Limited efficacy of low-dose dexamethasone for the treatment of severe COVID-19 pneumonia: A retrospective study.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2. Its symptoms range from mild to severe, with the latter often being life-threatening. This study aims to assess the effects of low-dose dexamethasone (DEX) in mild-to-severe COVID-19 pneumonia and examine the final clinical outcomes to identify the optimal therapeutic dose. METHODS: Clinical data from 132 patients hospitalized for COVID-19 pneumonia between January and October 2021 at Yamato Municipal Hospital were retrospectively analyzed. Based on the ratio of peripheral arterial oxygen saturation (SpO2) to inspired fraction of oxygen (FiO2), patients were categorized into the mild (>450, n = 65), moderate (315-450, n = 55), and severe (<315, n = 12) pneumonia groups. The event of interest was defined as the worsening of the patient's condition during treatment (need to increase FiO2 > 0.1). Patients were treated with low-dose DEX (6.6 mg/day) for 10 days. RESULTS: The event-free survival rate decreased significantly in patients with severe pneumonia compared with in those with mild and moderate pneumonia (Bonferroni-adjusted p < 0.02). A total of 16 patients were treated with high-dose corticosteroids because of severe hypoxia. Recovery was observed in all discharged patients with respiratory condition improvement. Low SpO2/FiO2 at admission was significantly associated with serum C-reactive protein levels. CONCLUSIONS: For Japanese patients with COVID-19, severe pneumonia, and SpO2/FiO2 of <315, it may be necessary to administer a dose of corticosteroids of >6.6 mg DEX.

Predictive value of computed tomography for short-term mortality in patients with acute respiratory distress syndrome: a systematic review.

The best available evidence and the predictive value of computed tomography (CT) findings for prognosis in patients with acute respiratory distress syndrome (ARDS) are unknown. We systematically searched three electronic databases (MEDLINE, CENTRAL, and ClinicalTrials.gov). A total of 410 patients from six observational studies were included in this systematic review. Of these, 143 patients (34.9%) died due to ARDS in short-term. As for CT grade, the CTs used ranged from 4- to 320-row. The index test included diffuse attenuations in one study, affected lung in one study, well-aerated lung region/predicted total lung capacity in one study, CT score in one study and high-resolution CT score in two studies. Considering the CT findings, pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio were 62% (95% confidence interval [CI] 30-88%), 76% (95% CI 57-89%), 2.58 (95% CI 2.05-2.73), 0.50 (95% CI 0.21-0.79), and 5.16 (95% CI 2.59-3.46), respectively. This systematic review revealed that there were major differences in the definitions of CT findings, and that the integration of CT findings might not be adequate for predicting short-term mortality in ARDS. Standardisation of CT findings and accumulation of further studies by CT with unified standards are warranted.

Clinical Utility of Surgical Lung Biopsy for Patients with Acute Respiratory Distress Syndrome: A Systematic Review and Meta-Analysis.

BACKGROUND: Surgical lung biopsy (SLB) is performed in patients with acute respiratory distress syndrome (ARDS); however, its clinical utility remains unclear. OBJECTIVES: We categorized the pathological diagnoses and investigated the predictive value for short-term mortality. METHOD: Three electronic databases (MEDLINE, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov) were searched for the included studies. The QUADAS-2 was used to evaluate the risk of bias and its applicability. The types and populations of pathological diagnoses were investigated. The pooled sensitivity, positive likelihood ratio (LR+), negative likelihood ratio (LR-), and diagnostic odds ratio (DOR) were estimated at a fixed specificity. Hierarchical summary receiver operating characteristic curves were drawn. RESULTS: A total of 16 studies that enrolled 758 patients were included. The pathological diagnoses were as follows: diffuse alveolar damage (DAD) 29.9%; infection 24.7%; interstitial lung disease 17.2%; malignancy 3.6%; cardiovascular disease 3.6%; drug toxicity 2.3%; connective tissue disease 2.2%; allergic disease 1.1%; and nonspecific diagnosis 15.4%. To predict short-term mortality, 13 studies that enrolled 613 patients used DAD as an index test and recorded a mortality rate of 56.9% (349 of 613 patients). A total of 3 studies that used index tests other than DAD were excluded. The pooled sensitivity, fixed specificity, LR+, LR-, and DOR were 0.46 (95% confidence interval [CI]: 0.29-0.56), 0.69, 1.48 (95% CI: 0.92-1.81), 0.78 (95% CI: 0.63-1.03), and 1.90 (95% CI: 0.89-2.86), respectively. CONCLUSIONS: SLB is unlikely to provide a specific diagnosis and should not be recommended for confirming DAD or predicting ARDS prognosis.

