Relapsing bronchopneumonia due to community-associated methicillin-resistant Staphylococcus aureus: a case report.

BACKGROUND: The emergence of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has increased the incidence of community-onset MRSA infection. Respiratory tract infections caused by MRSA has been noted for their severity; however, repeated relapses that require extended antibiotic therapy are rare. CASE PRESENTATION: We report a case of relapsing bronchopneumonia caused by CA-MRSA in a 56-year-old man. The patient responded to antibiotics, but repeatedly relapsed after stopping treatment. MRSA was consistently isolated from airway specimens during each relapse. Extended oral antibiotic treatment with trimethoprim/sulfamethoxazole (TMP/SMX) for 6 months achieved infection control. Whole-genome sequencing of the isolated strain revealed that the causative agent was sequence type (ST)1/staphylococcal cassette chromosome mec (SCCmec) type IVa, a clone that is rapidly increasing in Japan. DISCUSSION AND CONCLUSIONS: This patient had an unusual course of MRSA bronchopneumonia with repeated relapses. Although the choice of antibiotics for long-term use in MRSA respiratory tract infections has not been well established, TMP/SMX was effective and well tolerated for long-term therapy in this case. The clinical course of infections related to the rapid emerging clone, ST1/SCCmec type IVa warrants further attention.

Assessment of clinical relevance of antigen improves diagnostic accuracy of hypersensitivity pneumonitis.

BACKGROUND: Exposure assessment is integral to the diagnosis of hypersensitivity pneumonitis (HP). Although the clinical relevance of exposed antigens is essential for the assessment, many of the previous guidelines or reports have only evaluated simple exposure histories or immunological tests. To overcome this problem, the Exposure Assessment Form (EAF) was developed as an assessment tool for classifying the exposure grade from G0 to G4. The EAF was modified from the description in the Japanese clinical practice guide 2022 for HP published by the Japanese Respiratory Society. METHODS: One hundred and seventy-two consecutive patients with interstitial lung disease who underwent multidisciplinary discussion (MDD) at our hospital were retrospectively examined. We assessed whether the use of the EAF improved the diagnostic performance of the international guideline of HP. We also evaluated whether the exposure grade affected the prognosis of HP. RESULTS: Even when a HP diagnosis was made with a confidence of 70% or higher according to the international guideline, less than half of these cases resulted in a final diagnosis of HP when the exposure grades were lower than G3. When the result of the EAF was integrated into the exposure definition of the international guideline, the specificity of the diagnostic performance improved, while sensitivity was maintained. Furthermore, HP patients with an exposure grade of G3 or higher showed a tendency to take a longer time to initiate medication. CONCLUSIONS: This is the first study to evaluate the clinical relevance of possible antigens using the EAF. Assessing the exposure grade prevents overdiagnosis and improves the diagnostic performance of the international guideline.

A Case of Solitary Pure Ground-glass Opacity Suspected of Being the Initial Presentation of Nonfibrotic Hypersensitivity Pneumonitis.

We herein report a rare case of hypersensitivity pneumonitis (HP) that was initially demonstrated as solitary pure ground-glass opacity (GGO) on chest computed tomography (CT). A 51-year-old woman with a history of breast cancer underwent follow-up CT, which revealed solitary pure GGO. The patient developed exertional dyspnea after two years, and CT revealed diffuse centrilobular nodules in addition to GGO, which had increased in size. An antigen avoidance test was performed to diagnose HP, leading to the resolution of CT abnormalities, including the GGO. Our findings suggested that nonfibrotic HP can present as solitary pure GGO.

Pulmonary Artery Aneurysm in a Patient with Nontuberculous Mycobacteria Infection.

Nontuberculous mycobacterial (NTM) infection sometimes leads to the development of pulmonary artery aneurysm (PAA), a rare but life-threatening complication. We herein report a 64-year-old woman with a history of NTM infection who presented with severe hemoptysis. Computed tomography revealed a ruptured PAA, which was treated successfully with pulmonary artery embolization. Subsequent right total pneumonectomy was performed to control infection. This case emphasizes the need to consider PAA in patients with NTM infection who present with hemoptysis. Early detection and appropriate management are critical for preventing this fatal complication.

