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We encountered a very rare case of cT0N2M0 small cell lung cancer (SCLC) with Lambert-Eaton myasthenic syndrome (LEMS). A 69-year-old man with a complaint of muscle weakness was admitted to our hospital. Although his chest radiograph on admission showed no abnormal findings, CT scanning detected a mediastinal lymphadenopathy. Also, 2-[18F]-2-fluorodeoxy-D-glucose position emission tomography (FDG-PET) revealed increased accumulation in the same portion in the mediastinum. A diagnosis of LEMS was made from the distinctive electromyogram (EMG) findings (waning and waxing phenomenon in response to low-and high-frequency repetitive stimulation, respectively) in combination with the increased serum level of a P/Q-type anti-voltage-gated calcium channel (VGCC) antibody. Subsequent histopathological diagnosis by mediastinoscopic resection of a paraaortic lymph node was small cell carcinoma. No distant metastasis was detected by MRI of the brain, abdominal CT scan or an FDG-PET. Eight courses of chemotherapy (carboplatin + etoposide) with radiotherapy of the mediastinum (for a total dose of 45 Gy) was performed. A decreased serum level of P/Q-type anti-VGCC antibody titers followed by marked improvement of neurological dysfunction (muscle weakness, gait disturbance and scanning speech) and of an EMG finding (a loss of waning phenomenon) was observed. A close relationship between reduction of the antibody titers and improvement of neurological symptoms after the therapy was noticed. It was suggested that monitoring the level of a P/Q-type anti-VGCC antibody titer in the serum is important for evaluating the efficacy of chemotherapy for LEMS associated with SCLC.

We made a national questionnaire survey of conditions and results of lung volume reduction surgery (LVRS) performed for pulmonary emphysema in 273 hospitals. The survey covered: number of hospitals, number of patients, indications, operative procedures, improvement of FEV1% and dyspnea score, mortality, cause of death, 5-year survival rate, characteristics of patients who died, and current conditions of LVRS. The response rate was 63%. A total of 619 patients at 41 hospitals underwent LVRS. The most common types of surgical procedure were bilateral LVRS through median sternotomy and unilateral LVRS with video-assisted thoracoscopic surgery (VATS), followed by bilateral LVRS with VATS. Postoperative improvement in FEV1% averaged 39%. Dyspnea improved in 80% of patients. Mortality rate was 1.9% (8 of 432 cases). Postoperative infectious diseases, namely pneumonia and sepsis, were common causes of death. The 5-year survival was 65 +/- 8%. The causes of death over 5 years were respiratory failure in 60%, malignant neoplasms in 17%, cardiovascular accidents in 13% and others in 10%. The number of operations and hospitals decreased in 2002, compared to 2001.

A 65-year-old woman complained of dyspnea and a productive cough after surgical treatment and irradiation therapy for thymoma. Chest radiography and high-resolution computed tomography showed small nodules in centrilobular lesions in all of both lung fields, but predominantly in the lower fields. In addition, blood tests showed hypogammaglobulinemia. Chronic sinusitis, mild hypoxemia, severe obstructive impairment and the pathological findings of bronchiolitis led to a diagnosis of sinobronchial syndrome caused by Good syndrome. Treatment with oral erythromycin 600 mg/day was started. After 6 months, the patient improved both clinically and radiologically. Low-dose, long-term treatment with erythromycin was effective against sinobronchial syndrome caused by Good syndrome.

Smoking status, the extent of recognition of the relationship between smoking and COPD, and actual nature of education for smoking cessation by physicians have not yet been fully elucidated. To investigate perceptions about education for smoking cessation in the elderly by physicians who work in the clinic, questionnaires were sent to the 1,012 physicians who belong to the Yokohama City Medical Association. Of these, 311 respond and their data (31%) were included in the analysis. The questionnaire included questions on the importance of smoking cessation in the elderly, on the perception about the relationship between smoking and various diseases, and actual education for smoking cessation. The smoking status of the physicians themselves was also investigated. The distribution of current smokers, ex-smokers, and non-smokers among the physicians was 13%, 33%, and 54%, respectively. Seventy-five percent of ex-smokers answered that their experience of smoking cessation influenced their patient education for smoking cessation, and 39% of smokers answered that their smoking status did not influence it. Only 53% of the physicians replied that they actually performed education for smoking cessation to the elderly, and 8% of them replied that they hardly perform any or do not perform it. Smoking cessation is thought to be the only way to prevent the development of COPD. However, only a half of physicians recognized the importance of smoking cessation for the treatment and control of COPD in the elderly. In addition, less than one third of physicians perform nicotine replacement therapy for smoking cessation. Enlightenment for physicians should be needed to make them perform education for smoking cessation more aggressively.

Allergic responses at the level of the respiratory system are mostly mediated by IgE-dependent mechanisms. The first selective anti-IgE therapy, a recombinant humanized monoclonal anti-IgE antibody(rhuMAb-E25), binds with high affinity to the Fc epsilon RI receptor binding site on IgE, thereby reducing the amount of free IgE available to bind to Fc epsilon RI receptors on mast cells and basophils. In addition, administration of rhuMAb-E25 indirectly reduces Fc epsilon RI receptor density on cells involved in allergic responses. rhuMAb-E25 has been shown to reduce allergic responses in atopic individuals and to improve symptoms and reduce rescue medication and corticosteroid use in patient with allergic asthma. The clinical effectiveness of rhuMAb-E25 supports the central role of IgE in allergic reaction and the viability of anti-IgE therapy as an effective immunological intervention for allergic asthma.

