Preventing Loss of Femoral Periprosthetic Bone Mineral Density in Cementless Total Hip Arthroplasty Using a Tapered Wedge Stem: A Retrospective, Cohort Study in Osteoporotic Patients Treated with Denosumab.

Purpose: Bone quality is an important issue in elderly osteoporotic patients who undergo total hip arthroplasty (THA) because periprosthetic fracture or aseptic loosening of implant caused by periprosthetic bone loss is a serious concern. Denosumab has been approved for osteoporosis patients. Thus, the purpose of this study was to investigate whether denosumab prevents loss of proximal femoral periprosthetic bone mineral density (BMD) in cementless THA using a tapered wedge stem in patients with osteoporosis. Methods: Seventy consecutive patients who had undergone primary THA were included in this study. Twenty-seven patients who received denosumab for osteoporosis formed the denosumab group, and 43 patients without denosumab formed the control group. Bone turnover markers and femoral periprosthetic BMD were measured at two weeks, six months, and 12 months after THA. BMD was evaluated in seven regions of interest according to the zones of Gruen. Results: BMD in zone 1 was significantly increased from baseline at both six and 12 months after THA in the denosumab group (10.0±10.2%, p<0.001 and 13.1±12.7%, p<0.001, respectively) and significantly decreased in the control group (-3.6±9.7%, p<0.05, and -5.9±9.4%, p<0.001, respectively). BMD in zone 7 was significantly decreased compared to baseline at both six and 12 months after THA in the control group (-19.2±20.2%, p<0.001 and -22.3±16.8%, p<0.001, respectively) but not in the denosumab group (-0.7±18.5% and -1.1±16.6%, respectively). The use of denosumab for THA patients with osteoporosis was independently related to preventing loss of periprosthetic BMD of the femur at 12 months after surgery in zones 1 (p<0.001) and 7 (p<0.001) on multivariate analysis. Conclusions: Denosumab significantly increased proximal femoral periprosthetic BMD in zone 1 and prevented loss of BMD in zone 7 in patients with osteoporosis after cementless THA using a tapered wedge stem at both seven and 12 months. Future studies of denosumab treatment following THA in patients with osteoporosis should focus on clinical outcomes such as the risk of periprosthetic fracture and revision THA.

Pediatric femoral shaft fracture requiring revision surgery for nonunion associated with vitamin D and K deficiencies: a case report.

BACKGROUND: Nonunion of femoral shaft fractures in children is rare, and there is no clear treatment protocol. In this case report, a pediatric femoral shaft fracture that developed in nonunion due to vitamin deficiency after osteosynthesis, which was successfully treated with vitamin augmentation and replacement with a rigid antegrade intramedullary nail, is described. CASE PRESENTATION: The patient is an 11-year-old Japanese girl. She injured her right femoral shaft fracture when she hit a wall after kickboarding down a hill and underwent osteosynthesis with a titanium elastic nail. Six months postoperatively, she developed nonunion, was found to be deficient in vitamins D and K, and was started on vitamin supplementation. She underwent replacement with a rigid antegrade intramedullary nail at 7 months postoperatively, and bone union was achieved 3 months after reoperation. CONCLUSION: When delayed union of a fracture is observed postoperatively, even in children without underlying disease, the cause of the problem must be investigated and treated promptly.

Characteristics and Treatment Strategies for Basicervical and Transcervical Shear Fractures of the Femoral Neck.

This study aimed to define basicervical and transcervical shear fractures using area classification and to determine the optimal osteosynthesis implants for them. The clinical outcomes of 1042 proximal femur fractures were investigated. A model of the proximal femur of a healthy adult was created from computed tomography images, and basicervical and transcervical shear fractures were established in the model. Osteosynthesis models were created using a short femoral nail with a single lag screw or two lag screws and a long femoral nail with a single lag screw or two lag screws. The minimum principal strains of the fracture surfaces were compared when the maximum loads during walking were applied to these models using finite element analysis software. Basicervical fractures accounted for 0.96% of all proximal femur fractures, 67% of which were treated with osteosynthesis; the failure rate was 0%. Transcervical shear fractures accounted for 9.6% of all proximal femur fractures, 24% of which were treated with osteosynthesis; the failure rate was 13%. Finite element analysis showed that transcervical shear fracture has high instability. To perform osteosynthesis, multiple screw insertions into the femoral head and careful postoperative management are required; joint replacement should be considered to achieve early mobility.