Morphological and histological evaluation of the tendon-bone junction in porcine shoulders to create a rotator cuff tear and repair model.

BACKGROUND: This study aimed to morphologically and histologically examine whether pig is useful as models for rotator cuff tear (RCT). METHODS: The morphology of the scapula and humerus bones was evaluated by taking X-ray and three-dimensional computed tomography (3D CT) scans of the right shoulders of five female pigs (age: 4 months). The rotator cuff (RC) footprint at the humeral insertion of these was observed and its shape was measured. Next, they underwent general anesthesia and an acute rotator cuff tear/rotator cuff repair (RCT/RCR) model was created using a deltoid split approach. Four weeks after surgery, the animals were euthanized, the shoulder joints were harvested, and the repaired RC was evaluated by hematoxylin and eosin staining and toluidine blue staining. RESULTS: The scapula of the pig had a vestigial acromion, in contrast to that in humans. The supraspinatus and infraspinatus tendons were connected so as to overlap each other and attached to the postero-superior part of the greater tuberosity. These tendons were located extra-articularly, separate from the joint capsule. The average antero-posterior length of the foot print was 17.4 ± 0.7 mm on the medial margin and 19.1 ± 2.2 mm on the lateral margin. The maximum medial-to-lateral width of it was 5.1 ± 0.5 mm. In all RCT/RCR models at 4 weeks after surgery, the repaired RC compound tendon was visually confirmed to be continuous with the footprint. Histologically, it was confirmed that regeneration of the four-layer structure of the bone-tendon junction had occurred. CONCLUSION: Porcine supraspinatus and infraspinatus attachment to the greater tuberosity have a structure similar to that of sheep and dogs, which is advantageous for creating the RCT/RCR model. It might be used for future in vivo studies of shoulder joint diseases. THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE: Pigs could potentially serve as a viable model for rotator cuff tears.

Clinical outcomes and cost-effectiveness of manipulation under brachial plexus block versus physiotherapy for refractory frozen shoulder: a prospective observational study.

Background: Frozen shoulder (FS) is a pathological condition that involves a painful and stiff shoulder joint, most commonly in people aged 40-60 years. Most literature supports treatment with physical therapy (PT), although some studies have demonstrated years of continuing pain and functional deficits. Manipulation under anesthesia is effective at eliminating the contracture of intra-articular lesions for refractory FS. This study aimed to compare whether manipulation under anesthesia or PT is a more effective treatment in refractory FS. Methods: This study was a prospective observational study. A total of 102 patients with refractory FS were enrolled in this study in the medical records, all of whom had severe and multidirectional loss of motion and thickening of the joint capsule and coracohumeral ligament on magnetic resonance imaging. Fifty-one patients were in the manipulation under brachial plexus block (MUB) group (34 females, median age: 57 years), and 51 patients were in the PT group (34 females, median age: 59 years). The MUB procedure consisted of the conventional method with additional adduction manipulation, in which one examiner initially abducted the shoulder joint as much as possible. We recorded the visual analog scale, shoulder range of motion, and American Shoulder and Elbow Surgeons and Constant Scores at the initial baseline visit and at the 1-, 3-, 6-, and 12-month follow-ups. The total cost was calculated from the medical records, and cost-effectiveness was evaluated using quality-adjusted life year and incremental cost-effectiveness ratio. Results: Visual analog scale (P < .001), range of motion (P < .001), and American Shoulder and Elbow Surgeons and Constant Scores (P < .001) in the MUB group were significantly superior to those in the PT group at 1, 3, 6, and 12 months after treatment. The median cost and total quality-adjusted life year in the MUB and PT groups were $1375 versus $2751 and 2.95 versus 2.68, respectively, and the cost-effectiveness ratio between the MUB and PT groups was calculated as -$560. Conclusions: The new MUB procedure provides a shorter treatment period, better clinical outcomes, and higher cost-effectiveness in patients with refractory FS compared to PT.

The influence of COVID-19 epidemic on the number of orthopaedic surgeries in Japan.