We have conducted a survey of attitudes to chronic obstructive pulmonary disease (COPD) in the elderly, a survey of attitudes to the COPD guideline prepared by the Japanese Respiratory Society, and a survey of the therapies actually used for this disease among physicians belonging to the Yokohama Medical Association. The results showed that most respondents thought that physicians, mainly except for respiratory physicians, miss the COPD patients because of failure to recognize COPD. The spread of the COPD guideline among physicians and the amount of therapy conducted according to this guideline were also insufficient. However, most physicians who know this guideline have used it well, and have also appreciated the contents. Thus, the results of our surveys suggested that this COPD guideline, with its step-by-step pharmacologic therapy, should be more widely disseminated, mainly among clinics and physicians that are not respiratory specialists. This would enable them to follow the guideline and improve their treatment of COPD. In addition, it was also supposed that the comprehensive respiratory rehabilitation should be more executed in the hospitals.

The medicinal properties of coffee, making it a diuretic and stimulant, because of the effects of caffeine, have been known since ancient times, and coffee is today a popular beverage worldwide. In Japan it was introduced at the end of the eighteenth century through overseas trading with the Netherlands. During this period, various Western cultures flowed into Japan, and coffee was one of the subjects introduced through the translations of Dutch medical books. The pharmacological effects of coffee have been presented by Yamamoto in "Kōmō Honzou, (--, 1783)"; by K. Takahashi, G. Ohtsuki, and Y. Udagawa et al. in "Kōsei Shimpen (--, 1811)"; and by Kai Hirokawa in "Nagasaki Bunkenroku (--, 1795)." In the Chinese and Arabic traditional systems of medicine, the uses of coffee were based on its diuretic and central nervous system stimulant properties, attributed in general to caffeine. This study dealt with the uses of coffee in the traditional medicines of Asian countries and with some biological activities related to aging, infectious diseases, and cardioprotective effects. In various biological tests, the water extract of coffee showed no notable effect on myocardial cell beating; however, it did show superoxide anion-scavenging effects, inhibitory activity of lipid peroxidation, and suppression of hepatitis B virus surface antigen. These biological activities are closely related to the presence of caffeic acid derivatives, especially chlorogenic acid. The findings suggest that besides its stimulant effect, coffee has properties to prevent the deleterious actions of free radicals and viral infections.

Gliomatosis cerebri is a rare form of glioma, which diffusely extends to both cerebral hemispheres. Because it sometimes fails to show severe neurological symptoms in spite of diffuse invasion, the antemortem diagnosis is difficult. We report a case of a 77-year-old woman, who was admitted with progressive left hemiparesis and dysarthralgia. Plain CT scan of the brain showed almost no abnormal findings. MRI T2-weighted image revealed widespread and nearly symmetrical extension of a high intensity area from the corpus callosum to the deep white matter of both cerebral hemispheres. Open biopsy of the brain showed glioblastoma multiforme, which finally confirmed the clinical diagnosis of gliomatosis cerebri. We also review the classic and recent literatures.

Diffuse panbronchiolitis (DPB) and chronic obstructive pulmonary disease (COPD) are both characterized by chronic airflow obstruction of unknown etiology. It is hypothesized that neutrophils play the major role in the pathogenesis of these diseases. Recent studies have suggested that genetic factors may be related to individual susceptibility to these diseases. We have investigated the association between the C 242 T polymorphism of p 22 phox, a critical subunit of superoxide-generating NADH/NADPH oxidase, and susceptibility to DPB and COPD. Blood samples obtained from both patients with DPB (n = 82), COPD (n = 53), and control subjects (n = 82) were used for this genotyping assay; and the polymerase chain reaction (PCR) and restriction fragment length polymorphism (RFLP) were performed to genotype the gene. The frequency of the C allele was 0.91, 0.92, 0.92 in the DPB, COPD, and control groups, respectively. There were no differences in the distribution of the genotype of p 22 phox among these groups, either. We concluded that there is no association between the C 242 T polymorphism of p 22 phox, and susceptibility to DPB and COPD.

Hypoxia is an essential developmental and physiological stimulus that plays a key role in the pathophysiology of heart attack, cancer and other major causes of mortality. Recently studies have shown that hypoxia itself may directly activate NFk-B. NFk-B sites are also present in the promoter of the ICAM-1 gene. Therefore, it is possible that hypoxia could directly activate the ICAM-1, through activation of NFk-B. Hypoxia-inducible factor 1 is the only known mammalian transcription factor expressed uniquely in response to physiologically relevant levels of hypoxia. In the another cause of the induction of adhesion molecules with hypoxia adhesion molecules are induced by the inflammatory cytokine(IL-1, TNF alpha) that caused with anoxia/reperfusion. The adhesion molecules induced by hypoxia play one of the key rolls of the various diseases. For example the level of cICAM-1 in OSAS patients were increased. These observations suggest that OSAS-induced hypoxia activate adhesion molecules, resulting in the important risk factor of cardiovascular disorders.

To examine the roles of obstructive apnea (OA) and central apnea (CA) in oxygen desaturation on hypertension and sleep apnea syndrome (SAS), we performed a sleep study on 41 elderly subjects (mean age 69.5 +/- 6.8 years, male:female = 31:10). Nocturnal oxygen desaturation was documented with a pulse oximeter and apneas (OA and CA) were diagnosed on the basis of results of respiratory inductive plethysmography and oronasal flow. Significant desaturation (SDS, greater than 5% drop in SpO2 from baseline value) and desaturation index (DI; epsilon SDS (%) x duration (hour)) were calculated using the continuous nocturnal monitoring system with a pulse oximeter. We defined central type apnea above 50% as the central type group (n = 8, mean age 58.6 +/- 2.9, mean BMI 21.3 +/- 1.0, male:female = 7:1), and obstructive type and mixed type apnea above 50% as the obstructive type group (n = 21, mean age 70.0 +/- 3.2, mean BMI 25.3 +/- 1.0, male:female = 17:4). Other subjects were assigned to the control group (n = 12, mean age 64.3 +/- 2.3, mean BMI 23.8 +/- 1.2, male:female = 7:5). The DI (delta 5%) of the central type was 0.34 +/- 0.17, and that of the obstructive type was 1.78 +/- 0.7 showing a significant increase in the latter compared to the control group (p < 0.02). The DI (< 90%) of the central type was 0.14 +/- 0.07, and that of the obstructive type was 1.72 +/- 0.75, and that of the obstructive type was significantly greater than in the control group (p < 0.05) and central type (p < 0.05). There were 4 cases (33.3%) with hypertension in the control group and 4 cases (50.0%) with hypertension in the central type group, but there were 15 cases (71.4%) with hypertension in the obstructive type group. Hypertensive prevalence in the obstructive group was significantly more than in the control group (p < 0.05). No significant difference in body mass index or age were seen in the obstructive group and control group. There was a significant correlation between mean blood pressure and apnea index (AI). The AI of the hypertensive group was significantly higher than that of the normotensive group (p < 0.001). These results suggest that subjects with significant obstructive apneas may be at greater risk for hypertension than subjects with central apneas and that hypertension in the pathogenesis of SAS may be related to the severity of apneas rather than oxyhemoglobin desaturation.