What is the most fixable intramedullary implant for basicervical fracture and transcervical shear fracture? - A finite element study.

Objective: The objectives of this study are 1) to biomechanically compare six different intramedullary fixations for basicervical fracture (AO 31-B3, Type 2 in area classification) and transcervical shear fracture (AO 31-B2.3, Type 1-2 in area classification) using the finite element (FE) method, and 2) to investigate the effects of two different unstable fracture types on fixation. Methods: FE models of two different types of proximal femoral fractures are constructed from CT scan images of a patient with osteoporosis. The fracture models are fixed with a short femoral nail with a single lag screw, short femoral nail with a single blade, and short femoral nail with double lag screws, and then fixed with long femoral nails for each of the three nail types. Subsequently, the maximum loads during walking and stair climbing, as well as the minimum principal strain and compressive failure elements are calculated to assess the fixation of each implant. Results: In both fracture types, the long nail with double lag screws show the smallest volume of compressive failure elements (basicervical fracture, 2 mm3; transcervical shear fracture, 217 mm3). In all types of implants, the volume of the compressive failure elements is larger in the transcervical shear fracture than in the basicervical fracture. A similar trend is observed for the minimum principal strain (compressive strain). Conclusion: The present study shows that a long nail with double lag screws is the most fixative intramedullary nail device for basicervical fracture and transcervical shear fracture in any condition. Furthermore, it is shown that transcervical shear fracture is considerably more unstable than basicervical fracture.

Preoperative respiratory intervention eliminated the operation cancelations of lobectomy surgery.

In Nagasaki University Hospital, the patients undergoing surgery with abnormal respiratory function have been automatically referred to specialized clinic by Medical Support Center (MSC) since July 2016 to reduce surgery cancellations due to insufficient preoperative evaluation. Whether the MSC system decreased post-hospital surgery cancellation, variance rate, or length of hospital stays in patients received "lobectomy" were retrospectively compared between Period A (n = 264, before MSC introduction) and Period B (n = 264, after MSC introduction). Four patients' operations were cancelled after hospitalization in Period A, while 0 patients in Period B (p < 0.05). The length of hospital stay, operation time, anesthesia time, and postoperative extubation oxygen administration time were all shorten in Period B significantly. "Period B", "operation time", and "postoperation oxygenation time" were independent factors for "hospital days", but chronic obstructive pulmonary disease or age were not. The preoperative intervention eliminated the operation cancellation. Preoperative MSC interventions may have contributed to the reduction in hospital days even for the patients with pulmonary dysfunction.

Guideline-based Treatment of Glucocorticoid-induced Osteoporosis in Patients with Rheumatoid Arthritis: A Retrospective Study with the AORA Registry.

Glucocorticoid-induced osteoporosis (GIOP) is one of the side effects associated with glucocorticoid (GC) therapy. In 2014, the Japanese Society for Bone and Mineral Research (JSBMR) provided new guidelines for the management and treatment of GIOP. The aim of the present study was to clarify the prevalence of patients with rheumatoid arthritis (RA) requiring treatment according to the new guidelines and to identify risk factors associated with lack of treatment in these patients. Patients in the 2018 Akita Orthopedic group on Rheumatoid Arthritis (AORA) database were enrolled. Of 2,234 patients with RA in the database, 683 (30.6%) met the 2014 JSBMR guideline treatment criteria, and 480 (70.3%) had been treated. The untreated group included a larger number of males, younger patients, and patients treated in clinics rather than hospital (p<0.001, p=0.015, and p<0.001, respectively). Multivariate analyses found that male sex, younger age, and clinic-based RA care were significant risk factors associated with lack of treatment (p<0.001, p=0.013, and p<0.001, respectively). Thus, male sex, younger age, and clinic-based care were identified as risk factors.

Changes in Invasiveness and Latent Infection Rate Associated with Switching the Approach in Total Hip Replacement.