BACKGROUND: There is limited data on the impact of COVID-19 epidemic on the number of orthopaedic surgeries in Japan. METHODS: We conducted a nationwide hospital survey asking for the monthly number of orthopaedic surgeries performed at each facility from January 2019 to June 2021. Those facilities that had performed at least 100 surgeries in 2019 were included for analyses. The facilities were further grouped by prefecture and by hospital characteristics. A brief health economic evaluation was also performed. Risk ratios were compared using univariate analyses with P < 0.05 considered statistically significant. RESULTS: Questionnaire was sent to 1988 hospitals with 1671 hospitals (84%) responding. The survey data indicated a total number of orthopaedic surgeries decreased in 2020 compared to 2019 (1,061,541 vs 1,119,955 P < 0.01), and also for the first six months of 2021 compared to the same period in 2019 (530,388 vs 550,378 P < 0.01). In 2020, over 50% of all facilities in nearly all of the prefectures saw a decline in surgical procedures. The risk of incurring more than a 25% decease in the number of surgeries was significantly higher in 2020 for class I designated medical institutions compared to those that were not designated for any types of infectious diseases among the institutions with a tertiary emergency medical center in 2020 (crude risk ratio 2.9: 95% CI 1.2-7.4, p = 0.02) and in 2021 (crude risk ratio 4.7: 95% CI 1 0.9-12.1, p < 0.01). The estimated total nationwide decrease of revenue were in the range of approximately ¥29.2 to ¥116.8 billion per year for orthopaedic surgeries alone. CONCLUSION: There was a statistically significant decrease in the number of orthopaedic surgeries in Japan. The magnitude of the decline varied by prefectures and hospital characteristics, with the greater impact imposed on medical institutions with higher classification functions. The estimated immediate health economic impact was sizable.

Relationship between pain and range of motion in frozen shoulder.

Background: A frozen shoulder (FS) is characterized by pain and limited range of motion (ROM). Although physical assessment of ROM is important for diagnosing and staging FS, ROM cannot be accurately assessed in clinical practice because of pain and muscle contraction. This study aimed to measure changes in shoulder joint ROM before and after anesthesia (ΔROM) in patients with FS and investigate the factors affecting these changes. Methods: This study included 54 patients (age, 55.6 ± 9.4 years; 17 males; disease duration, 6.6 ± 3.4 months) with FS before manipulation under transmission anesthesia. FS was defined as having a ROM in external rotation (ER) that was less than 50% of that in the unaffected shoulder. Pain at night and during motion was assessed using a numerical rating scale. Before anesthesia, the passive ROM of forward flexion (FF), abduction (AD), and ER were measured in the supine position. After confirming that the anesthesia was effective, passive ROM was measured again. Results: The ROM in the FF, AD, and ER after anesthesia was significantly higher than that before anesthesia (P < .001). ΔROM in the FF, AD, and ER was significantly correlated with pain at night (r = 0.51, P < .001; r = 0.45, P < .001; and r = 0.39, P = .004, respectively). Furthermore, ΔROM in the ER was significantly correlated with pain during motion (r = 0.31, P = .023) and disease duration (r = -0.31, P = .021). Conclusion: The ROM of the FS is susceptible to pain and muscle contraction. Interventions, such as physical therapy, may be recommended after pain relief.

Evaluation of muscle stiffness in adhesive capsulitis with Myoton PRO.

Background: Adhesive capsulitis (AC) is characterized by pain and limited range of motion, caused by stiffness of the joint capsule and coracohumeral ligament. On the other hand, there have been few reports on muscle stiffness in AC. The purpose of this study was to assess muscle stiffness in patients of AC with a portable and noninvasive device, Myoton PRO. We hypothesized that muscle stiffness around shoulder joint increases in AC. Methods: At first, we surveyed correlation between Myoton PRO and shear wave elastography with phantoms. Second, reproducibility and repeatability of healthy volunteers with Myoton PRO were evaluated. Finally, muscle stiffness was measured in 40 patients who were diagnosed with AC. Muscle stiffness was quantitatively measured with Myoton PRO. We compared the stiffness of the anterior deltoid (AD), pectoralis major, and latissimus dorsi (LD) in AC patients on both the affected and nonaffected sides. Results: Correlation coefficient in shear wave elastography and Myoton PRO was 0.99(P = .001). Reliability of intraoperator and interoperator with Myoton PRO was 0.9 or higher. Muscle stiffness values (N/m) of the AD, pectoralis major, and LD were 355 ± 61, 252 ± 54, 207 ± 51 in the affected sides and 328 ± 50, 252 ± 41, 186 ± 37 in the nonaffected sides, and the differences were significant in the AD and LD (P = .005, P = .002, respectively). Conclusions: We used Myoton PRO to evaluate muscle stiffness in AC. The AD and LD muscles of AC patients were significantly stiffer on the affected side compared to the nonaffected side.

