BACKGROUND: Patients sometimes misidentify upper respiratory tract secretions or saliva as "sputum." The objective of this study was to investigate the prevalence of such misidentification and its clinical associations. METHODS: We conducted a cross-sectional study of adults with cough and/or sputum symptoms, examining how often patients referred to upper respiratory tract secretions or saliva as "sputum," and explored related clinical features. RESULTS: Of 72 patients with sputum symptoms, 32% and 13% referred to upper respiratory tract secretions and saliva, respectively, as "sputum." Patients who misidentified upper respiratory secretions more often reported post-nasal drip (41.2% vs. 6.1%) and rhinitis (64.7% vs. 26.5%) than those who did not, which remained significant after adjustment for covariates (p < 0.05). Saliva misidentification was more common in older patients (p = 0.03). CONCLUSIONS: 32% of the patients with sputum production referred to upper respiratory tract secretions as "sputum," highlighting a potential source of miscommunication in clinical practice.

PATIENTS AND METHODS: A questionnaire survey was administered to 18, 14, and 3 patients introduced to home self-injection of dupilumab or mepolizumab using a pen-type device for atopic dermatitis, asthma alone, and asthma plus chronic rhinosinusitis with nasal polyps, respectively. RESULTS: All but one participant wished to continue self-injection. Most participants affirmed the reduction in copayment (88.6%) and saving time and labor for hospital visits (88.6%). Six patients who received dupilumab complained of side effects, but all, except for one, continued the treatment. Of the 13 patients who had previously used a syringe-type device, 10 preferred the pen type because of its ease of use, while 3 (23%) preferred the syringe type because of the self-adjustable injection speed for pain control. CONCLUSION: Administration of biologics using pen-type devices is easier, and the introduction of home self-injection leads to a reduction in outpatient visits and copayment.

BACKGROUND: In chronic obstructive pulmonary disease (COPD) patients, combination treatment with long-acting muscarinic antagonist (LAMA) and long-acting β2 agonist (LABA) increases forced expiratory volume in one second and reduces symptoms compared to monotherapy. In Japan, three different once-daily fixed-dose combinations (FDCs) have been prescribed since 2015, although a direct comparison of these FDCs has never been performed. The objective of the present study was to compare the effectiveness, preference, and safety of three LAMA/LABA FDCs-glycopyrronium/indacaterol (Gly/Ind), umeclidinium/vilanterol (Ume/Vil), and tiotropium/olodaterol (Tio/Olo)-in patients with COPD. METHODS: We enrolled 75 COPD outpatients (male:female ratio, 69:6; 77.4 ± 6.9 years). A prospective, randomized, crossover study was conducted on three groups using three FDCs: Gly/Ind; Ume/Vil; and Tio/Olo. Each medication was administered for 4 weeks before crossover (total 12 weeks). After each FDC administration, a respiratory function test and questionnaire survey were conducted. A comparative questionnaire survey of all three LAMA/LABA FDCs was conducted after 12 weeks (following administration of final FDC). RESULTS: No significant differences in COPD Assessment Test or modified Medical Research Council dyspnea questionnaire were reported in the surveys completed after each FDC administration; no significant differences in spirometric items were observed. In the final comparative questionnaire survey, patients reported better actual feeling of being able to inhale following Gly/Ind administration compared with Tio/Olo, although no significant differences in adverse events or other evaluations were reported. CONCLUSIONS: The three LAMA/LABA FDCs administered to COPD patients show similar effects and safety, although some minor individual preference was reported. Trial registration This study retrospectively registered with the University Hospital Medical Information Network Clinical Trials Registry (number UMIN000041342, registered on August 6, 2020).

BACKGROUND: Eosinophils play an important role in allergic inflammation. Glucocorticosteroids have been used as an anti-inflammatory medication for inflammatory diseases involving eosinophil infiltration. Some effect of nebulized lidocaine has been reported when treating certain patients with asthma, which is also an inflammatory disease. The goal of this study was to examine the effects of dexamethasone and lidocaine on eosinophil proliferation and differentiation using a model of human umbilical cord blood mononuclear cells (UCMC) cultured with IL-5. METHODS: UCMC were cultured with IL-5 (5 ng/mL) for 4 weeks. The effects of dexamethasone and lidocaine on the number and morphology of eosinophilic cells were visualized with Wright-Giemsa and cyanide-resistant peroxidase stains. Moreover, the effect on eosinophil-derived neurotoxin (EDN) and eosinophil peroxidase (EPX) contents in cultured cells were evaluated using radioimmunoassay. RESULTS: The number of eosinophilic cells and EDN and EPX content in cultured cells increased in a time-dependent manner in the presence of IL-5. Dexamethasone treatment slightly decreased the number of eosinophilic cells in one week, but this effect was lost in 2-4 weeks. Macrophages in cultured UCMC treated with dexamethasone contained more eosinophil granule proteins. Both EDN and EPX content in cultured cells were reduced by dexamethasone. Lidocaine decreased the number of eosinophilic cells and reduced both EDN and EPX contents in cultured cells. CONCLUSIONS: Dexamethasone suppressed the production of eosinophil granule proteins and may also induce apoptosis of eosinophils, while lidocaine suppresses eosinophilopoiesis.