PURPOSE: Muscle-sparing approaches for total hip replacement (THR) involve learning curves. This study aimed to clarify changes in invasiveness and infection rate with changes in approach. METHODS: One surgeon changed the approach of THR from Dall's approach (Dall) to anterolateral modified Watson-Jones approach (OCM). Another changed from Dall to a direct anterior approach (DAA). Another 3 surgeons changed from posterolateral approach (PL) to OCM. Subjects were 150 cases, comprising the last 25 cases with conventional approaches and the first 25 cases with new approaches (Dall to OCM: 25 + 25; Dall to DAA: 25 + 25; PL to OCM: 25 + 25 cases). Differences in operative time, bleeding volume, hospital stay, haemoglobin (Hb), white blood cell count, lymphocyte count, creatine kinase (CK) and C-reactive protein (CRP) were investigated. RESULTS: In the change from Dall to OCM, only hospital stay decreased. In the change from Dall to DAA, hospital stay and CRP decreased, but bleeding volume increased. In the change from PL to OCM, operative time, CRP and CK decreased, but Hb also decreased. Cases with lymphocyte count <1000/µL or lymphocytes comprising <10% of total white blood cells at around day 4 after surgery were defined as latent infection cases. In these cases, operative time was longer, Hb was lower and CK was higher. CONCLUSION: Introducing muscle-sparing approaches improved many markers of invasiveness, but some items deteriorated. In the early stages of introducing a new approach, choosing cases without obesity and without high muscle volume may reduce the risk of infection.

Preoperative medications is one of the factor affecting patient-reported outcomes after total hip arthroplasty.

Although the reported clinical outcomes of total hip arthroplasty (THA) for hip osteoarthritis are satisfactory, not all patients are completely satisfied. Thus, there is interest in predicting postoperative satisfaction before surgery. The influence of comorbidities and preoperative medications on the incidence of complications and duration of hospitalization following THA has become apparent. However, studies about the associations of preoperative medication with clinical outcomes of THA are limited. Therefore, this study aimed to clarify the relationship between preoperative medications and postoperative patient-reported outcomes. This retrospective cross-sectional multicenter study enrolled post-THA patients (79 patients, 90 hips) who were examined from February to March 2019 in eight general hospitals. Outcome measures included patient-reported outcome as Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ) score. Preoperative medications were investigated from medical records. Medications were categorized, and analgesics were categorized into non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, pregabalin, duloxetine, neurotropin (an extract from inflammatory rabbit skin inoculated by vaccinia virus), and opioid. To identify the factors associated with JHEQ score, the patients were divided into lower (<55 score) and higher (≥55) JHEQ score groups. Spearman rank correlation coefficient (r) showed significant difference between the total number of preoperative medications and postoperative JHEQ movement subscale (r = -0.37, p < 0.01), mental subscale (r = -0.29, p < 0.01), and JHEQ (r = -0.30, p < 0.01) scores. In the multiple logistic regression analysis, only the total number of preoperative medications was identified as a risk factor for lower JHEQ score (p < 0.01). This study clarified an inverse correlation between the total preoperative medication count and postoperative outcomes and found that larger total count of preoperative medications is a risk factor of poor postoperative patient-reported outcomes of THA.

A new double level osteotomy procedure to restore a joint line and joint angles in severe varus osteoarthritis. - Double level osteotomy associated with tibial condylar valgus osteotomy (DLOTO).

High tibial valgus osteotomy (HTO) is a well-established surgical procedure to correct a varus malalignment and treat medial compartment osteoarthritis. Recently, double level osteotomy (DLO) was recommended for extensive varus knees as a single level osteotomy (SLO) approach may create an excessive joint line obliquity and eventually result in a new bony deformity. However, a severe varus knee in cases of advanced osteoarthritis involves not only a bony deformity (extra-articular deformity) but also a medial joint space narrowing with a widened lateral joint space (intra-articular deformity). A DLO alone cannot reduce this intra-articular deformity. However, tibial condylar valgus osteotomy (TCVO) can complement DLO as to reduce this intra-articular deformity. This technical note describes a novel modified DLO procedure associated with TCVO which can restore a normal alignment and a joint line and achieve joint preservation even in cases of extensive varus osteoarthritis.

Characteristic imaging findings of tendinosis of the direct head of rectus femoris and their interpretation.