COVID-19 Pneumonia Followed by Anti-signal Recognition Particle Antibody-positive Fibrosing Interstitial Lung Disease.

Coronavirus disease 2019 (COVID-19) pneumonia is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and is frequently accompanied by various sequelae. Interstitial lung diseases (ILDs) are observed in COVID-19 pneumonia patients after recovery, probably due to persistent inflammation in the lungs. We herein report a case of ILD with anti-signal recognition particle antibodies following severe COVID-19 pneumonia. The patient was diagnosed with ILD three months after COVID-19 pneumonia. Although the exact mechanism is unknown, the autoantibody-induced immune response might have been the pulmonary fibrosis trigger in this patient.

Efficacy of fracture stem in reverse shoulder arthroplasty for 3- or 4-part proximal humerus fractures.

BACKGROUND: This study compared the clinical results of fracture stems and conventional stems using the same glenoid component in reverse shoulder arthroplasty for proximal humerus fractures in the elderly. METHODS: This retrospective study included 35 patients who underwent Grammont-type reverse shoulder arthroplasty for proximal humerus fractures from 2014 to 2020. The average age at surgery was 79.2 (range, 65-92) years, with 33 female shoulders. Fracture types per Neer classification were 3-part fracture, 4-part fracture, in 13 and 22 shoulders, respectively. The final follow-up period was 35 (range, 24-81) months. The Constant score, American Shoulder and Elbow Surgeons score, shoulder range of motion, and healing of greater tuberosities at the final follow-up of AEQUALIS™ REVERSED (Conventional stem group: n = 15) and AEQUALIS™ REVERSED FX (Fractured stem group: n = 20) were retrospectively investigated. RESULTS: There were no statistically significant differences in age at surgery, sex, body mass index, fracture type, waiting time from injury to surgery, or preoperative general condition between the groups. The Constant and American Shoulder and Elbow Surgeons scores of the fractured stem group were significantly higher than those of the conventional stem group (P = 0.038 and P = 0.023, respectively). The anterior elevation and external rotation at the side of the fractured stem group also showed significantly higher values than those of the conventional stem group (fractured stem group vs. conventional stem group: anterior elevation 127° ± 25° vs. 105° ± 35°, P = 0.041; external rotation 28° ± 13° vs. 13° ± 12°, P = 0.015). The greater tuberosity healing rate was 46.7% (7/15) in the conventional stem group and 85.0% (17/20) in the fractured stem group (P＝0.027). CONCLUSIONS: The findings suggest that use of a fracture-specific stem rather than a conventional stem in Grammont-type reverse shoulder arthroplasty for proximal humerus fractures improves tuberosity healing, postoperative range of motion, and clinical scores.

Association of SARS-CoV-2 RNA Copy Number with the COVID-19 Mortality Rate and Its Effect on the Predictive Performance of Mortality in Severe Cases.

Factors associated with mortality are important in the treatment of coronavirus disease 2019 (COVID-19). Polymerase chain reaction (PCR) is the gold standard for diagnosing COVID-19, which reflects the viral load in the upper respiratory tract. In total, 523 patients were enrolled in this study; of them, 441 and 75 patients underwent PCR testing of nasopharyngeal swabs and sputum samples, respectively, within 20 days from onset of COVID-19. We investigated the association between RNA copy number and the COVID-19 severity and mortality rate and its effect on the predictive performance for severity and mortality. RNA copy numbers in nasopharyngeal swabs were higher in the non-survivor group than in the survivor group. Multivariate logistic regression analysis identified that the high RNA copy number (≥9 log10 /swab) in nasopharyngeal swabs was a factor associated with mortality (odds ratio, 4.50; 95% confidence interval, 1.510-13.100; P = 0.008). Furthermore, adding RNA copy number (≥9 log10 /swab) in severe cases, adjusted by duration from onset to PCR, improved mortality predictive performance based on known factors. The RNA copy number is a factor associated with the mortality of patients with COVID-19 and can improve the predictive performance of mortality in severe cases.