A 88-year-old woman was admitted with appetite loss and dehydration in April 1999. She first noticed finger swelling in May 1996 and systemic sclerosis (SSc) was diagnosed in February 1997 on the basis of a clinical picture of low-grade fever, diffuse skin thickening, Raynaud's phenomenon, and pulmonary fibrosis. Retrospectively pulmonary fibrosis could have been identified on chest X ray film in September 1995. Although her appetite loss and dehydration were improved by hydration, pleural effusion continued. After detailed examinations, anti-topoisomerase 1 (Scl-70) antibody, anti-Sm antibody, and an anti-double-stranded DNA antibody (dsDNA) were found in her serum. However, the other antibodies to anti-SS-A, SS-B, Jo-1, and RNP were not detected. These results suggest that this elderly case was a very late onset overlap syndrome of systemic lupus erythematosus (SLE) and SSc. Thus, the pleural effusion in this case may have been caused by SLE-associated pleuritis. Although the late onset elderly cases with overlap syndrome are very rare, SLE, SSc, and their combination can be found in aged patients over 80 years old. SLE and SSc should be carefully considered for the differential diagnosis of pleural effusion and skin thickening even in elderly patients.

Recently, a step-by-step pharmacologic therapy for chronic obstructive pulmonary disease (COPD) has been recommended by several principal organizations. The characteristic of this therapy is that it is a stepwise approach organized according to the severity of disease and is mainly composed of bronchodilators including beta 2-agonists and anticholinergic agents, theophylline, and oral corticosteroids, and the goal of this therapy is to induce bronchodilation, decrease the inflammatory reaction, and facilitate expectoration. Since the effectiveness of one of the inhaled corticosteroids has been also indicated by the multicentre randomised trial in a few years, they may have an important role in the long-term treatment of COPD.

A 82-year-old woman was admitted because of dehydration and chronic renal failure. Although her renal function was improved by hydration, granulocytopenia (granulocyte number 645/mm3) occurred. Treatment with a relatively high dose of H2 blocker for one month before admission may have caused the granulocytopenia. To prevent possible infection in the patient, we administered 75 g of granulocyte-colony stimulating factor (G-CSF) for 5 consecutive days but 4 days after commencement of administration of G-CSF, pain in both knee joints suddenly appeared. Synovial fluid aspiration revealed granulocytosis (10,400/mm3) and deposition of calcium pyrophosphate dihydrate in the knee joints. The level of G-CSF in the synovial fluid was increased in the joints (700 pg/ml), compared with the serum concentration (62 pg/ml). Furthermore, the concentrations of interleukin-6 and interleukin-8 were markedly increased in the synovial fluid. The results indicated that her pseudogout exacerbation by G-CSF was at least in part explained by the increased production of cytokines in the knee joints. Because the prevalence of pseudogout and gout is overwhelming in the elderly, the possibility of GCSF induced exacerbation of joint pain should be carefully considered in elderly patients.

The sensitivity and specificity of the simple swallowing provocation test (S-SPT) were evaluated in a group of patients who were being examined for aspiration pneumonia (ASP) (ASP group: 72.5 +/- 3.9 years old) and in a group of age-matched control subjects (CTRL group: 69.5 +/- 2.9 years old). The S-SPT was evaluated in terms of the swallowing response and latent time (LT) for swallowing after a bolus injection of 0.4 ml of distilled water at the suprapharynx. Responses to the S-SPT were classified as normal or abnormal, dependent on induction of the swallowing reflex within 3 seconds after bolus injection. The sensitivity and specificity of the S-SPT in detecting ASP were calculated. Of the 40 patients in the ASP group, 18 were given a diagnosis of ASP on the basis of clinical findings and laboratory examinations. The sensitivity and specificity of the S-SPT were 94.4% and 86.4%, respectively, compared to 77.8% and 68.1%, respectively, for the water swallowing test. Because the S-SPT can be performed without any need for special patient effort or cooperation, it should be effective in diagnosing ASP in a wide variety of patients, including those who are bedridden.

The mechanism of Adenovirus (Ad) and Adeno-associated virus (AAV) vector-mediated gene transduction in murine tracheae has not been fully understood. Excised tracheae from mice were exposed to either Ad vector (Ad-CMV-LacZ) or AAV vector (AAV-CMV-LacZ) for 1 hour. LacZ gene expression in tracheal epithelial cells was detected by X-gal staining. Only patch distributions of LacZ expressing cells were observed. The percentage of LacZ expressing cells to total cells was less than 1% with either vector. Ad-mediated LacZ transduction was increased by mechanical damage using forceps. AAV-mediated gene transduction in tracheal epithelial cells was also increased by mechanical damage. Furthermore, this increased expression of vector LacZ by damaged epithelial cells was not affected by pretreatment with anti-ICAM-1 mAb or platelet-activating factor receptor antagonist. Although the Ad and AAV vectors were inefficient in transferring genetic material to murine trachea ex vivo, our results suggest that mechanical damage can enhance their transduction efficiency.