BACKGROUND: Tendinosis at the origin of the direct head of rectus femoris causing anterior hip pain is termed AIISpinitis, but no study has investigated its imaging findings. The aim of the present study was to determine the characteristic imaging findings of AIISpinitis and clarify their pathological significance. METHODS: We reviewed the preoperative imaging findings of 62 hips in 58 patients who had undergone endoscopy with a diagnosis of AIISpinitis. The origin of the direct head of rectus femoris was evaluated by ultrasound (US) and magnetic resonance imaging (MRI), and the positive rate of abnormal findings and their agreement with endoscopy regarding injury of the direct head of rectus femoris were measured. Signal changes in the fat pad around the anterior inferior iliac spine (AIIS fat pad) in MRI were compared with the pathological findings of that harvested endoscopically. RESULTS: Hypoechoic regions in US (53/62, 85%) and signal change in MRI (55/62, 89%) were observed with high frequency and corresponded with injury of the direct head of rectus femoris observed by endoscopy (58/62, 94%) (kappa coefficient, 0.43 [moderate agreement], 0.69 [good agreement] respectively). Hypoechoic regions had high sensitivity (85%) and specificity (86%) for AIISpinitis. Regarding the AIIS fat pad, punctate and completely hypo-intense change relative to normal fat corresponded to fibrosis and scar formation, respectively (weighted kappa coefficient, 0.51 [moderate agreement]). CONCLUSIONS: Hypoechoic regions on US which had high sensitivity and specificity; and signal change at the origin of the direct head of rectus femoris and hypo-intensity of the AIIS fat pad on MRI were characteristic findings of tendinosis of the direct head of rectus femoris. These findings correspond pathologically to injury of the direct head of rectus femoris and fibrosis or scar formation in the AIIS fat pad, respectively.

Initial Rotational Instability of the Tapered Wedge-Shaped Type Cementless Stem.

BACKGROUND: Because the tapered wedge-shaped type cementless stem has a small anteroposterior width and a low occupation rate in the medullary space, postoperative rotational instability and stem subsidence due to inadequate proximal fixation are concerns. The purpose of this study was to clarify the relationship between the rotational instability of the tapered wedge-shaped type cementless stem and femoral canal shape. METHODS: A total of 61 primary total hip arthroplasties with the tapered wedge-shaped type cementless stem Accolade® TMZF (11 males, 50 females; mean age 60 years) from January 2012 to June 2015 who underwent computed tomography before surgery and within 4 weeks and 1 year after surgery were evaluated. The preoperative femoral neck anteversion angle, preoperative femoral canal flair index, the degree of postoperative stem subsidence within 1 year after operation, and the degree of rotational change in the stem setting angle within 1 year after operation were investigated. RESULTS: The mean preoperative femoral neck anteversion angle was 32.2° ± 17.8° (0°-69°), and the mean preoperative canal flair index was 3.68 ± 0.58 (2.44-5.55). There were no stem subsidence cases within 1 year after operation. The mean degree of rotational change in the stem from immediately to 1 year after surgery was -0.4° ± 1.7° (-3°-3°). There was no significant correlation between the canal flair index and the rotational change in the stem. In addition, the mean difference between the preoperative femoral neck anteversion angle and the stem rotational angle immediately after surgery was only 1.3° ± 5.3° (-29°-15°). CONCLUSIONS: In all cases, including stove-pipe cases, the degree of rotational change in the Accolade® TMZF stem from immediately to 1 year after surgery was within 3°. In other words, regardless of femoral canal shape, the tapered wedge-shaped type cementless stem has little initial rotational instability.

Successful treatment of a habitual patellar dislocation after a total knee arthroplasty with a closing-wedge distal femoral varus osteotomy and medial patello-femoral ligament reconstruction.

A 68-year-old female suffering from habitual patellar dislocations following a mal-positioned total knee arthroplasty (TKA) was successfully treated with a biplanar closed wedge distal femoral osteotomy (CWDFO) and medial patello-femoral ligament (MPFL) reconstruction. To the best of our knowledge, no such case has been previously described. Our experience with this case suggests that treatment for a patella dislocation following valgus mal-positioning of TKA should be considered positively. LEVEL OF EVIDENCE: V.

Intra-abdominal fat accumulation is an important predictor of metabolic syndrome in young adults.