Two main types of devices are used to facilitate the administration of inhaled corticosteroid (ICS) and long-acting β-agonist (LABA) in combination, dry powder inhalers (DPIs) and pressurized metered-dose inhalers (pMDIs). There are few reports comparing the effects of the two devices, and it is unknown which should be recommended for asthma patients with given sets of characteristics. In the current study, the beneficial effects and side effects associated with DPIs and pMDIs were compared, and the question of which device should be recommended for asthma patients was investigated. A prospective, randomized, crossover, comparative study in adult outpatients with asthma was conducted using salmeterol/fluticasone propionate combination (SFC) 50 μg/250 μg, one inhalation of Adoair® 250 Diskus® twice daily or two inhalations of Adoair® 125 Aerosol twice daily, for 8 weeks. Questionnaires, exhaled nitric oxide (FeNO) tests and pulmonary function tests were administered after the use of each device for 8 weeks, and the results derived from each device were compared. Sixty-eight subjects were included in the final analysis. There were no significant differences between quality-of-life scores, FeNO, spirometry test results and forced oscillation results. With regard to patient preferences, 57.4% preferred the Adoair® Aerosol and 35.3% preferred the Adoair® Diskus®, as determined via the comparative evaluation questionnaire. Although DPI prescription accounts for the predominant market share of combined ICS/LABA in Japan, patients preferred a pMDI device to a DPI device. Compared to DPIs, pMDIs may be the preferential choice for patients with asthma.

BACKGROUND: Exertional dyspnea is the primary symptom that limits exercise in patients with chronic obstructive pulmonary disease (COPD). It is unknown which activated brain area is associated with this symptom in COPD patients. OBJECTIVES: To investigate the activation of cortical areas associated with dyspnea during exercise in COPD patients. METHODS: COPD patients (n = 10) and age-matched controls (n = 10) performed mild-intensity constant work rate cycle exercise (40% of their symptom-limited peak work rates) for 10 min, while cerebral hemodynamics and oxygenation were measured by near-infrared spectroscopy (NIRS). Ventilatory responses (breathing pattern and pulmonary gas exchange) and Borg scale ratings of dyspnea and leg fatigue were measured during exercise. Three NIRS probes were placed over the prefrontal and temporoparietal cortical regions of the subjects' heads. Changes in cortical oxyhemoglobin (oxy-Hb), deoxyhemoglobin (deoxy-Hb), and total hemoglobin (total Hb) concentrations from baseline recordings were measured. Increased oxy-Hb (oxygenation) was assumed to reflect cortical activation. RESULTS: Oxy-Hb concentration was significantly increased in the prefrontal region during exercise in both groups but not in the temporoparietal regions. The change in prefrontal oxy-Hb concentration of COPD patients was not different from that of controls. Dyspnea scores were positively correlated with changes in oxy-Hb concentrations of the prefrontal regions in both groups. Multivariate analysis showed that oxy-Hb concentration in the prefrontal region was the best predictor of dyspnea in both groups. CONCLUSIONS: Exertional dyspnea was related to activation (oxygenation) of the prefrontal cortex in COPD patients and control subjects.

BACKGROUND: Various factors have been reported to be useful for predicting future exacerbations. OBJECTIVE: This study was intended to determine a usefulness of a combination of a patient-based questionnaire, such as the Asthma Control Test (ACT) score with objective assessments, such as forced expiratory volume in 1 second (FEV(1)) and/or exhaled nitric oxide (FE(NO)), for predicting future exacerbations in adult asthmatics. METHODS: We therefore enrolled 78 subjects with mild to moderate asthma, who were clinically stable for 3 months who all had been regularly receiving inhaled steroid treatment. All subjects underwent a routine assessment of asthma control including the ACT score, spirometry, and FE(NO), and then were followed up until a severe exacerbation occurred. The predictors of an increased risk of severe exacerbation were identified and validated using decision trees based on a classification and regression tree (CART) analysis. The properties of the developed models were the evaluated with the area under the ROC curve (AUC) (95% confidence interval [CI]). RESULTS: The CART analysis automatically selected the variables and cut-off points, the ACT score

[抄録]胸水貯留は胸腔内に過剰な液体が貯留する病態であり，胸水の性状より漏出性および滲出性胸水に分類される.胸水貯留の原因疾患に伴い治療方針が異なるため，鑑別が重要となる.今回我々は胸水の貯留を認め，その原因疾患の診断に苦慮した1例を経験したため，鑑別診断を中心に文献的考察を加えて報告する.