Because the incidence of sleep apnea is known to increase in both hypothyroidism and with age, elderly hypothyroid patients may experience more sleep apnea than younger hypothyroidism patients. However, the features of nocturnal disturbed breathing in elderly hypothyroid patients have not been fully elucidated. Concise polysomnographic studies including respiratory movement and oxyhemoglobin saturation (SaO2) were done on 18 elderly subjects with hypothyroidism (73.6 +/- 5.9 years old) before and after thyroid hormone replacement therapy. Fourteen of the patients exhibited a significant incidence of nocturnal apnea. Lower incidence of nocturnal apnea and higher nocturnal nadir SaO2 were observed in the patients 3 to 6 months after thyroxine therapy. Although the levels of thyroid hormones returned to normal in the patients, 9 patients had more than 5 bouts of nocturnal apnea per hour after the hormone replacement therapy. Further, no relationship was found between the level of thyroid hormones and the frequency of nocturnal apnea. These results suggest that levels of thyroid hormones are not indicators of the potential severity of nocturnal apnea in elderly hypothyroid patients, and that sleep studies may be necessary to assess the efficacy of thyroid hormone replacement therapy in the treatment of nocturnal apnea.

A 73-year-old woman was admitted to the geriatric ward of the University of Tokyo Hospital with anemia, osteepeina, and renal dysfunction. Although symptoms typical of multiple myeloma such as punched-out lesions and hyperproteinemia were not found, protein electrophoresis revealed that lambda type Bence-Jones protein was excreted in urine. Multiple myeloma was diagnosed. Furthermore, renal dysfunction was accompanied renal tubular acidosis type II (proximal type). Renal dysfunction in patient with multiple myeloma in usually caused by so-called myeloma casts in the distal tubules, but renal tubular acidosis type II is rarely observed. It is possible that injury of the proximal renal tubular eithelium by Bence-Jones protein resulted in renal tubular acidosis type II in this patient.

Growth factors are known not only to cause a mitogenic response and alter differentiated characteristics of the target cells, but also to play important roles in intercellular signaling. Many growth factors are expressed in the embryonic and regulate embryogenesis. Pulmonary fibrosis is characterized by a complex process involving chronic inflammatory reaction, fibroblast proliferation, and abnormal deposition of interstitial collagen as a result of excess healing reaction. In the early phases, TNF-alpha, IL-beta and GM-CSF secreted by alveolar macrophages regulate and enhance pulmonary inflammation. On the contrary, TGF-alpha, KGF and HGF have been reported to enhance repair of alveolar epithelium and vascular endothelium in the injured lung. Furthermore, growth factors produced by alveolar macrophages and epithelium, such as PDGF, TGF-beta and activin A and belongs to the TGF-beta supergene family are known to play cardinal roles in fibroblast proliferation and pulmonary fibrosis. Further works concerning this complex growth factors (cytokines) network are required to provide a basis of the pathophysiology of pulmonary fibrosis.

To examine the relationship between disturbed upper airway reflexes and aspiration pneumonia, we administered a total volume of 20 microliters of Ad-CMV-lacZ (Ad vector) or 20 microliters of phosphate buffer solution (PBS) intranasal to C57 black mice. In nostrils, the lacZ gene expression was investigated in each mouse with or without anesthesia. Under anesthesia, the lacZ gene expression was detected by Xgal staining in the lungs of every mouse given the Ad vector. However, no gene expression was measured in the lungs of those given the Ad vector without anesthesia. In mice treated with PBS, there was no lacZ gene expression in the nostrils, trachea, or lungs, irrespective of anesthesia. These results suggest that unconsciousness or disturbed upper airway reflexes caused by anesthesia caused aspiration, resulting in an intranasal bolus that can reached the lower airways. This process can be analyzed in mice tracted with adenovirus vectors carrying the E. coli LacZ gene. Mice given Ad-CMV-lacZ transnasally can be used to study aspiration pneumonia in relation to unconsciousness.

The effects of pulmonary function and respiratory muscle strength on exertional dyspnea in patients with chronic obstructive pulmonary disease (COPD) have not been fully elucidated. We examined the relationships between pulmonary function, static respiratory pressure, and dyspneic sensation during exercise in 48 patients with COPD. Dyspneic sensation during exercise was quantitated by a Borg scale slope (BSS, BS/VO2) and the threshold load of dyspnea (TLD). BSS was negatively correlated with VC, FEV1, V 25, RV/TLC (%). DLCO and PImax, whereas TLD was positively correlated with VC, FEV1, V 25, FRC and RV/TLC. Linear regression analysis revealed that FEV 1 and FRC were independent predictors for TLD, and that RV/TLC (%) was an independent predictor for BSS. These results suggest that an increase of air trapping as indicated by RV/TLC may be a major factor contributing to both decreased TLD and increased BSS, resulting in an increased sensation of dyspnea during exercise in patients with COPD.

To examine the influence of kyphosis on pulmonary function in the elderly, 300 consecutive healthy subjects (aged 20-94 years old) were evaluated using pulmonary function tests (TLC, VC, FEV1, RV) and static maximal pressures (PImax and PEmax). Kyphosis of the thoracic bones was measured at Cobb's angle. VC, FEV1. PImax and PEmax showed a significant age-dependent decline. Cobb's angle had a positive relationship with age and was negatively correlated with TLC, VC, FEV1 and PImax. Further, RV/TLC strongly correlated with Cobb's angle and PImax. Stepwise regression analysis revealed that the kyphotic angle was an independent determinant for PImax and RV/TLC. These results indicate that kyphosis significantly affects lung volume and maximal inspiratory pressure in the elderly and those affected should have careful assessment of their pulmonary function and respiratory pressures.