Reduction of abnormal blood flow in frozen shoulder after shoulder manipulation under ultrasound-guided cervical nerve root block: semiquantitative analysis using dynamic magnetic resonance imaging.

Background: We previously reported a characteristic dynamic magnetic resonance imaging (MRI) change in patients with frozen shoulder (FS) and named this abnormal blood flow pattern the "burning sign". In this study, a semiquantitative method was used to evaluate changes in this abnormal blood flow pattern on dynamic MRI after shoulder manipulation under ultrasound-guided cervical nerve root block (MUC) in patients with FS. Methods: Nineteen patients with FS underwent MUC, with dynamic MRI performed before and after. We used dynamic MRI to semiquantitatively assess changes in the burning sign at the axillary pouch (AP) and rotator interval (RI) by examining the enhancement rate in the signal intensity and the enhancement velocity. Functional assessments included a numeric rating scale score, the range of shoulder motion, the American Shoulder and Elbow Surgeons score, and the Constant score. Results: The burning sign in the AP and RI was observed with dynamic MRI in all patients before MUC. The average interval from MUC until dynamic MRI was 8.2 months (range, 6-12). Clinical results for all patients improved after MUC. The before and after MUC enhancement rates (%) were 217 ± 51 and 85 ± 36 in the AP and 233 ± 61 and 73 ± 40 in the RI, respectively (both P < .001). The before and after MUC enhancement velocities (ms/s) were 902 ± 335 and 203 ± 125 in the AP and 1249 ± 634 and 213 ± 146 in the RI, respectively (both P < .001). Conclusion: Dynamic MRI semiquantitatively demonstrated a reduction in abnormal blood flow and improvement in clinical results after MUC in patients with FS.

Successful diagnosis of humidifier lung by individual provocation test to a responsible environment, a case report.

A 52-year-old woman presented with repeating episodes of pneumonia which spontaneously resolved after hospitalization. Hypersensitivity pneumonitis was suspected, but the causative antigen was not determined whether the parakeets she kept or the humidifier she owned was causative exposure. To identify which exposure is culprit, individual provocation test to a responsible environment was sequentially conducted. First, a home-returning provocation test to the parakeet was negative. Contrarily, the humidifier provocation test to her own humidifier was positive for symptoms, radiological changes, and inflammatory responses in blood test. Finally, she was diagnosed as having humidifier lung. When several antigens are suspected to be the causative agents for hypersensitivity pneumonitis, a step-by-step provocation tests is useful.

Prognostic factors of shoulder manipulation under ultrasound-guided cervical nerve root block for frozen shoulder for patient with diabetes mellitus: A retrospective cohort study.

INTRODUCTION: Shoulder manipulation under ultrasound-guided cervical nerve root block (MUC) gives good clinical results in patients with frozen shoulder 1 week after the procedure. However, some patients are refractory to MUC. The present study was performed to investigate the prognostic factors of MUC for frozen shoulder. METHODS: We evaluated 73 frozen shoulders (70 patients) to investigate the prognostic factors of MUC. The patients' mean age was 56.6 years, and 60% were female. The mean duration of symptoms before MUC was 8.6 months. We assessed pain using a numeric rating scale (NRS), range of motion (ROM), and the American Shoulder and Elbow Surgeons (ASES) score before and 1 year after MUC. We compared patients with an ASES score of <80 (defined as a poor clinical result) with those with an ASES score of ≥80 (good clinical result). To identify the risk factors for a poor clinical result, multiple logistic regression analysis was performed using the following variables: age, sex, duration of symptoms before MUC, diabetes mellitus (DM), initial NRS score, and initial ROM. RESULTS: The initial NRS score and the prevalence of DM were significantly greater in the poor clinical results group. Multiple logistic regression analysis revealed that DM was the only independent risk factor for a poor clinical result after MUC (odds ratio, 51; 95% confidence interval, 10.9-237; p = .01). CONCLUSIONS: DM is a negative prognostic factor of MUC for frozen shoulder, and patients with DM should be informed of this before they undergo treatment for frozen shoulder.

