosis diagnosed by the presence of nasal allergic symptoms during pollen season and high titer of Japanese cedar-specific IgE antibody. Exacerbation of asthma symptoms, including wheezing, dyspnea, cough, and sputum, was detected in 41 of 116 patients (35.3%) during pollen season. Decrease in morning PEF more than 10% compared with the baseline values before pollen season was observed in 13 of 41 patients (11.2% of total asthmatic patients who complicated with Japanese cedar pollinosis). No significant differences in airway responsiveness to histamine and the titer of Japanese cedar-specific IgE antibodies before pollen season were observed between the patients whose asthma exacerbated and the patients whose asthma was not exacerbated. These results suggest that Japanese cedar pollinosis is one of risk factors for asthma in Japanese adult patients with asthma.

Distinct role of adiposity and insulin resistance in glucose intolerance: studies in ventromedial hypothalamic-lesioned obese rats.

It remains unclear whether adiposity plays an important role in glucose intolerance independently of insulin resistance. We investigated whether adiposity and insulin resistance had distinct roles in glucose intolerance in rats. We examined glucose tolerance and insulin resistance using ventromedial hypothalamic (VMH)-lesioned rats in the dynamic and the static phases of obesity (2 and 14 weeks after lesioning, respectively). Rats were fed either normal chow or a fructose-enriched diet (60% of total calories). The intravenous glucose tolerance test (IVGTT) was performed by bolus injection of glucose solution (1 g/kg) and blood sampling after 0, 5 10, 30, and 60 minutes. Insulin resistance was evaluated from the steady-state plasma glucose (SSPG) value during continuous infusion of glucose, insulin, and somatostatin. SSPG was not increased in VMH-lesioned rats in the dynamic phase of obesity, but increased markedly in the static phase. The area under the glucose curve (glucose AUC) during IVGTT was increased in VMH-lesioned rats in the static phase, but not in the dynamic phase, when compared with their sham-operated counterparts. A fructose-enriched diet for 2 or 14 weeks increased SSPG values to a similar extent in both sham-operated and VMH-lesioned rats without inducing excess adiposity, but glucose intolerance was only developed in the obese rats. The plasma leptin level, an excellent indicator of adiposity, was significantly related to the glucose AUC independently of the insulin level. Insulin resistance or increased adiposity alone is not sufficient to impair glucose tolerance, but increased adiposity plays an important role in the development of glucose intolerance in an insulin-resistant state.