We evaluated 240 consecutive subjects (aged 20-91) without cardiopulmonary, endocrine or, neuromuscular disease consecutively regarding pulmonary function (TLC, VC, FEV1, RV) and static maximal inspiratory (PImax) and expiratory (PEmax) pressures. PImax and PEmax declined with advancing age. PImax correlated with grip strength, VC, FEV1, height, weight, and RV/TLC. PEmax also correlated with grip strength, TLC, VC, FEV1, height, and weight. Age, height, weight, and grip strength were entered stepwise into multiple linear regression models with PImax or PEmax as the dependent variable. Stepwise regression analysis revealed that grip strength was an independent predictor for both PImax and PEmax. However, age itself was not an independent predictor for PImax or PEmax. These results suggest that static maximal respiratory pressures decrease with aging, and that age-dependent changes in respiratory muscle function may depend on other factors, including lung volume, skeletal muscle status, and body composition.

We tested the effects of a DNA topoisomerase inhibitor (camptothecin; CPT) on the transduction efficiency of AAV vectors in cultured human airway epithelial cells. The cells were treated with CPT for 24 hours, then exposed to AAV-CMV-LacZ for 1 hour at different multiplicities of infection (moi). Transduction efficiency of AAV vectors was assessed using X-gal staining as the percentage of LacZ-expressing cells. The transduction efficiency was approximately 1.5 to 10 fold increased by treatment with CPT prior to AAV vector exposure. However, treatment with CPT after AAV vector infection did not enhance the transduction efficiency of the vectors. These results suggest that pre-treatment with CPT increases the transduction efficiency of AAV vectors, probably by nodulating cellular function.

The mechanism underlying the relief of the sensation of dyspnea during exercise following the inhalation of anticholinergic drug in patients with chronic obstructive pulmonary disease (COPD) has not been fully elucidated. We examined pulmonary function, static respiratory pressure, and dyspneic sensations during exercise before and after the inhalation of oxitropium bromide (OTB) in 14 male patients with COPD. FEV1 and FVC were increased after the inhalation of OTB, whereas RV and the ratio of RV to TLC were decreased after inhalation. Maximum inspiratory pressure (PImax) was significantly increased after the administration of OTB. Dyspneic sensation during exercise, measured as a Borg scale slope (BSS, delta BS/ delta Vo2) were reduced after the inhalation of OTB. There were significant correlations among BSS, PImax and RV/TLC. These results suggest that a reduction in air trapping after the inhalation of OTB may enhance the ability of the to diaphragm generate pressure at a given neural input, resulting in a reduced sensation of dyspnea during exercise in patients with COPD.

It has been suggested that pulmonary rehabilitation compined with inspiratory muscle training (IMT) might improve pulmonary function and respiratory muscle strength in elderly patients with chronic obstructive pulmonary disease (COPD). To test this hypothesis, inspiratory muscle strength (PImax), expiratory muscle strength (PEmax) and resting pulmonary function were measured in 13 elderly patients with COPD (aged 70.3 +/- 2.7 years). Inspiratory muscle training (IMT) was performed for 15 min twice a day, using a pressure threshold device, for a total of 12 weeks. The inspiratory threshold was set at 15% of maximal inspiratory pressure (PImax) for each individual. Pulmonary rehabilitation was performed for 12-h sessions over a 12-week period. Patients with COPD were assigned randomly to two groups: pulmonary rehabilitation combined with IMT (group A) (n = 7), and conventional pulmonary rehabilitation only (group B) (n = 6). Functional residual capacity (FRC) decreased significantly from 4.3 +/- 0.4 L at baseline to 3.9 +/- 0.4 L after rehabilitation (p < 0.01), Vp significantly increased from 4.6 +/- 0.8 L/sec at baseline to 5.1 +/- 0.7 L/sec after rehabilitation (p < 0.05) and the PImax increased significantly from 51.5 +/- 5.4 cmH2O at baseline to 80.9 +/- 7.0 cmH2O after rehabilitation (p < 0.02) in group A. However, these variables did not change in group B. There was no improvement in the 10-minutes walking distance of group A, but there was a significant increase in that of group B. It can be concluded that pulmonary rehabilitation combined with IMT improves pulmonary function and inspiratory muscle strength in elderly patients with COPD.

Pulmonary rehabilitation has been reported to be effective in patients with chronic obstructive pulmonary disease (COPD). To investigate the effect of a moderate period of pulmonary rehabilitation combined with inspiratory muscle training (IMT) in elderly patients with COPD, we instituted pulmonary rehabilitation for 60 weeks in five elderly patients (age: 65.4 +/- 3.7 SE years). IMT was performed for 15 min twice daily using a pressure threshold device. The inspiratory threshold was set at 15% of the maximal inspiratory pressure (PImax) of each individual. Maximal peak flow significantly increased from 3.0 +/- 0.6 (L/s) at baseline to 4.1 +/- 0.7 (L/s) after 12 weeks (p < 0.02) and was maintained at that level for 60 weeks. PImax increased significantly from 49.9 +/- 6.4 cmH2O at baseline to 67.3 +/- 3.0 cmH2O after 12 weeks (p < 0.05) and to 72.8 +/- 3.5 cmH2O (p < 0.02) after 60 weeks of rehabilitation. The 10-minute walking distance increased from 666.6 +/- 55.0 to 764.0 +/- 49.9 m (p < 0.05) after 12 weeks and was maintained at the same level. We conclude that pulmonary rehabilitation combined with IMT improves pulmonary function and inspiratory muscle strength in elderly patients with COPD between for 12 weeks after commencement, but occurs that no significant increase on lung function or 10-minute walking distance from 12 to 60 weeks. Respiratory muscle strength may further increase after 60 weeks.

Transfer of genes via DNA virus vectors to human airway epithelial cells is not fully understood. We tested the effects of multiplicities of infection (moi) and incubation time on the efficiency of gene transfer by adenovirus vectors and AAV vectors in cultures of human airway epithelial cells. The cells were exposed to Ad-CMV-lacZ or AAV-CMV-LacZ for 1 to 48 hours at different moi from 0.1 to 100. Efficiency of transduction was assessed as the percentage of cells that expressed LacZ, and was measured by using X-gal staining. A dose-dependent relationship was found between vector moi and the percentage of cells that expressed LacZ. For both vectors, gene expression was greater when incubation time was longer (up to 12 hours), which suggests that the uptake of vectors into the cells is not selective. Efficiency of transduction did not differ between adenovirus and AAV vectors at the same moi. These results suggest that (1) gene transfer via DNA virus vectors increases in a moi-dependent fashion, and that (2) gene expression of the DNA virus vector may be increased by prolonged exposure of the vector to human airway epithelial cells.

