Search

Background The joint committee of the Japanese Society of Intensive Care Medicine/Japanese Respiratory Society/Japanese Society of Respiratory Care Medicine on ARDS Clinical Practice Guideline has created and released the ARDS Clinical Practice Guideline 2021. Methods The 2016 edition of the Clinical Practice Guideline covered clinical questions (CQs) that targeted only adults, but the present guideline includes 15 CQs for children in addition to 46 CQs for adults. As with the previous edition, we used a systematic review method with the Grading of Recommendations Assessment Development and Evaluation (GRADE) system as well as a degree of recommendation determination method. We also conducted systematic reviews that used meta-analyses of diagnostic accuracy and network meta-analyses as a new method. Results Recommendations for adult patients with ARDS are described: we suggest against using serum C-reactive protein and procalcitonin levels to identify bacterial pneumonia as the underlying disease (GRADE 2D); we recommend limiting tidal volume to 4–8 mL/kg for mechanical ventilation (GRADE 1D); we recommend against managements targeting an excessively low SpO2 (PaO2) (GRADE 2D); we suggest against using transpulmonary pressure as a routine basis in positive end-expiratory pressure settings (GRADE 2B); we suggest implementing extracorporeal membrane oxygenation for those with severe ARDS (GRADE 2B); we suggest against using high-dose steroids (GRADE 2C); and we recommend using low-dose steroids (GRADE 1B). The recommendations for pediatric patients with ARDS are as follows: we suggest against using non-invasive respiratory support (non-invasive positive pressure ventilation/high-flow nasal cannula oxygen therapy) (GRADE 2D), we suggest placing pediatric patients with moderate ARDS in the prone position (GRADE 2D), we suggest against routinely implementing NO inhalation therapy (GRADE 2C), and we suggest against implementing daily sedation interruption for pediatric patients with respiratory failure (GRADE 2D). Conclusions This article is a translated summary of the full version of the ARDS Clinical Practice Guideline 2021 published in Japanese (URL: https://www.jsicm.org/publication/guideline.html). The original text, which was written for Japanese healthcare professionals, may include different perspectives from healthcare professionals of other countries.

Immune checkpoint inhibitors (ICIs) can cause immune-related adverse events (irAEs), such as neurological toxicity. A 46-year-old man was diagnosed with squamous cell lung cancer. Lung cancer recurred 3 years after he experienced left segmental lung rejection. Therefore, he received atezolizumab as fourth-line chemotherapy. He experienced fever, headache, and decreased consciousness 10 days after the first dose of atezolizumab. Plain head computed tomography and cerebrospinal fluid examination showed no significant findings. Magnetic resonance imaging (MRI) with a Gadolinium (Gd)-enhanced Cube fluid-attenuated inversion recovery (FLAIR) sequence showed nodular abnormalities with contrast enhancement. Thus, aseptic meningitis caused by ICIs was suspected. His consciousness level gradually improved with glucocorticoid therapy. Moreover, most nodular abnormalities observed on cerebral MRI disappeared concurrently. Thus, Gd-enhanced Cube FLAIR sequence has the unique ability to reveal immune-related aseptic meningitis

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.

Background/Aims Chronic constipation and lifestyle factors can affect sleep quality. We evaluated the relationship between chronic constipation and sleep in the Japanese population. Methods This cross-sectional internet-based survey included 3000 subjects with constipation, classified according to sleep status (good/poor). Primary endpoints were Bristol stool form scale (BSFS) score and correlations between sleep disorder criteria of the Pittsburgh Sleep Quality Index (PSQI) and sleep status (good/poor sleep). Secondary endpoints included correlations between quality of life (QOL) and mood, medical, lifestyle, and sleep factors. Results The proportion of participants with BSFS category 4 (normal stool) was significantly higher in the good sleep group (P < 0.001). Sleep disturbance (P < 0.05), sleep quality, and duration, use of hypnotic medication, and daytime dysfunction of PSQI (all P < 0.001) significantly correlated with poor sleep. In the poor sleep group, QOL was significantly worse and anxiety and depression levels were significantly higher (all P < 0.001) compared with the good sleep group. Anemia and smoking (both P < 0.05), recent body weight increases, and poor eating habits (all P < 0.001) were significantly higher in the poor sleep group. Male sex, onset associated with change in frequency of stools, sensation of incomplete evacuation for at least 25% of defecations, and manual maneuvers to facilitate at least 25% of defecations correlated with poor sleep. Conclusions Subjects with constipation and poor sleep experienced severe symptoms and had poor QOL. These data support the need for a multifocal treatment approach, including lifestyle advice and pharmacotherapy.

