Usefulness of SMART-COP score in prognosis of aspiration pneumonia / Utilidad de la puntuación en la escala SMART-COP para el pronóstico de la neumonía por aspiración

Introduction: Aspiration pneumonia is becoming a common syndrome in the elderly in aging societies such as Japan. Although a number of tools have been validated for prediction of mortality in patients with community-acquired pneumonia, none have been established for aspiration pneumonia. The purpose of this study was to access the correlations of the A-DROP, CURB-65 and SMART-COP scores at the emergency visit with the 30-day mortality risk in patients with aspiration pneumonia.MethodsWe Titleretrospectively investigated 210 patients who presented to the emergency department at Mishuku Hospital in Tokyo, Japan.ResultsThe areas under the curve for the ability of A-DROP, Curb-65 and SMART-COP scores to predict the 30-day mortality risk were 0.6359, 0.6468 and 0.7594, respectively. Among the parameters of SMART-COP, involvement of multiple lobes on chest radiographs is the best predictor of the mortality.ConclusionsThe SMART-COP score can be a better predictor of the 30-day mortality risk. (AU)

Introducción: La neumonía por aspiración se está convirtiendo en un síndrome frecuente entre las personas de la tercera edad en sociedades envejecidas como Japón. A pesar de que se han aprobado diversas herramientas para la predicción de la mortalidad en pacientes con neumonía adquirida en la comunidad, no se ha logrado ninguna para la neumonía por aspiración. El objetivo de este estudio fue obtener correlaciones entre las puntuaciones en las escalas A-DROP, CURB-65 y SMART-COP en las visitas al servicio de urgencias y el riesgo de mortalidad a 30 días en pacientes con neumonía por aspiración.MétodosInvestigamos de forma retroactiva 210 pacientes que acudieron al servicio de urgencias del Hospital Mishuku en Tokio, Japón, y que fueron hospitalizados con neumonía por aspiración.ResultadosLas áreas bajo la curva de capacidad de las puntuaciones en las escalas A-DROP, CURB-65 y SMART-COP para predecir el riesgo de mortalidad a 30 días fueron 0,6359; 0,6468 y 0,7594, respectivamente. Entre los parámetros de la escala SMART-COP, la afectación de múltiples lóbulos en las radiografías de tórax es el mejor indicador de la mortalidad.ConclusionesLa puntuación en la escala SMART-COP puede ser un mejor indicador del riesgo de mortalidad a 30 días. (AU)

Usefulness of SMART-COP score in prognosis of aspiration pneumonia.

INTRODUCTION: Aspiration pneumonia is becoming a common syndrome in the elderly in aging societies such as Japan. Although a number of tools have been validated for prediction of mortality in patients with community-acquired pneumonia, none have been established for aspiration pneumonia. The purpose of this study was to access the correlations of the A-DROP, CURB-65 and SMART-COP scores at the emergency visit with the 30-day mortality risk in patients with aspiration pneumonia. METHODS: We Titleretrospectively investigated 210 patients who presented to the emergency department at Mishuku Hospital in Tokyo, Japan. RESULTS: The areas under the curve for the ability of A-DROP, Curb-65 and SMART-COP scores to predict the 30-day mortality risk were 0.6359, 0.6468 and 0.7594, respectively. Among the parameters of SMART-COP, involvement of multiple lobes on chest radiographs is the best predictor of the mortality. CONCLUSIONS: The SMART-COP score can be a better predictor of the 30-day mortality risk.

Acute eosinophilic pneumonia following aromatherapy with essential oil.

Essential oils are liquid extracts of various plants with potential health benefits and are often used in aromatherapy. Contact allergy, including skin irritation, is a well-known side effects of these extracts. A Japanese woman visited our emergency department complaining of dyspnea, cough, and fever. Two weeks earlier, she had started aromatherapy using a humidifier and essential oil. Based on clinical and imaging findings, and the results of bronchoalveolar lavage, we diagnosed acute eosinophilic pneumonia due to inhalation of essential oil. Her symptoms resolved after steroid therapy. This case makes the clinicians aware the possibility of acute eosinophilic pneumonia induced by aromatherapy using essential oil.

A rare case of atypical bone marrow sarcoidosis without pulmonary involvement in a Japanese woman.