A 65-year-old man was admitted to our department due to severe dysphagia, dysarthria, and aspiration pneumonia. Dysphagia and dysarthria were caused by lateral medullary infarction (Wallenberg' s syndrome). After the patient recovered from pneumonia, the abnormality of swallowing was assessed by a swallowing provocation test and videofluorography. Two months after the start of swallowing training, a swallowing provocation test showed that the swallowing reflex had improved and videofluorography showed that the magnitude of aspiration to the trachea had decreased. The patient began taking food by mouth. These tests are useful for quantitative assessment of dysphagia and for deciding when to start oral intake in elderly patients.

A 92-year-old woman was admitted to our hospital due to hypertension, nausea, pain in the anterior part of the chest, epigastralgia, and tachypnea. During the initial examination of the patient in the emergency ward, she was very excited, howled, and both her hands were numb. Arterial blood gas analysis revealed a marked alkalemia (pH greater than 7.55) and hypocapnia (Pco2 24.1 mmHg). After paper bag re-breathing, the pH and Pco2 were within normal limits. Because there was no lesion in the lungs or the brain that would account for hyperventilation and convulsions, the attack was considered to be a manifestation of hyperventilation syndrome should be carefully considered in the differential diagnosis of disturbance of consciousness even in elderly patients.

Rhabdomyolysis is not common in the elderly. Two elderly patients with rhabdomyolysis and respiratory infection with Streptococcus pneumoniae. The first patient was a 71-year-old woman with bronchiectasis who admitted to our hospital due to pneumonia. The second patient was an 84-year-old man who was admitted because of appetite loss, fever, and a cough producing of yellowish sputum. In both patients, sputum cultures were positive for S. pneumoniae, but blood cultures were not. The serum creatine kinase levels peaked on the day of admission at levels ten to thirty times higher than fold above the upper limit of normal; the serum lactate dehydrogenase levels were 1.5 times higher than the upper limit of normal. The creatine kinase levels returned to normal 5 to 7 days after admission, treated with antibiotics and recovered from pneumonia. The cases of these two patients, along with those described in previous reports of rhabdomyolysis associated with pneumococcal pneumonia indicate that measuring the serum creatine kinase level is important in detecting rhabdomyolysis, especially in elderly patients with respiratory infection caused by S. pneumoniae, and detection may help to prevent renal failure.

To help plan for the future of undergraduate education in geriatric medicine in Japan, we reviewed the literature concerning undergraduate teaching of geriatric medicine in western countries. Undergraduate teaching in geriatric medicine in the UK is well developed: 22 of 25 universities have a full department of geriatric medicine. Training in geriatric medicine is mandatory in almost all universities. In contrast, geriatric medicine is an elective in most universities in the US. There is a shortage of geriatric medicine faculty in the US, which is similar to the situation in Japan. Clinical and basic research in geriatric medicine and gerontology should be encouraged to attract persons into this field.

With the aging of Japan's population, physicians need to be aware of advances in geriatric medicine. To assess the status of geriatric medicine in undergraduate education, we surveyed of medical student's opinions on gerontology and geriatric medicine. A questionnaire was sent to six-year medical students at a total of 20 schools that did not include geriatric medicine in their curriculum. Responses were obtained from 950 students (47.6%) at 16 schools (80%). Almost half of the students (42%) had experiences in health care facilities for the elderly. Ten percent were content with their education in geriatric medicine education and 59% were not. A total of 41.4% felt that geriatric medicine is difficult because it involves many different subjects. Some students had experience as volunteers working with elderly people; they were aware of the aging of Japan's population, and felt that their training in basic geriatrics and in geriatric diseases was insufficient. A total of 56% agreed that all medical schools should have classes in geriatric medicine and 14% did not. Medical students in the schools without classes in geriatric medicine identified dementia (73%), cerebral vascular accidents (51%), cancer (24%) and osteoporosis (19%) as common in elderly people, with no differences between schools. The corresponding data for medical students in schools with classes in geriatric medicine were dementia (77%), cerebral vascular accidents (44%), osteoporosis (29%), and cancer (16%). Undergraduate medical students seem to be exposed to widely differing curricula with regard to geriatric medicine. We found a lack of uniformity in the teaching of gerontology and geriatric medicine to undergraduate medical students in Japan.

With the rapid aging of Japan's population, medical professionals who specialize in geriatric medicine are in unprecedented demand. To meet that demand and to improve the curriculum for teaching geriatric medicine and gerontology in Japan, we surveyed medical students' understandings of these specialties. Students at 14 schools with classes in geriatric medicine and gerontology were surveyed. A questionnaire was sent to sixth-year medical students after their classes had ended. Questionnaires were collected from 849 students (60.1%) at ten medical schools (74.1%). One quarter (24.5%) of the students were satisfied with the contents of the classes in geriatric medicine and gerontology taught in their school, whereas 39.4% were not. These specialties encompass many fields of clinical and basic medicine, and many students found the lectures difficult to understand (41.4%). Inter-school comparisons of the results showed that students' strengths and weaknesses in the various areas of geriatric medicine reflected differences in the contents of the classes among the schools. Only 35.4% of students had ever visited hospitals or other health-related facilities for the elderly. Many students (58.8%) had never lived with elderly people. Most students (63.9%) wanted visits to health-care facilities for the elderly to be included in their regular curriculum. Medical students are conscious of the medical implications of the ageing of Japan's population; 13.2% had volunteered to work with the elderly.