Metabolic syndrome (MetS), mainly caused by intra-abdominal fat (IAF) accumulation, is an important risk factor for cardiovascular disease. The prevalence of MetS increases rapidly after the age of 40 years, and it is presumed that there is a substantial proportion of MetS in younger age groups. However, the association of IAF with MetS in adults aged 20 to 30 years has not been fully investigated.This study aimed to determine the prevalence of MetS and to verify whether IAF accumulation is associated with other MetS-related metabolic disorders including dyslipidemia, high blood pressure, and high blood glucose among the Japanese population in their 20s.In this cross-sectional study, IAF area (IAFA) and MetS-related metabolic parameters were evaluated in university students in their 20s (n = 1822, 21.5 ±â€Š1.5 years). IAFA was measured using a non-invasive device, DUALSCAN, which can be readily measured through the dual impedance method. The participants were divided into four groups according to IAFA: 0-49.9, 50-74.9, 75-99.9, and ≥100 cm.MetS was prevalent in 3.3% and 0.0% of the males and females, respectively, according to the Japanese criteria of MetS. The sex- and lifestyle-adjusted odds ratios (ORs) for the three metabolic component levels of Mets were elevated in the larger IAFA groups compared to the smallest IAFA group, according to the level of IAFA. The levels particularly increased in participants with abdominal obesity, defined by both, IAFA and waist circumference rather than by waist circumference alone.IAF accumulation was significantly associated with MetS-related metabolic disorders in young adults. An evaluation of IAFA may contribute to the early prediction of the risk of developing MetS in the future.

The Differences in Imaging Findings Between Painless and Painful Osteoarthritis of the Hip.

PURPOSE: In osteoarthritis of the hip, the pain may be strong even if the deformity is mild, but the pain may be mild even if the deformity is severe. If the factors related to the pain can be identified on imaging, reducing such factors can alleviate the pain, and effective measures can be taken for cases where surgery cannot be performed. In addition, imaging findings related to the pain are also important information for determining the procedures and the timing of surgery. Thus, the purpose of this study was to identify the differences in features of osteoarthritis seen on imaging between painless and painful osteoarthritis of the hip. METHODS: The subjects were the patients with hip osteoarthritis who visited our department in 2015 and who underwent x-ray, computed tomography (CT), and magnetic resonance imaging (MRI), a total of 29 patients (54 hip joints; mean age 63 years; 8 males and 21 females). The degree of osteoarthritis was determined using the Tönnis grade from the x-ray image. The cartilage morphology, intensity changes of bone marrow on MRI (subchondral bone marrow lesions [BMLs]), osteophytes, joint effusions, and paralabral cysts were scored based on the Hip Osteoarthritis MRI Scoring System (HOAMS). The cross-sectional area of the psoas major muscle at the level of the iliac crest was measured on CT, and the psoas index (PI; the cross-sectional area ratio of the psoas major muscle to the lumbar 4/5 intervertebral disc) was calculated to correct for the difference in physique. Then, the relationships between these and visual analog scale (VAS) scores of pains were evaluated. RESULTS: The average VAS was 55.4 ± 39 mm. The PI and all items of HOAMS correlated with the VAS. The average VAS of Tönnis grade 3 osteoarthritis was 75.8 ± 26 mm. When investigating only Tönnis grade 3 osteoarthritis, the differences between cases with less than average pain and those with above average pain were the BML score in the central-inferior femoral head (P = .0213), the osteophyte score of the inferomedial femoral head (P = .0325), and the PI (P = .0292). CONCLUSION: Investigation of the differences between painless and painful osteoarthritis of the hip showed that the cases with more pain have BMLs of the femoral head on MRI that extend not only to the loading area, but also to the central-inferior area. Even with the same x-ray findings, the pain was stronger in patients with severe psoas atrophy. Thus, the instability due to muscle atrophy may also play a role in the pain of hip osteoarthritis.

A Comparison of the Incidences of Venous Thromboembolism after Total Hip Arthroplasty between the Direct Anterior Approach and the Direct Lateral Approach, Especially in the Early Period after Introduction of the Direct Anterior Approach.

OBJECTIVE: To compare the incidence of venous thromboembolism (VTE) after total hip arthroplasty (THA) using the direct anterior approach (DAA) with that using the direct lateral approach (DLA). In addition, patient background characteristics and the incidence of VTE were compared between the first half and the latter half of the period after introducing DAA and against DLA. METHOD: This was a retrospective, multicenter study involving 109 patients (116 hips) who had undergone primary unilateral THA. Thirty-six hips underwent THA using DAA and 80 hips underwent THA using DLA. Patient information including sex, age, and preoperative diagnosis was collected. The incidence of VTE was compared between DAA and DLA. Moreover, the patients who underwent THA using DAA were divided into 2 groups (first half and latter half groups), and sex, age, body mass index (BMI), and surgical time were compared between the 2 groups. Moreover, the incidence of VTE was compared among the 3 groups (first half of DAA, latter half of DAA, and DLA). RESULTS: The incidence of VTE in the DAA group was significantly higher than that in the DLA group (p=0.014). The incidence of VTE in the first half group was significantly higher than in the latter half group and the DLA group (p=0.035 and p=0.001, respectively), and there was no difference in the incidence of VTE between the latter half group and the DLA group (p=0.923). Surgical time was significantly longer in the first half group than in the latter half group (p=0.046). CONCLUSIONS: In the first half of the period after introducing the DAA, more VTEs occurred than in the DLA. It may be important to shorten the surgical time in the early stage of introducing the DAA, and aggressive anticoagulation therapy may be required until the surgeon becomes familiar with the procedure.