BACKGROUND Myasthenia gravis (MG) is an autoimmune neuromuscular disorder, which is often accompanied by various complications. Partial dysgeusia is an uncommon nonmotor symptom of MG, and dysgeusia preceding typical MG symptoms is rare. Although ageusia and hypogeusia have been reported in patients with MG, increased perception of taste has not been reported. CASE REPORT A 47-year-old Japanese woman presented with a reduced perception of sweet taste and an increased perception of salty taste. Meanwhile, she was diagnosed with thymoma-associated generalized MG and underwent extended thymectomy. Three months later, her anti-acetylcholine receptor (AChR) antibody (Ab) titer increased to 70 nmol/L, when she had completely lost perception of sweet taste and had developed a markedly increased perception of salty taste. Prednisolone and tacrolimus were then added to the medication, and her partial dysgeusia gradually improved. As the AChR Ab titer decreased, disturbance of sweet taste resolved, although a slight decrease persisted. The increased perception of salty taste returned to normal. CONCLUSIONS This is a rare case of a patient with MG who developed an increased salty taste perception with a reduced sweet taste perception 3 months before the onset of her motor symptoms. We suggest that MG should be considered as a differential diagnosis in patients with partial dysgeusia but no motor symptoms.

Background/aim Continuation maintenance therapy is standard for advanced nonsquamous non-small cell lung cancer; however, the optimal maintenance strategy has yet to be determined. Patients and methods Patients without disease progression after four cycles of carboplatin (CBDCA)+ pemetrexed (PEM)+ bevacizumab (BEV) were randomized to maintenance therapy with BEV, PEM, or BEV+PEM. The primary endpoint was 1-year progression-free survival (PFS) rate. Results Of the 90 patients enrolled, 64 were randomly assigned to maintenance therapy. The 1-year PFS rate was 9.1% in the BEV arm, 19.1% in the PEM arm, and 19.1% in the BEV+PEM arm. The median PFS and overall survival (OS) were 4.0 and 43.1 months in the BEV arm, 4.5 and 32.0 months in the PEM arm, and 6.4 and 41.8 months in the BEV+PEM arm. Conclusion The median PFS was numerically better in the BEV+PEM arm, but the median OS was not significantly different among the three arms.

Objectives: The usefulness of serial procalcitonin (PCT) measurements for predicting the prognosis and treatment efficacy for hospitalised community-acquired pneumonia (CAP) patients was investigated. Methods: This prospective, multicentre, cohort study enrolled consecutive CAP patients who were hospitalised at 10 hospitals in western Japan from September 2013 to September 2016. PCT and C-reactive protein (CRP) were measured on admission (PCT D1 and CRP D1), within 48–72 h after admission (PCT D3 and CRP D3), and within 144–192 h after admission. CURB-65 and the Pneumonia Severity Index (PSI) were assessed on admission. The primary outcome was 30-day mortality; secondary outcomes were early and late treatment failure rates. Results: A total of 710 patients were included. The 30-day mortality rate was 3.1%. On multivariate analysis, only PCT D3/D1 ratio >1 [odds ratio (95% confidence interval): 4.33 (1.46–12.82),P = 0.008] and PSI [odds ratio (95% confidence interval): 2.32 (1.07–5.03), P = 0.03] were significant prognostic factors. Regarding treatment efficacy, PCT D3/D1 >1 was a significant predictor of early treatment failure on multivariate analysis. PCT D3/D1 with the PSI significantly improved the prognostic accuracy over that of the PSI alone. Conclusions: PCT should be measured consecutively, not only on admission, to predict the prognosis and treatment efficacy in CAP. Keywords: Biomarker, C-reactive protein, Pneumonia, Procalcitonin, Prognosis

Introduction: Bronchial thermoplasty (BT) improves asthma-related quality of life and decreases the number of asthma exacerbations. However, the effectiveness of BT in the treatment of severe asthma with smoking history is unclear because previous studies have excluded patients with smoking history of more than 10 pack-years. Objective: The aim of the study was to clarify the effectiveness and safety of BT for severe asthma with smoking history. Methods: We retrospectively reviewed patients who received BT and compared its effectiveness and safety with and without smoking history. Results: Seven patients were assigned to the smoking group and 9 to the nonsmoking group. Before BT, despite Global Initiative for Asthma step 4 or 5 treatment including oral corticosteroids (OCS) or monoclonal antibody drugs, most patients in both groups had asthma-related symptoms every day (85.7 vs. 77.8%; p = 0.475) and frequent asthma exacerbations. After BT, in the smoking group, 3 patients could discontinue or reduce OCS and all 3 patients treated with monoclonal antibody drugs could discontinue them. In the smoking group, 6 patients (85.7%) experienced a reduction in the rate of symptoms, of which 3 patients (42.9%) had a disappearance of symptoms, similar to the nonsmoking group. BT was effective in 5 patients (83.3%) in the smoking group and 6 patients (75.0%) in the nonsmoking group. There were no severe complications. Conclusions: BT was found to be effective and safe for treatment of severe asthma with smoking history. Our results suggest that BT may be a therapeutic option for asthma-chronic obstructive pulmonary disease overlap.