Sarcoidosis is a systemic granulomatous disease of unknown origin characterised by the presence of non-caseating granulomatous lesions. Extrapulmonary sarcoidosis with bone marrow involvement is rare and even more so without pulmonary involvement. Here, we describe a case of 69-year-old woman diagnosed as having bone marrow and hepatic sarcoidosis without pulmonary involvement based on 18F-fluorodeoxyglucose positron emission tomography findings. She was successfully treated with systemic glucocorticoid therapy.

p53/p66Shc-mediated signaling contributes to the progression of non-alcoholic steatohepatitis in humans and mice.

BACKGROUND & AIMS: The tumor suppressor p53 is a primary sensor of stressful stimuli, controlling a number of biologic processes. The aim of our study was to examine the roles of p53 in non-alcoholic steatohepatitis (NASH). METHODS: Male wild type and p53-deficient mice were fed a methionine- and choline-deficient diet for 8 weeks to induce nutritional steatohepatitis. mRNA expression profiles in normal liver samples and liver samples from patients with non-alcoholic liver disease (NAFLD) were also evaluated. RESULTS: Hepatic p53 and p66Shc signaling was enhanced in the mouse NASH model. p53 deficiency suppressed the enhanced p66Shc signaling, decreased hepatic lipid peroxidation and the number of apoptotic hepatocytes, and ameliorated progression of nutritional steatohepatitis. In primary cultured hepatocytes, transforming growth factor (TGF)-ß treatment increased p53 and p66Shc signaling, leading to exaggerated reactive oxygen species (ROS) accumulation and apoptosis. Deficient p53 signaling inhibited TGF-ß-induced p66Shc signaling, ROS accumulation, and hepatocyte apoptosis. Furthermore, expression levels of p53, p21, and p66Shc were significantly elevated in human NAFLD liver samples, compared with results obtained with normal liver samples. Among NAFLD patients, those with NASH had significantly higher hepatic expression levels of p53, p21, and p66Shc compared with the group with simple steatosis. A significant correlation between expression levels of p53 and p66Shc was observed. CONCLUSIONS: p53 in hepatocytes regulates steatohepatitis progression by controlling p66Shc signaling, ROS levels, and apoptosis, all of which may be regulated by TGF-ß. Moreover, p53/p66Shc signaling in the liver appears to be a promising target for the treatment of NASH.

Pressure loading and ethanol exposure differentially modulate rat hepatic stellate cell activation.

Ethanol may cause an increase in sinusoidal pressure accompanied by portal hypertension. Hepatic stellate cells (HSCs) located in hepatic sinusoids may therefore be frequently exposed to dual stimulations of mechanical pressure and ethanol exposure in alcoholic liver injury. In this study, the effects of pressure loading and ethanol exposure on activation of rat cultured HSCs were investigated using an in vitro pressure-inducing apparatus. HSCs were cultured in media containing ethanol (0-100 mM) under different pressures (1-40 mmHg). Morphological changes and migration index were determined. We also determined the expression levels of alpha-smooth muscle actin (alpha-SMA) and mitogen-activated protein kinases (MAPKs) by Western blot analysis and the level of collagen IV and transforming growth factor beta1 (TGF-beta1) by ELISA. Pressure loading alone induced up-regulation of alpha-SMA via the extracellular signal-regulated kinases 1 and 2 (ERK1/2) and c-jun N-terminal kinase (JNK) signaling pathways, prolonged extension of marginal length, and increased production of collagen IV. In contrast, ethanol exposure alone increased only extension of marginal length and cell migration. Dual stimulations of pressure loading and ethanol exposure enhanced the production of TGF-beta1 and migration index. The TGF-beta1-dependent p38 MAPK pathway may operate for production of extracellular matrix (ECM) or enhanced migration in the case of dual stimulations. In conclusion, static pressure loading is an important factor directly accelerating the activation of HSCs. Although increased sinusoidal pressure and ethanol exposure might differentially modulate HSC activation, both stimuli are involved in an additive manner in some situations.

Effects of intratumoral injection of CCL2 on monocyte-endothelial cell interactions in mouse pancreatic cancer.