The location of the fracture determines the better solution, osteosynthesis or revision, in periprosthetic femoral fractures.

PURPOSE: Periprosthetic femoral fractures are difficult to treat, but few reports have included many periprosthetic femoral fractures. The purpose of this study was to investigate the trends and characteristics of a large number of periprosthetic femoral fractures and to determine the best treatment strategy for such fractures. METHODS: The fracture type according to the Vancouver classification, the stem fixation style of previous surgery, the elapsed time from previous surgery, and the treatment method for periprosthetic fractures of 51 patients with periprosthetic femoral fractures who were seen between 2006 and 2018 were investigated. RESULTS: The types of fractures according to the Vancouver classification were: type A 5.9%, type B1 47%, type B2 20%, type B3 2.0%, and type C 25%. Of the previous surgeries, 76% were cementless fixation, and 24% were cemented fixation. The mean duration from previous surgery to periprosthetic femoral fracture was 8 years and 7 months (1-358 months), and injury within 1 year from previous surgery was most commonly observed (24%). As treatment for periprosthetic femoral fractures, conservative treatment was performed in 8%, and surgery was performed in 92%. Of the surgery cases, 53% underwent osteosynthesis, and 39% underwent revision surgery. Of type B1 surgery cases, 58% were treated with osteosynthesis, and 33% underwent revision surgery, although type B1 had no stem loosening. CONCLUSION: Many periprosthetic femoral fractures occurred within 1 year after the previous surgery. Therefore, preventive measures for periprosthetic femoral fractures should be started immediately after total hip replacement. In addition, revision surgery was performed even if the stem was not loosened in cases where it was judged that sufficient osteosynthesis could not be performed.

Comparison of 12-Week Additional Effect Features of Formoterol Co-Inhalation and Tulobuterol Patch on Budesonide Inhalation in Elderly Patients With Asthma.

BACKGROUND: For asthma strategy, to avoid the aggravation of bronchial inflammation and contraction, the long acting beta agonist (LABA) addition on inhaled corticosteroids (ICS) has been recommended. OBJECTIVES: To know whether there is any clinical difference between the additional efficacies of Formoterol (FOR) and Tulobuterol (TUL) onto Budesonide (BUD) may be useful for the elderly patients' asthma treatment strategy. METHODS: Eighteen outpatients with mild to moderate bronchial asthma with FEV1.0% < 80% treated by intermediate ICS dosages visited Respiratory Division of Nagasaki University Hospital or Isahaya General Hospital, Japan Community Health care Organization were subjected, and were randomly assigned (9 cases per group) to either the FBC group (BUD/FOR 160/4.5 µg, 2 inhalations twice daily) or BUD + TUL group (BUD 200 mcg: 2 inhalations twice daily + TUL 2 mg daily) and were compared in parallel with 2 arms for 12 weeks prospectively. Peak expiratory flow, forced expiratory volume in 1 second, impulse oscillometry (IOS), fractional exhaled nitric oxide (FeNO), Asthma Control Questionnaire, mini-Asthma Quality of Life Questionnaire (mini-AQLQ), and occurrence of adverse reactions were compared. RESULTS: The "Fres" of IOS was improved in FBC group (p = 0.03). The "emotion" domain of mini-AQLQ was improved in BUD + TUL group (p = 0.03). CONCLUSION: By changing the drug formulation, the patch was superior in terms of satisfaction, but it was thought that the inhaled combination was superior in improving the respiratory function itself. It is necessary to pay attention to the characteristics of the patient when selecting treatment.