We report a case of sleep apnea syndrome (SAS) with nocturnal pulmonary hypertension (NPH) in a 71-year-old man suffering from dyspnea during sleep. Severe snoring at night and daytime sleepiness were noticed before admission by his wife. Nocturnal oxygen desaturation (NOD) was documented with a pulse oximeter and severe sleep apnea syndrome was diagnosed on the basis of results of respiratory inductive plethysmography, an apnea index (AI) > 20, minimum SpO2 56%. NPH was diagnosed by Swan-Ganz catheter. The levels of NPH were severe. Elevation of systolic pulmonary arterial pressure (PAP) above 40 mmHg was observed 137 episodes at night. Both NPH and NOD were improved by 1 L/min of nasal oxygen therapy. A number of episodes of systolic PAP above 40 mmHg with oxygen therapy was 55 episodes. Peak mean PAP was 36 mmHg in room air vs 33 mmHg in oxygen therapy. Minimum SpO2 with oxygen therapy was improved to 69%. Total time of SpO2 < 90% at night was 153 minutes in room air vs 37 minutes in oxygen therapy. In this case, NPH and NOD due to severe SAS were remarkably improved by oxygen therapy.

A 76-year-old woman was admitted to our hospital because of productive cough, fever and anorexia in January 1995. She had suffered from bronchial asthma for 25 years. From 1983, exacerbation of PIE was recorded three times, on which occasions prednisolone and antibiotics were quite effective. On admission, marked leukocytosis (28,000/microliters) and eosinophilia (18,000/microliters) were found. However, plasma IgE level was normal, and specific antigen for eosinophilia was not detected by RAST or the skin allergic reaction test. Chest X-ray film and CT scan revealed extensive bilateral pulmonary infiltration. Increase in eosinophils (33%) was demonstrated in bronchoalveolar lavage. Furthermore, biopsy specimen of the affected lung revealed diffuse infiltration of eosinophils into alveolar septa. On the basis of these findings, the patient was diagnosed as chronic eosinophilic pneumonia (PIE syndrome). Hyponatremia (117 mEq/l) was persistent after the hydration with normal saline. Plasma ADH was not suppressed (2.29 pg/ml) in spite of hypoosmolality of plasma. Laboratory examination showed that renal, adrenal and thyroid function as well as plasma renin activity were normal. Taking these findings together, she was diagnosed as having SIADH. Treatment with prednisolone improved not only the PIE syndrome but also SIADH.

We recently reported that diffuse aspiration bronchiolitis (DAB) was detected in 1% of autopsied lungs of aged cases of pneumonia. We hypothesized whether repeated HCl micro-aspiration (RHMA) is involved in DAB and established an animal model by administering HCl intratracheally to rats every two days for 2 weeks. Saline was given to control animals in the same fashion. Then, we performed bronchio-alveolar lavage (BAL) or excised lungs for histologic examination. There was no difference in BAL cell counts, TNF alpha-production, elastase-like activity or albumin levels between the HCl and control groups. Histologically, DAB-like findings were observed in the HCl-treated animals. These data suggest that RHMA might be involved in DAB, while neither TNF alpha-production nor elastase-like activity may play a significant role in inducing DAB.

The purpose of this study is to evaluate chemical and pathological changes of the lung and to elucidate the role of TNF alpha and elastase in acute lung injury induced by HCl or lipopolysaccharide (LPS). Anesthetized rats were injected with pH 1.4 0.7 ml/kg body weight of HCl and 0.5 mg/kg body weight (BW) of LPS (E. coli) into the lung. Acute tracheal injury model (Mendelson Syndrome) were made. Control animals received only saline. Animals were sacrificed 1, 6, or 12 hours after the HCl or LPS or HCl and LPS injection, bronchoalveolar-lavage (BAL) was performed in the same way in control and experimental groups. The other animals which were treated as well were excised by histology. There was neither increase in TNF alpha-production nor increase in neutrophils resulting from HCl injection only. Elastase-like activity was not detected in animals treated only with HCl. However, 1 hour after LPS injection, the production of TNF alpha (37.0 +/- 8.0 Units/ml) was significantly greater than that of the control group (12.1 +/- 4.2 Units/ml) in BALF. Six hours after HCl and LPS injection, the concentration of elastase-like activity (0.023 +/- 0.002 nM) was significantly greater than that of the LPS group (0.011 +/- 0.001 nM). Only patches of intraalveolar hemorrhage and elevation of fibrin was observed in the HCl injected rats at 1 hour after injection. Six hours after LPS injection, the alveolar spaces were filled with large amounts of neutrophils. These findings suggest that TNF alpha and elastase play a significant role in HCl and LPS-induced acute lung injury.

We studied two cases of the elderly with acute exacerbation of interstitial pneumonia to elucidate a prognostic role of super oxide generation in peripheral whole blood. The first case was a 70-year-old man, who presented with acute exacerbation of interstitial pneumonia and was hospitalized. Following steroid-pulse therapy, CRP, ESR, blood-gas and his physical condition improved, resulting in successful discharge. In this case, super oxide generation standardized by the number of neutrophils (K) decreased to less than 1.0 in association with the improvement of physical condition. The second case was a 92-year-old woman in whom acute exacerbation of interstitial pneumonia was diagnosed. While the pulse therapy, CRP, LDH and blood-gas temporarily improved, K was continuously greater than 1.0 and the physical condition worsened, resulting in her death. These cases suggest that the measurement of super oxide generation in peripheral whole blood may play a useful role in assessing the prognosis of the elderly with acute exacerbation of interstitial pneumonia.

A 73-year-old male was admitted to Tokyo University Hospital due to cardiac arrest secondary to ventricular arrhythmias. Although the patient survived after cardiopulmonary resuscitation, he needed mechanical ventilation. When we tried to wean the patient from mechanical ventilation, we found that he suffered from frequent sleep apneas of over 40 times/hour. To evaluate the severity and frequency of the apneas, we performed polysomnographic study on the patient under assist ventilation. The polysomnographic study revealed that frequency of apneas was very high but the magnitude of desaturation was not so severe during the night. Since we confirmed the lowest SaO2 in this patients was over 90% during day and night, we tried to wean from the patient from the ventilator again and succeeded. The clinical application and usefulness of nocturnal ventilatory monitoring for patients with mechanical ventilation was discussed.