OBJECTIVE: Although monocyte infiltration is an important aspect of the host response to tumor growth, the mechanisms of recruitment and their impact on tumor growth are still unknown. The authors studied monocyte-endothelial interaction and the effect of chemokine CCL2 in orthotopic mouse pancreatic cancer. METHODS: The rolling and adhesion of labeled monocytes in peritumoral and intratumoral areas were assessed by using an intravital microscope. Further, the effects of intratumoral injection or superfusion of CCL2 on in situ recruitment of monocytes and other immune cells and adhesion molecules were investigated. RESULTS: More monocytes were recruited in the peritumoral area than in the intratumoral area with increased vascular interaction, and the effect was more apparent by intratumoral CCL2 injection than superfusion. In both CCL2-treated groups infiltration of CD11b(+), CD68(+), and CD4(+) cells were increased, but the magnitude of increase was larger in intratumoral injection. Quantitative RT-PCR for the tumor tissue revealed that ICAM-1 expression was increased by the injection of CCL2. CONCLUSION: These results show intratumoral injection of CCL2 induces effective interaction between monocytes and endothelial cells in the peritumoral area of pancreatic cancer accompanied by the upregulation of ICAM-1 and may possibly become a tool for immunotherapy by promoting the infiltration of immune cells in cancers.

Expression of PD-1, PD-L1, and PD-L2 in the liver in autoimmune liver diseases.

OBJECTIVES: PD-L1 (also B7-H1) and PD-L2 (also B7-DC) are ligands for programmed death-1 (PD-1), which is a member of the CD28/B7 superfamily of costimulatory molecules and plays an inhibitory role on the periphery. Impaired regulation of this system may cause disruption to self-tolerance leading to autoimmunity; however, the role of these molecules in the liver is unknown. Therefore, we examined the expression of PD-1, PD-L1, and PD-L2 in the liver in autoimmune liver diseases. METHODS: We examined the liver expression of these molecules in autoimmune hepatitis (AIH) and primary biliary cirrhosis (PBC) with no previous medical treatment using immunohistochemical staining and real-time PCR, and compared with chronic hepatitis type C (CHC) as a control. RESULTS: Although PD-1, PD-L1, and PD-L2 were expressed in the liver in AIH, PBC, as well as CHC, the expressions were relatively lower in PBC. In AIH, despite more severe inflammation than in CHC, the expression of these molecules was not greater than in CHC, and when compared with the relative expression of PD-L1, PD-L2 was lower in AIH. PD-L1 and PD-L2 expressions were well correlated with the level of IFN-gamma; however, relatively decreased induction for PD-L1 and PD-L2 by IFN-gamma was observed in AIH or PBC than in CHC. CONCLUSION: Modulation of PD-1/PD-L1 and PD-L2 systems may play a role in the development of autoimmune liver diseases.

[A case of Churg-Strauss syndrome discovered with hematemesis].

A 68-years-old Japanese woman was hospitalized emergently because of hemorrhagic gastric ulcer. For the hospitalization period, elevated levels of white blood cell count, eosinophilic leucocyte count, serum IgE and positive MPO-ANCA were recognized. With considering clinical course and these laboratory findings, we diagnosed Churg-Strauss syndrome (CSS). Steroid therapy in combination with cyclophosphamide was effective. CSS is a rare disease, but we should discriminate this disease when we encounter gastrointestinal bleeding of unknown etiology, especially PPI-resistant gastric ulcer.

Serum reactivity against bacterial pyruvate dehydrogenase: increasing the specificity of anti-mitochondrial antibodies for the diagnosis of primary biliary cirrhosis.

Antimitochondrial antibodies (AMA) are the serum hallmark of primary biliary cirrhosis (PBC). However, AMA-positivity can be found in non-PBC sera when lower dilutions are used, thus raising issues about the specificity and sensitivity of the test. AMA reacts primarily with the lipoylated domains of pyruvate dehydrogenase-E2 (PDC-E2) which is highly conserved across species, including bacteria. We studied 77 serum samples, including 24 from patients with anti-PDC-E2-positive PBC and 53 controls (16 with autoimmune hepatitis (AIH), 10 with primary sclerosing cholangitis (PSC), and 27 healthy individuals) for their reactivities at serial dilutions (1:10, 1:20 and 1:40) against Escherichia coli DH5 alpha lysate overexpressing human PDC-E2 using immunoblotting (IB). A murine anti-human PDC-E2 monoclonal antibody (mAB) was used as control. We further studied positive sera using adsorption with a synthetic E. coli peptide sharing similarity with human PDC-E2. Finally, we verified whether a unique buffer for E. coli preparation could reduce non-specific serum reactivity. Results demonstrated that 100% of anti-PDC-E2-positive PBC and up to 38% of control sera at 1:10 dilution recognized E. coli PDC-E2 at IB while dilution tests indicated that the overall potency of PBC reactivity was 100-fold higher compared to controls. In fact, a subgroup (20-38%) of non-PBC sera were positive at low titers but lost the reactivity when absorbed with the synthetic E. coli peptide. Finally, our unique buffer reduced the reactivity of non-PBC sera as measured by ELISA. In conclusion, we demonstrated that weak cross-reactivity with E. coli PDC-E2 occurs in non-PBC sera at lower dilutions and that such reactivity is not due to AMA-positivity. The use of a specific buffer might avoid the risk of false positive AMA determinations when E. coli-expressed recombinant antigens are used.