Safety of pyrazinamide-including regimen in late elderly patients with pulmonary tuberculosis: A prospective randomized open-label study.

Pyrazinamide (PZA) -including regimen had not been fully recommended for late elderly patients with tuberculosis (TB) by Japanese Society for Tuberculosis until 2018. Studies on the safety of adding PZA to other first-line TB drugs for late elderly patients are limited. In this prospective randomized open-label study, we aimed to assess the safety of regimen including PZA for patients aged 80 or older. Patients in their eighties with smear-positive pulmonary TB without any liver diseases were randomly assigned to HRE (isoniazid, rifampicin, ethambutol) group or HREZ (HRE and PZA) group. The primary endpoint was discontinuation or interruption rate of treatment due to liver injury. Other endpoint included overall rate of liver injury, time to culture conversion, and overall mortality. Eighty-nine patients were assigned to either HRE group (n = 45) or HREZ group (n = 44). Clinical background was not different in two groups including age, smear grade, body weight, serum albumin, and activity degree. Discontinuation of treatment due to liver injury occurred in 15.6% of HRE group and 9.1% of HREZ group, which showed no statistical difference. Incidence of liver injury was also comparable between two groups. Overall mortality was statistically higher in HREZ group (3 in HRE vs. 10 in HREZ), although all deaths seemed to be irrelevant to PZA use. Time to culture conversion was significantly shorter in HREZ group (43.6 days vs. 30.2 days). In conclusion, regimen including PZA seems to be safe for late elderly patients with pulmonary TB.

Mortality and risk factor analysis for Candida blood stream infection: A multicenter study.

Candida blood stream infection (candidemia) is severe systemic infection mainly develops after intensive medical cares. The mortality of candidemia is affected by the underlying conditions, causative agents and the initial management. We retrospectively analyzed mortality-related risk factors in cases of candidemia between April 2011 and March 2016 in five regional hospitals in Japan. We conducted bivariate and multivariate analysis of factors including causative Candida species, patients' predisposing conditions, and treatment strategies, such as empirically selected antifungal drug and time to appropriate antifungal treatment, to elucidate their effects on 30-day mortality. The study enrolled 289 cases of candidemia in adults. Overall 30-day mortality was 27.7%. Forty-nine cases (17.0%) were community-acquired. Bivariate analysis found advanced age, high Sequential Organ Failure Assessment (SOFA) score, and prior antibiotics use as risk factors for high mortality; however community-acquired candidemia, C. parapsilosis candidemia, obtaining follow-up blood culture, and empiric treatment with fluconazole were associated with low mortality. Logistic regression revealed age ≥65 years (adjusted odds ratio, 2.13) and sequential organ failure assessment (SOFA) score ≥6 (6.30) as risk factors for 30-day mortality. In contrast, obtaining follow-up blood culture (0.38) and empiric treatment with fluconazole (0.32) were found to be protective factors. The cases with candidemia in associated with advanced age and poor general health conditions should be closely monitored. Obtaining follow-up blood culture contributed to an improved prognosis.