Liposomal Amphotericin B Fosters the Corticosteroids' Anti-inflammatory Effect on Murine Allergic Bronchopulmonary Aspergillosis Model Airways.

Fungus is an antigen for bronchial asthma causing allergic bronchopulmonary mycosis (ABPM). As a therapy other than corticosteroids, itraconazole (ITCZ) is known to suppress the allergic inflammation induced by Aspergillus fumigatus (Af). However, the efficacy of liposomal amphotericin B (LAMB) with/without corticosteroid on ABPM is unknown. Mice sensitized to Dermatophagoides farinae (Df) allergen were intranasally infected with Af (DfAf group). After the infection, corticosteroid (dexamethasone (Dex)) was administered for 5 days (DfAf/Dex group). The effects of ITCZ or LAMB with/without Dex were also evaluated. Pathologically, Dex and LAMB combination treatment decreased the allergic inflammation evidently. The bronchoalveolar lavage fluid (BALF) concentrations of IL-5, IL-13, and MIP-2 were significantly elevated in DfAf mice compared with control mice (p < 0.05, each). In DfAf mice, ITCZ and LAMB significantly decreased the elevation of MIP-2 (p < 0.05 vs the DfAf group). The addition of both Dex and LAMB suppressed the MIP-2 elevation in DfAf mice (p < 0.05 vs the Df/Af/Dex/LAMB group), but the addition of Dex and ITCZ did not (DfAf/Dex/ITCZ group). None of Dex, ITCZ, or LAMB decreased pulmonary IL-13 concentration. It was suggested that combination of antifungal drugs and corticosteroid enhanced the suppressing effect of airway inflammations. This finding will give a hope for the treatment of severe fungus-related asthma.

Fluctuation of Hepatic Focal Nodular Hyperplasia Size with Oral Contraceptives Use.

BACKGROUND Focal nodular hyperplasia (FNH) of the liver is a rare benign nodular lesion that arises in women of reproductive age. Although a role of female hormones has been suggested, their influence on the course of FNH has remained controversial. CASE REPORT A 44-year-old woman with a 12-year history of oral contraceptive use was referred to our hospital for examination of an asymptomatic liver mass (3 cm in diameter) identified by computed tomography. We diagnosed FNH using imaging methods and fine-needle biopsy. Oral contraceptives were discontinued because the mass increased over a period of 21 months. Four months later, the mass had decreased in size, indicating that FNH can spontaneously regress when oral contraceptives are discontinued. CONCLUSIONS Discontinuation of oral contraceptives use can reduce the size of FNH, as in this case.

Associations of chemical composition and sources of PM2.5 with lung function of severe asthmatic adults in a low air pollution environment of urban Nagasaki, Japan.

Previous studies have linked ambient PM2.5 to decreased pulmonary function, but the influence of specific chemical elements and emission sources on the severe asthmatic is not well understood. We examined the mass, chemical constituents, and sources of PM2.5 for short-term associations with the pulmonary function of adults with severe asthma in a low air pollution environment in urban Nagasaki, Japan. We recruited 35 asthmatic adults and obtained the daily record of morning peak expiratory flow (PEF) in spring 2014-2016. PM2.5 filters were extracted from an air quality monitoring station (178 days) and measured for 27 chemical elements. Source apportionment was performed using Positive Matrix Factorization (PMF). We fitted generalized linear model with generalized estimating equation (GEE) method to estimate changes in PEF (from personal monthly maximum) and odds of severe respiratory deterioration (first ≥ 15% PEF reduction within a 1-week interval) associated with mass, constituents, and sources of PM2.5, with adjustment for temperature and relative humidity. Constituent sulfate (SO42-) and PM2.5 from oil combustion and traffic were associated with reduced PEF. An interquartile range (IQR) increase in SO42- (3.7 µg/m3, average lags 0-1) was associated with a decrease of 0.38% (95% confidence interval = -0.75% to -0.001%). An IQR increase in oil combustion and traffic-sourced PM2.5 (2.64 µg/m3, lag 1) was associated with a decrease of 0.33% (-0.62% to -0.002%). We found a larger PEF decrease associated with PM2.5 from dust/soil on Asian Dust days. There was no evidence linking total mass and metals to reduced pulmonary function. The ventilatory capacity of adults with severe asthma is susceptible to specific constituents/sources of PM2.5 such as sulfate and oil combustion and traffic despite active self-management of asthma and low air pollution levels in the study location.