A highly hydrophobic domain within hypervariable region 1 may be related to the entry of hepatitis C virus into cultured human hepatoma cells.

Interaction of the envelope glycoprotein of hepatitis C virus (HCV) with a cellular receptor(s) is thought to be essential for the initial steps of HCV infection. However, the mechanisms of HCV infection remain unclear. The aim of the present study was to determine the features of HCV that enable efficient entry of the virus into human hepatocytes. Variations of hypervariable region 1 (HVR1) sequences in HCV inocula and in infected human hepatoblastoma HepG2 cells were examined. Immunofluorescence of inoculated HepG2 cells with anti-HCV core antibodies demonstrated that HCV structural proteins were expressed in the cytoplasm, and their entry into HepG2 cells was confirmed. When the HVR1 amino acid sequences were compared, HVR1 quasispecies in the inoculated cells showed more uniformity than those of the inocula. Although there were no statistically significant differences between the two groups, hydrophobic residues were observed more frequently in the HVR1 amino acids from inoculated cells than in the HVR1 amino acids from the inocula. Results of hydropathy analysis revealed that highly hydrophobic domains exist in the middle of HVR1 in the inoculated cells in 7 of 10 patients. The results suggest that limited HCV populations are able to enter HepG2 cells and that the highly hydrophobic domain existing within the HVR1 may play an important role in the entry of HCV into cells.

Efficacy of a glycyrrhizin suppository for the treatment of chronic hepatitis C: a pilot study.

Intravenous administration of glycyrrhizin has potential efficacy on decreasing serum aminotransferase levels in patients with chronic hepatitis. However, patients receiving this treatment are recommended to attend hospital regularly for several years. To improve the quality of life for these patients, we developed a glycyrrhizin suppository. In this pilot study, we examined the most effective and safe material contents of the suppository and revealed clinical efficacy for patients with biopsy-proven chronic hepatitis C comparing intravenous administration of glycyrrhizin. As content combinations of the suppository, a mixture of 300 mg of glycyrrhizinic ammonium salt and 60 &mgr;g of sodium capric acid, with pH neutralization, was confirmed to be most effective and safe condition, based on analysis of serum glycyrrhizin levels and the grade of rectal irritations in tested patients. The efficacy on decreasing serum alanine aminotransferase levels for 12-week administration of the suppository in 13 patients with chronic hepatitis C was similar to that in another 13 patients intravenously administered glycyrrhizin. Moreover, no serious side effects were observed. In conclusion, the usage of the newly developed suppository of glycyrrhizin can improve the quality of life for chronic hepatitis C patients, especially those who do not respond with viral clearance to interferon therapy. Using this suppository, larger and longer-term studies are needed.

Clinical usefulness of a new infrared videoendoscope system for diagnosis of early stage gastric cancer.

BACKGROUND: Infrared light can penetrate tissue more deeply than visible light. Therefore, an infrared video endoscope may be useful for assessment of gastric submucosal vessels. However, the resolution of currently available infrared video endoscope systems has been unsatisfactory. A new infrared video endoscope system was developed and its clinical utility assessed for diagnosis of early stage gastric cancer. METHODS: Twenty-five patients with early stage gastric cancer and 8 with gastric adenoma underwent endoscopy with the infrared video endoscope system after intravenous injection of indocyanine green. RESULT: Indocyanine green pooling did not appear in adenomas and some intramucosal gastric cancers, whereas it was noted in all submucosally invasive gastric cancers. Tumors not exhibiting indocyanine green pooling were intramucosal, well-differentiated adenocarcinomas of low height (flat-type cancers). CONCLUSION: These results suggest that our new infrared video endoscope provides valuable information about the submucosal aspect of early stage gastric cancer. Infrared video endoscopy may become a powerful technique for determining whether to perform endoscopic mucosal resection.