Prevalence of, and risk factors for, hematogenous fungal endophthalmitis in patients with Candida bloodstream infection.

PURPOSE: Endogenous fungal endophthalmitis (EFE) is a severe consequence of candidemia. The prevalence of, and risk factors for, EFE is not well studied. METHODS: We retrospectively collected cases of patients with candidemia who had undergone ophthalmological examination between April 2011 and March 2016 in five regional hospitals. We conducted bivariate and multivariate analyses using patients' age, gender, causative Candida species, diabetes status, corticosteroid use, cancer status, neutropenia, intensive care unit admission, presence of central venous catheter (CVC), presence of shock, prior antibiotic use, 30-day mortality, and highest Sequential Organ Failure Assessment (SOFA) score. Data on sustained positive blood culture, ß-D glucan, CVC removal, empirical antifungal drug used, and time to appropriate antifungal therapy were also collected if available. RESULTS: Of 174 patients with candidemia, 35 (20.1%) were diagnosed with EFE, including 31 (17.8%) with chorioretinitis and 4 (2.3%) with vitritis. Bivariate analysis (EFE group vs. non-EFE group) found that Candida albicans candidemia (77.1 vs. 34.5%, P < 0.001), neutropenia (14.3 vs. 5.8%, P = 0.141), CVC placement (94.3 vs. 71.2%, P = 0.004), and the presence of shock (28.6 vs. 16.5%, P = 0.145) were each higher in the EFE group. Multivariate logistic regression analysis found C. albicans candidemia (adjusted odds ratio 6.48; [95% CI 2.63-15.95]) and CVC placement (7.55 [1.56-36.53]) to be significant risk factors for EFE. CONCLUSIONS: Candida albicans is the most common causative agent for Candida EFE. Patients with candidemia and CVC placement should be closely monitored by ophthalmologists.

Desquamative Interstitial Pneumonia Complicated with IgG4-related Lung Disease.

As an idiopathic interstitial pneumonia, desquamative interstitial pneumonia (DIP) is an uncommon form of interstitial lung disease and is considered to be a smoking- or dust inhalation-related interstitial pneumonia in the majority of cases. However, the details regarding immunoglobulin G4 (IgG4)-related lung disease remain unclear and controversial. We herein report the first case of DIP complicated with IgG4-related lung disease. Even if a patient has a smoking history, we emphasize the importance of exploring the association between DIP and IgG4-related lung disease to clarify the pathogenesis of these two disorders.

[Clinical features of pulmonary Mycobacterium avium complex disease diagnosed through gastric aspirate culture].

OBJECTIVES: The diagnostic significance of gastric aspirate culture has been established in pulmonary tuberculosis, but not in pulmonary Mycobacterium avium complex (MAC) disease. This study aimed to verify the diagnostic significance of gastric aspirate culture in pulmonary MAC disease. SUBJECTS AND METHODS: This retrospective study analyzed 77 cases of pulmonary MAC disease tentatively diagnosed through gastric aspirate culture in comparison with 308 cases diagnosed through sputum culture. RESULTS: There was no significant difference in the clinical symptoms, laboratory data, or type of disease in both groups. Patients diagnosed through gastric aspirate culture had a significantly lower chance of having underlying respiratory disease (26.0% vs. 46.8%), which indicates the difficulty in obtaining sputum specimens from this group of patients. In 114 patients without chemotherapy intervention, more patients achieved spontaneous remission in the gastric aspirate group than in the sputum group. Among 271 patients treated with chemotherapy, there were no significant differences in the course of radiological findings and clinical symptoms between both groups. During the observation period, a definitive diagnosis through sputum culture or histological confirmation was reached in 34 of 47 patients (72%). There was no significant difference in the clinical characteristics, course of radiological findings, and clinical symptoms in the definitive group and tentative group. CONCLUSION: Gastric aspirate is a minimally invasive, easy to conduct, and useful test for diagnosing pulmonary MAC disease.