A 38-year-old man with atopic dermatitis presented with right chest pain and dyspnea. Previously, he had received 2mg of betamethasone daily, to prevent rejection of the right transplanted cornea, for 24 days. His body temperature was 37.4 degrees C, peripheral leucocyte count measured 12,000/mm3, and C-reactive protein was 6.3 mg/dl. A computed tomogram of the chest revealed infiltration in the right lower lung field, and he was then treated for pneumonia. The second day he fell down one flight of stairs due to a syncopal attack and received a head injury. At this point his vital blood pressure was 102/55 mmHg, heart rate was 130/min and SpO2 under breathing room air was 76%. These findings indicated possible acute pulmonary thromboembolism. Enhanced computed tomography revealed pulmonary arteries occluded by massive thrombosis and anomalous inferior vena cava with azygous continuation. To decrease the risk of further cerebral bleeding, anti-coagulation therapy was administered with only 24,000 IU/day of heparin. Following treatment, the patient completely recovered. We reported this rare case of acute pulmonary thromboembolism accompanied by anomalous inferior vena cava with azygous continuation.

Our medical institution does not have a bacterial culture facility, requiring outsourcing of bacterial culture tests. Due to the time elapsed from the time of specimen collection to culturing, the identification of causative bacteria in respiratory tract infections tends to be difficult. We therefore used transport medium for sputum bacteria examinations. Expectorated purulent or purulent-mucous sputum specimens were collected from 32 patients with lower respiratory tract infection. We divided each of the sputum specimens into the two treatment groups: transport medium (Seedswab gamma2) ndar and stad disinfection container. Paired samples prepared from each patient were sent out for bacterial culture together. The time elapsed from collection to delivery to the lab were as follows: day 0 (same day, n = 14 patients), day 1 (n = 15), day 2 (n = 2), and day 3 (n = 1). The identified causative bacteria were Streptococcus pneumoniae (n = 6 patients), Haemophilus influenzae (n =5), Pseudomonas aeruginosa (n = 4), Staphylococcus aureus (n = 2), Moraxella catarrhalis (n = 2), Klebsiella pneumoniae (n = 1), and Streptococcus agalactiae (n = 1). Samples prepared by each of the two methods gave similar results. The utility of transport medium for examination of general bacteria for lower airway infection from sputum samples was not demonstrated. The rate of detection of bacteria decreased, when the transport of samples was delayed. Therefore, we need to send the sputum specimens as quickly as possible.

Recently, efforts in comprehensive pulmonary rehabilitation for COPD have been made, including education, physical therapy, occupational therapy, nutrition, nursing, medication and counseling. Each patient focuses on a different element. Supplying adequate nutrition, among others, is essential for comprehensive pulmonary rehabilitation, as well as survival. In this study, the utility of efficient nutritional supplement therapy before and after pulmonary physical therapy was investigated by adding an amino acid drink with a high Fisher ratio to comprehensive pulmonary rehabilitation. The subjects were eight patients with COPD with obstructive ventilation disorder as severe as 31.5 +/- 6% of FEV 1.0%. Pulmonary physical therapy was performed for eight weeks in a group administered one bottle of dietary supplement with a high Fisher ratio abundant in branched chain amino acids once daily (200 kCal/ 200 mL, Fisher ratio 40), and in another group without administration. Before and after the physical therapy, six-minute waking examination, QOL assessment (using CRQ), serum protein and serum Fisher ratio were comparatively examined between the two groups. After the eight weeks of pulmonary physical therapy, serum Fisher ratios were evidently reduced and serum protein measurements were also decreased in the group without dietary supplement abundant in branched chain amino acids. Accordingly, more amino acid is needed due to enhanced consumption of muscular protein during pulmonary physical therapy, during which nutrient ingestion including a sufficient amount of branched amino acid is necessary. It is an important element in continuing comprehensive pulmonary rehabilitation for a longer period.

We studied respiratory mucosa immune responses in bronchial asthma using guinea pigs and human respiratory epithelial cells. In asthma models (guinea pigs), CD4⁺ T cells enhanced LAR, and CD8⁺ T cells inhibited LAR after antigen inhalation. Regulatory effects of IL-5 and ICAM-1 on LAR were detected. PAF enhanced the adhesion of human respiratory epithelial cells and eosinophils. TNF-α stimulated the production of GM-CSF in human respiratory epithelial cells, while TGF-β₁ depressed human eosinophil survival.

症例は55歳, 女性, 発熱および労作性呼吸困難のため某院入院精査中, 左腎腫瘍を発見され, 当院泌尿器科を紹介され転入院となった. 高度の低酸素血症, 拘束性障害, 胸部X線写真上両側びまん性間質性陰影のため手術困難で当科に紹介された. TBLBにて間質性肺炎像があり, GOT, LDH, CPK高値がみられたが, プレドニゾロン60mg/日にて改善, 左腎摘出術が無事行われた. 病理組織像は clear cell carcinoma (Grawits) であった. ステロイドを漸減し経過良好であったが, 手術の約6ヵ月後より再び発熱出現. 抗生剤不応でGOT, LDH, CPKの著明な高値, 筋電図, 筋生検所見および抗Jo-1抗体陽性より多発性筋炎と診断した. 多発性筋炎にはしばしば間質性肺炎や悪性腫瘍が合併するが, その両者を同時に合併する例は比較的まれで, 悪性腫瘍の中でも腎癌合併はさらに稀有であり, 興味深い症例と考えられたので報告した.