Characteristics of dynamic magnetic resonance imaging for shoulder stiffness in postoperative breast cancer patients: A preliminary case series.

INTRODUCTION AND IMPORTANCE: Shoulder stiffness in postoperative breast cancer causes a decrease in their quality of life. However, the underlying pathology is not fully understood, and no study has investigated the dynamic magnetic resonance imaging (MRI) findings in these patients. Therefore, the current preliminary study aimed to investigate the dynamic MRI findings in patients with shoulder stiffness occurring after breast cancer surgery. METHODS: We retrospectively analyzed the electronic medical records of postoperative breast cancer patients with shoulder stiffness, dated from January 2015 to December 2020. The baseline characteristics, breast cancer treatment methods, range of active shoulder motion, and location of the abnormal enhancement on dynamic MRI were assessed. RESULTS: The mean age of the patients was 57.8 ± 6.1 years (range, 47-63 years) and the mean duration of shoulder symptoms was 5.6 ± 3.6 months (range, 2-12 months). An abnormal enhancement of the rotator interval and axillary pouch was observed on dynamic MRI of all the included patients. CONCLUSION: This study presents the first case reports of the dynamic MRI findings in postoperative breast cancer patients with shoulder stiffness. All patients had abnormal enhancement of the rotator interval and axillary pouch.

Treatment of advanced lung cancer based on genomic profiling using liquid biopsy (plasma): A review of three cases.

Of the 80 solid tumor cases in which liquid biopsy (LB) was performed using Guardant360 in the PROFILE study, nine were lung cancer cases. Here, we review three cases in which LB was useful in diagnosing ALK fusion-positive lung cancer, selecting sequential ALK-tyrosine kinase inhibitors, confirming uncommon EGFR mutations, and receiving biomarker-compatible therapy.

Corticosteroids for hospitalized patients with mild to critically-ill COVID-19: a multicenter, retrospective, propensity score-matched study.

Corticosteroids use in coronavirus disease 2019 (COVID-19) is controversial, especially in mild to severe patients who do not require invasive/noninvasive ventilation. Moreover, many factors remain unclear regarding the appropriate use of corticosteroids for COVID-19. In this context, this multicenter, retrospective, propensity score-matched study was launched to evaluate the efficacy of systemic corticosteroid administration for hospitalized patients with COVID-19 ranging in the degree of severity from mild to critically-ill disease. This multicenter, retrospective study enrolled consecutive hospitalized COVID-19 patients diagnosed January-April 2020 across 30 institutions in Japan. Clinical outcomes were compared for COVID-19 patients who received or did not receive corticosteroids, after adjusting for propensity scores. The primary endpoint was the odds ratio (OR) for improvement on a 7-point ordinal score on Day 15. Of 1092 COVID-19 patients analyzed, 118 patients were assigned to either the corticosteroid and non-corticosteroid group, after propensity score matching. At baseline, most patients did not require invasive/noninvasive ventilation (85.6% corticosteroid group vs. 89.8% non-corticosteroid group). The odds of improvement in a 7-point ordinal score on Day 15 was significantly lower for the corticosteroid versus non-corticosteroid group (OR, 0.611; 95% confidence interval [CI], 0.388-0.962; p = 0.034). The time to improvement in radiological findings was significantly shorter in the corticosteroid versus non-corticosteroid group (hazard ratio [HR], 1.758; 95% CI, 1.323-2.337; p < 0.001), regardless of baseline clinical status. The duration of invasive mechanical ventilation was shorter in corticosteroid versus non-corticosteroid group (HR, 1.466; 95% CI, 0.841-2.554; p = 0.177). Of the 106 patients who received methylprednisolone, the duration of invasive mechanical ventilation was significantly shorter in the pulse/semi-pulse versus standard dose group (HR, 2.831; 95% CI, 1.347-5.950; p = 0.006). In conclusion, corticosteroids for hospitalized patients with COVID-19 did not improve clinical status on Day 15, but reduced the time to improvement in radiological findings for all patients regardless of disease severity and also reduced the duration of invasive mechanical ventilation in patients who required intubation.Trial registration: This study was registered in the University hospital Medical Information Network Clinical Trials Registry on April 21, 2020 (ID: UMIN000040211).