Background Immune-mediated pneumonitis has a high mortality rate; however, information regarding the related risk factors remains limited. This study aimed to analyze risk factors for pneumonitis, including smoking and lung metastasis (LM), in patients with extrapulmonary primary tumors. Methods Data of 110 patients treated with immune checkpoint inhibitors (ICIs) (nivolumab/pembrolizumab) for treating extrapulmonary primary tumors at the Shiga University of Medical Science Hospital between January 2015 and December 2019 were retrospectively collected. The association between the onset of pneumonitis and treatment-related factors was analyzed by logistic regression. The severity of pneumonitis was graded according to the Common Terminology Criteria for Adverse Events version 5.0. Risk factors, such as the absence or presence of interstitial lung disease (ILD) and LM, or other clinical factors, including smoking status before ICI administration, were analyzed. Results Multivariate analyses indicated that the amount of smoking was significantly associated with an increase in the development of all-grade pneumonitis types (odds ratio (OR) = 20.33, 95% confidence interval (CI) = 20.03–20.66; p = 0.029). LM and ILD were significantly related to an increase in the development of symptomatic pneumonitis (≥ Grade 2) (OR = 10.08, 95% CI = 1.69–199.81; p = 0.076, and OR = 6.76, 95% CI = 1.13–40.63; p = 0.037, respectively). Conclusions Pre-screening for ILD and LM and recognizing patients’ smoking history is important for determining the risk of ICI-induced pneumonitis and allowing safe ICI administration.

This study aimed to investigate the influence of educational pressure on myopia. A less-intense school curriculum was introduced nationally in Japan beginning in 2012 based on a pressure-free education policy. In this retrospective observational study, a total of 1025 Japanese medical students of Asahikawa Medical University underwent measurements of the cycloplegic refractive error and axial length (AL), from 2011 to 2020. The spherical equivalent (SE) and AL were correlated significantly with the fiscal year of births (p = 0.004 and p = 0.034, respectively) only during enforcement of the system of high-pressure education. The SE and AL regression rates during the two educational approaches differed significantly (p = 0.004 and p = 0.037, respectively). The prevalence of high myopia was correlated significantly (p &lt, 0.001) only during the system of high-pressure education. The regression of the prevalence rate of high myopia during the two education approaches differed significantly (p = 0.010). The progression rates of myopia and increased prevalence of high myopia were observed only during high-pressure education, suggesting that not only ophthalmologists but also educators and the government should work on together to control the progression of myopia.

Background/Aims: Our study aimed to evaluate the effect of oral litholysis in patients with chronic calcific pancreatitis (CCP) unresponsive to or ineligible for extracorporeal shock wave lithotripsy (ESWL) and endoscopic therapy. Methods: Trimethadione, an antiepileptic agent, was administered orally at a dose of 0.6–0.9 g/day to 15 patients with this condition. Treatment outcome was evaluated by assessment of dissolution of the pancreatic stones on plain X-ray films and computed tomography scans of the upper abdomen. Plasma glucose, hemoglobin A1c, and body mass index (BMI) were also monitored throughout the therapy. Results: Litholysis was observed in 13 out of 15 patients (86.7%) and was definite in 10 and partial in 3. Six patients had pancreatitis attacks during the therapy; 5 of whom showed definite litholysis and had only 1 mild attack. Of the 11 patients with normal or impaired glucose tolerance at baseline, none developed diabetes mellitus and all showed litholysis. BMI significantly increased in patients whose pancreatic stones dissolved. There was no vital organ impairment by trimethadione. Conclusion: Oral litholysis using trimethadione may represent a noninvasive and effective complementary treatment in patients with CCP unresponsive to or ineligible for ESWL and endoscopic therapy.

