Nontuberculous mycobacteriosis oligoarthritis of the right hand misdiagnosed as rheumatoid arthritis: A case report.

Infection with Mycobacterium marinum has several different clinical presentations. Most commonly, it appears as a solitary papulonodular lesion on an extremity. A rare presentation of osteoarticular M. marinum involving multiple small joints and tenosynovitis of the hand, which was misdiagnosed as rheumatoid arthritis, is reported. The patient was initially treated for seronegative rheumatoid arthritis but failed to respond to methotrexate. Magnetic resonance imaging showed arthritis and tenosynovitis. Subsequently, synovial biopsy led to histological and microbiological diagnosis. Antimycobacterial treatment should be started promptly in such cases. The combined use of rifampicin, ethambutol, and clarithromycin appears to be effective, and debridement is indicated in patients with deep-seated infections.

The Effects of Using Pancreases Obtained from Brain-Dead Donors for Clinical Islet Transplantation in Japan.

BACKGROUND: The pool of brain-dead donors (BDDs) was increased with the revision to the relevant law in 2010, and islet transplantation from BDDs was started in 2013. The present study assessed the influence of using pancreases from BDDs on islet transplantation in Japan. METHODS: The donor information registered with the secretariat of islet transplants from 2012 was reviewed, and the results of 86 clinical islet isolations performed in Japan between 2003 and 2018 with non-heart-beating donors (NHBDs) (n = 71) and BDDs (n = 15) were investigated. RESULTS: The number of cases for which donor information was registered with the secretariat of islet transplants increased to 1.84 cases/month from 2013 to 2018 in comparison to 1.44/month in 2012, when only NHBDs were used. The median pancreatic islet yield was 275,550 IEQ (Islet equivalents) in the NHBD group but 3,627,000 in the BDD group, which amounted to a statistically significant difference (p = 0.02). As a result, 38/71 cases (53.5%) were achieved successful islet isolation (>5000 IEQ per recipient weight (kg)) was achieved in 38/71 cases (53.5%) in the NHBD group, and 12/15 cases (80.0%) in the BDD group; thus, the rate of successful islet transplantation was higher in the BDD group. CONCLUSION: The use of pancreases from BDDs has increased the overall number of cases for which donor information is registered with the secretariat of islet transplants and has improved the performance of islet isolation, thereby increasing the probability of successfully achieving islet transplantation.

Exhalation immediately before inhalation optimizes dry powder inhaler use.

OBJECTIVE: Although exhalation immediately prior to inhalation (EPI) from dry powder inhalers (DPIs) is universally advised, its benefit has not been investigated. The objective of this study to assess the effects of EPI on inhaled flow from a DPI. METHODS: We measured peak inhaled flow rate (PIFR) and inhaled gas volume of 25 volunteers unfamiliar with DPIs. They inhaled strongly and deeply through a flow meter either with or without EPI before and after connecting Turbuhaler or Diskus. RESULTS: Median PIFR increased significantly with EPI both without connection to DPIs (178.8 versus 140.4 L min(-1)), and with connection to Diskus (75.6 versus 67.8 L min(-1)), or to Turbuhaler (51.0 versus 48.0 L min(-1)). As a result, the number of subjects whose PIFR exceeded 60 L min(-1) was significantly increased with connection to either Diskus (76 versus 64%) or to Turbuhaler (24 versus 4%). EPI significantly increased median inhaled volume both without connection to DPIs (2.84 versus 1.84 L), and with connection to Diskus (1.95 versus 1.66 L), or to Turbuhaler (1.86 versus 1.28 L). EPI significantly increased F0.2 (flow at 0.2 s after onset of inhalation) and AC30 (flow acceleration at 30 L min(-1)), parameters representing the rate of flow increase during the early phase of inhalation, in all the three groups. CONCLUSIONS: EPI increases PIFR which may augment drug dispersion and facilitate fine particle generation from a DPI.

[Resistances of dry powder inhalers and training whistles and their clinical significance].

BACKGROUND: Flow resistance of dry powder inhaler (DPI) is important information when physician choose a suitable DPI to individual patient. We previously reported flow resistances of several DPIs and training devices. In the present in vitro study, we measured resistances of new DPIs and new trainers. METHOD: Flow resistances were obtained from driving pressure and flow through the devices. RESULTS: All devices had parabolic relationships between the driving pressure and flow. Resistances were: 8.44 ± 0.45×10-2(mean±SD) for Elipta®, 5.53±0.13×10-2 for Breezhaler®, 7.27 ± 0.40×10-2 for new Diskhaler®, 12.15 ± 0.40×10-2 for Swinghaler®, 7.07 ± 0.24×10-2 for new Diskus trainer, 8.72 ± 0.4.5×10-2(√cmH2O/L/min) for Elipta trainer. Sounding threshold of Diskus trainer was 38.1 ± 5.1 and that of Elipta trainer was 39.9 (meidan) L/min. INTERPRETATIONS: In change from Diskus® to Elipta®, flow instruction is not necessary. Breezhaler® is a suitable DPI for patients with low pulmonary function but patients should be alert to avoid excessively high inhalational flow. In flow instruction, a flow higher than trainer sounding should be advised.

[Flow and inspiratory pressure characteristics of In-Check(tm) and training whistles].

BACKGROUND: The optimal inhalation effort using dry powder inhalers (DPI's) varies with the specific inhaler. Accordingly, the device used for instruction in the proper use of the specific DPI should have physical characteristics similar to the actual DPI. However, the precision with which these devices mimic the actual DPI's has not been established. METHODS: We measured mouthpiece pressure (PI) and flow through the In-Check with an added flow resistance (for DiskusTM, DiskhalerTM, PulmicortTM, HandihalerTM, and ClickhalerTM) and the training whistles (for Diskus, Pulmicort, SymbicortTM, TwisthalerTM) at different inhalation pressures. RESULTS: Both the In-Check with an added flow resistance for individual DPI and the training whistles for each DPI had parabolic PI-flow relationships similar to the actual DPI. When a curve was drawn from direct readings of the In-Check scale, it fell consistently below that based on the pneumotachometer values. PI-flow curves of the actual DPI fell below both of the above curves. Among the same type of DPI, PI-flow relationships resembled each other, but one of 13 in the Diskus group demonstrated curves above and one of 6 in Pulmicort demonstrated curves below the others. The flows at which sounds were generated from the whistle were between 25-50 L/min. CONCLUSIONS: Both In-Check and training whistles had suitable PI-flow relationships. Flow readings taken directly from In-Check tended to be lower than the measured value. A few training whistles might generate sounds with efforts below the optimal one.

Significant relationship between platelet activation and apnea-hypopnea index in patients with obstructive sleep apnea syndrome.

Obstructive sleep apnea syndrome (OSAS) is an independent risk factor for arterial thrombosis, which is associated with high cardiovascular morbidity and mortality. To investigate the possible involvement of activated platelets, we evaluated the relationship between severity of OSAS and appearance of platelet aggregates (a marker of activated platelets) in 35 OSAS patients. Platelet aggregates were quantitatively determined by means of flow cytometry. There was a significant correlation between platelet aggregates and apnea-hypopnea index in the severe (AHI≥30 events/hour) group (r=0.756, p<0.001), but not in the mild-moderate (5≤AHI<30 events/hour) group (r=-0.032, p=0.905). The results indicate that the appearance of platelet aggregates increases with an increase in the severity of OSAS.