This study was conducted to examine the nocturnal ventilatory parameters and gas exchange in the elderly with nocturnal disturbed breathing. In order to facilitate analysis of ventilatory parameters with minimum manpower, we developed an unattended continuous nocturnal monitoring system for ventilation and arterial oxygen saturation. Using this system, nocturnal ventilatory parameters and gas exchange were investigated in our geriatric ward. We investigated 30 elderly subjects aged between 65 and 94 (mean age 77.8 +/- 6.5 years, male; female = 15:15). The subjects were free of severe cardiovascular and cerebrovascular disorders, and underwent 10 hours of continuous monitoring of ventilation and arterial oxygen saturation (SaO2). Number of significant desaturation (SDS; desaturation greater than 4% in SaO2 from the baseline value) and desaturation index (DI; sigma SDS(%) x duration (hour)) were calculated using the same system. The number of apnea episodes significantly correlated with DI and the number of SDS. DI also significantly correlated with lowest SaO2, while the number of SDS and the number of apneas were not found to be correlated with lowest SaO2. The number of SDS and the number of apnea episodes did not correlated with lowest SaO2. From the view point of gas exchange during the night, newly introduced DI is more comprehensive parameter when compared with the number of apneas or SDS. Subjects with a DI of over 0.5 were assigned to the group A (n = 8, mean age = 77.8) and the remaining subjects were assigned to group B (n = 22, mean age = 77.8). We compared the group A with the group B regarding nocturnal ventilatory parameters and SaO2.(ABSTRACT TRUNCATED AT 250 WORDS)

To elucidate the effects of aging on ventilation in nocturnal disturbed breathing (NDB), we investigated 16 subjects aged 65 years or over with system developed by the authors using a respiratory inductive plethysmography connected to a personal computer. The subjects underwent 10 hours of continuous monitoring of lung volume and SaO2. Significant desaturation (SDS, greater than 4% drop in SaO2 from baseline value) and desaturation index [DI, sigma SDS(%) X duration (hr)] were calculated using the same program. The subjects with SDS below 50 were assigned to group A (n = 9, mean age = 79.7, male:female = 8:1) and the remaining subjects with SDS over 50 (n = 7, mean age = 74.7, male:female = 3:4) to group B. There was no significant difference in ventilatory parameters between group A and B. We then compared the male group (n = 11, mean age = 77.8) with the female group (n = 5, mean age = 76.8). The number of SDS in the female group (101.4 +/- 34.7) was significantly greater than that of the male group (33.4 +/- 8.3*, p less than 0.02), while minute ventilation of the female group (5.25 +/- 0.31 l/min) was significantly smaller than that of the male group (8.86 +/- 1.36* l/min, p less than 0.05). DI was found to significantly correlate with the SaO2 nadir and the number of apnea and SDS. There was no significant relationship between SDS and ventilatory parameters in this study. NDB among elderly female may be of more importance than has been reported.

Incremental exercise test with a bicycle ergometer was performed on thirty eight patients (11 patients with chronic obstructive pulmonary disease, 6 patients with interstitial lung disease, 21 patients with preoperative check up for respiratory disease). In 34 patients except four patients with interstitial lung disease, there was a close correlation between dyspnea expressed on the Borg scale (BS) and oxygen consumption (VO2) (r = 0.778-0.998). To evaluate dyspnea in more quantitative manner, we introduced three parameters by the BS-VO2 regression line. The Borg scale slope (BSS) represents the slope of the regression line, threshold load of dyspnea (TLD) represents the onset of dyspnea on the regression line, and the breakpoint load of dyspnea (BLD) represents the maximum oxygen consumption before the subject interrupted exercise. BSS had significant negative correlations with VC, %VC, FEV1.0, TLC, DLco, and %DLco. TLD and BLD had significant positive correlations with VC, FEV1.0, DLco, and %DLco. No correlation was found between dyspnea evaluated by the Hugh-Jones classification and the parameters of pulmonary functions (VC, FEV1.0, DLco) at rest. From these findings, we conclude that the degree of dyspnea sensation on exercise correlated with parameters of pulmonary function at rest, and that these newly introduced parameters using the Borg scale were useful for a quantitative assessment of dyspnea in health and disease.

Fifteen patients aged over 65 years of age with advanced non-small-cl lung cancer (mean age = 70.7, stage IIIb: IV = 4:11) were treated with combination chemotherapy consisting of Cisplatin (50 or 80 mg/m2) and a vinca-alkaloid (Vindesine 3 mg/m2 or Etoposide 80 mg/m2). The effectiveness and side effects of this cisplatin therapy in different combinations of vinca-alkaloid regimens (Vindesine vs Etoposide) were examined. The mean dose of Cisplatin in the Etoposide combination group (75.2 mg/m2) was significantly higher than that in the Vindesine combination group (54.3 mg/m2) (p less than 0.01). A notable reduction the tumor size was observed in 25% of the Etoposide group, only. The 6-month survival rate and one-year survival rate were respectively 85.7%, 57.1% in the Vindesine + Cisplatin group, and 87.5%, 50% in the Etoposide + Cisplatin group. The common side effects were nausea, vomiting, anorexia, and alopecia. These symptoms were either alleviated by antiemetic drugs or followed by spontaneous recovery. Leucopenia, anemia and thrombocytopenia were found in both groups, and there was no difference in the time course of myelosuppression between the two groups. The extent of nephrotoxicity was assessed by creatinine clearance rate. Its decrease in the Vindesine group (60.1----38.9 ml/min) was higher than that in the Etoposide group (64.9----48.9 ml/min), while there was no significant change in BUN, serum creatinine and urine NAG between the two groups. There were no cases in which chemotherapy schedules had to be interrupted due to myelosuppression and nephrotoxicity.(ABSTRACT TRUNCATED AT 250 WORDS)