The constraint values of dose-volume histogram (DVH) parameters for radiation pneumonitis (RP) prediction have not been uniform in previous studies. We compared the differences between conventional DVH parameters and DVH parameters with high attenuation volume (HAV) in CT imaging in both esophageal cancer and lung cancer patients to determine the most suitable DVH parameters in predicting RP onset. Seventy-seven and 72 patients who underwent radiation therapy for lung cancer and esophageal cancer, respectively, were retrospectively assessed. RP was valued according to the Common Terminology Criteria for Adverse Events. We quantified HAV with quantitative computed tomography analysis. We compared conventional DVH parameters and DVH parameters with HAV in both groups of patients. Then, the thresholds of DVH parameters that predicted symptomatic RP and the differences in threshold of DVH parameters between lung cancer and esophageal cancer patient groups were compared. The predictive performance of DVH parameters for symptomatic RP was compared using the area under the receiver operating characteristic curve. Mean lung dose, HAV30% (the proportion of the lung with HAV receiving ≥30 Gy), and HAV20% were the top three parameters in lung cancer, while HAV10%, HAV5%, and V10 (the percentage of lung volume receiving 10 Gy or more) were the top three in esophageal cancer. By comparing the differences in the threshold for parameters predicting RP between the two cancers, we saw that HAV30% retained the same value in both cancers. DVH parameters with HAV showed narrow differences in the threshold between the two cancer patient groups compared to conventional DVH parameters. DVH parameters with HAV may have higher commonality than conventional DVH parameters in both patient groups tested.

Une femme de 20 ans sans antecedents medicaux importants s’est presentee a notre consultation externe avec un mal de gorge, de la toux et une douleur persistante au quadrant superieur droit aggravee par le mouvement ou une respiration profonde et perdurant depuis 7 jours. L’examen

To investigate whether or notThe hSUV

Introduction and Objectives: Disease Probability Measure (DPM) is a useful image assessment tool for gas-trapping and emphysema using inspiratory and expiratory computed tomography (CT) data for chronic obstructive pulmonary disease (COPD). We hypothesized that the cluster analysis using DPM parameters could help to understand the relationship between the pathological changes of the lungs and other parameters in COPD. Methods: A total of 131 COPD patients were enrolled. Forced oscillation technique (FOT), spirometry and inspiratory and expiratory CT scans were conducted. Using CT data, the percentage of low attenuation voxels (LAV%) and the square root of airway wall area of the hypothetical airway with an internal perimeter of 10 mm (√Aaw at Pi10) were quantitatively evaluated. DPM analysis was performed and hierarchical cluster analysis was applied. The COPD patients were classified into five imaging clusters using DPM parameters; DPMNormal, DPMGasTrap and DPMEmphy. The clusters were named as follows; Normal (NL), Normal-GasTrap (NL-GT), GasTrap (GT), GasTrap-Emphysema (GT-EM) and Emphysema (EM). Results: FEV1%predicted and respiratory reactance at 5Hz (X5) were gradually decreased in the order of the NL, NL-GT, GT, GT-EM, and EM. LAV% was significantly higher in the GT-EM than in the NL, NL-GT and GT. LAV% was also significantly higher in the EM than in the GT-EM. Four clusters other than the NL showed significantly higher values of √Aaw at Pi10 than the NL cluster but there were no significant differences among the four clusters. Conclusions: The five DPM clusters could reflect the pathophysiological changes in COPD.

Background: Pneumonectomy for lung cancer with interstitial lung disease (ILD) has been shown to cause postoperative acute exacerbation (AE) of the ILD. The accumulation of 18F-flurodeoxyglucose (FDG) on normal parenchymal or less-affected lung fields in 18F-FDG-positron emission tomography (PET)/computed tomography (CT) has been reported to be related to ILD disease activity and prognosis. To determine whether 18F-FDG accumulation in normal parenchymal or less-affected lung fields on 18F-FDG-PET/CT can predict postoperative AE of ILD in non-small cell lung cancer (NSCLC) patients with ILD.Methods: This retrospective study included 36 NSCLC patients with ILD, who underwent 18F-FDG-PET/CT at 2 institutions before pulmonary surgery. A single volume-of-interest (VOI) was placed to measure the mean standardized uptake value (SUVmean) in normal or less-affected lung fields at 12 areas on the ventral and dorsal locations of both lungs, in each level of the aortic arch, tracheal bifurcation, and the orifice of the right lower pulmonary vein into the left atrium. The region to which the target VOI was set corresponded to no or minimally increased attenuation on high resolution CT. The SUVmean was defined as the mean SUV of the target VOI, SUVtissue fraction (TF) as the corrected SUVmean by using TF and mean computed tomography density (CTDmean) as the mean attenuation of the corresponding target VOI on HRCT. We performed a phantom study to optimize SUV difference among 2 institutions. The corrected SUVmean (cSUVmean) and corrected SUVTF (cSUVTF) were calculated based on the phantom study result.Results: Among 36 NSCLC patients with ILD who underwent pulmonary surgery, 8 patients developed postoperative AE of ILD. The cSUVmean values in the ventral and dorsal locations at the aortic arch level, and in the ventral location at the tracheal bifurcation level in the group with postoperative AE were higher than in the group without postoperative AE. There was no significant difference in the value of cSUVTF and CTDmean between the groups with and without postoperative AE.Conclusion: 18F-FDG accumulation in the normal or less-affected lung fields can potentially predict postoperative AE of ILD in NSCLC patients with ILD.