Factors associated with readmission for community-onset pneumonia among older people: A retrospective study.

BACKGROUND: Although older individuals are prone to pneumonia relapse, little real-world evidence is available on the main factors contributing to pneumonia recurrence. This study assessed the impact of patients' lifestyles on hospital readmission due to pneumonia recurrence. METHODS: We retrospectively included consecutive patients (aged ≥65 years) who were admitted for community-onset pneumonia. A binary or multiple-choice postal questionnaire survey on lifestyles after hospitalization was conducted to identify the factors associated with readmission due to pneumonia recurrence. RESULTS: Of 117 patients who responded to the questionnaires, 89 were included in the analyses after excluding 28 patients who died within 1 year of discharge. Twenty-four of 89 (27%) patients were readmitted to the hospital for pneumonia within 1 year of discharge. Multivariate analysis revealed that cerebrovascular disease (odds ratio [OR], 3.912; 95% confidence interval [CI], 1.104-13.861; p = 0.035) and need of assistance at mealtime (OR, 2.225; 95% CI, 1.182-4.186; p = 0.013) were significantly associated with readmission due to pneumonia recurrence. Oral care and mealtime body position were not associated with readmission. CONCLUSIONS: Host factors, not patients' lifestyles such as oral care and body position, mainly contribute to the development of pneumonia among older people. These results should be considered risk factors for readmission by medical workers and family members.

Impact of Antibiotics Used for Acute Aspiration Bronchitis on the Prevention of Pneumonia.

BACKGROUNDS: It remains unclear if antibiotics should be used for the treatment of acute aspiration bronchitis to prevent the development of pneumonia. This study aimed to assess the associations between the use of antibiotics and the development of pneumonia among patients with acute aspiration bronchitis. METHODS: We retrospectively reviewed consecutive patients with acute aspiration bronchitis aged ≥75 years. Acute aspiration bronchitis was defined as a condition with aspiration risk, high fever (body temperature, ≥37.5 °C), respiratory symptoms, and the absence of evidence of pneumonia. RESULTS: There was no significant difference in the incidence of pneumonia between patients treated with and without antibiotics for acute aspiration bronchitis (6/44, 14% vs. 31/143, 22%; p = 0.242). Lower estimated glomerular filtration rate (adjusted odds ratio, 0.956; 95% confidence interval, 0.920-0.993) was significantly associated with the development of pneumonia. CONCLUSIONS: Antibiotic administration should not be routinely recommended to prevent pneumonia following acute aspiration bronchitis, and patients with decreased renal function should be closely monitored. A randomized controlled trial is necessary to validate these results.

Factors associated with changes in activities of daily living from admission to discharge among older patients with pneumonia.

INTRODUCTION: It has not been fully elucidated that nutritional parameters affect the change of activities of daily living (ADL) during pneumonia treatment. This study assessed the impact of nutritional status, including erector spinae muscle (ESM) size on ADL changes from admission to discharge among older patients with community-acquired pneumonia (CAP). METHODS: We retrospectively included patients (age: ≥65 years) who were admitted to the hospital for CAP and underwent chest computed tomography (CT) on admission. ADL was evaluated using the Barthel index, and patients were divided into the maintained or improved ADL group and the declined ADL group from admission through discharge. The ESM cross-sectional area was measured on a single-slice CT image. Logistic regression models were applied for assessing factors associated with changes in ADL. RESULTS: A total of 523 patients hospitalized for CAP (median age 86 years) were evaluated. The declined group had significantly higher ADL levels on admission, a greater frequency of smoking history and malignancy, and a lower frequency of cerebrovascular disease and dementia. No significant difference in ESM size was observed between the groups. Multivariate analysis revealed that higher ADL levels on admission (odds ratio 1.034, interquartile range 1.026-1.043) and malignancy (3.002, 1.150-7.836) were associated with a decline in ADL, whereas cerebrovascular disease (0.579, 0.373-0.900) was related to improvement or maintenance of ADL. CONCLUSIONS: Although nutritional status might not affect the change of ADL among older patients hospitalized with pneumonia, a cerebrovascular disease history may be a good predictor for ADL improvement.

A prospective cohort study of periostin as a serum biomarker in patients with idiopathic pulmonary fibrosis treated with nintedanib.

This study investigated the utility of periostin, a matricellular protein, as a prognostic biomarker in patients with idiopathic pulmonary fibrosis (IPF) who received nintedanib. Monomeric and total periostin levels were measured by enzyme-linked immunosorbent assay in 87 eligible patients who participated in a multicenter prospective study. Forty-three antifibrotic drug-naive patients with IPF described in previous studies were set as historical controls. Monomeric and total periostin levels were not significantly associated with the change in forced vital capacity (FVC) or diffusing capacity of the lungs for carbon monoxide (DLCO) during any follow-up period. Higher monomeric and total periostin levels were independent risk factors for overall survival in the Cox proportional hazard model. In the analysis of nintedanib effectiveness, higher binarized monomeric periostin levels were associated with more favorable suppressive effects on decreased vital capacity (VC) and DLCO in the treatment group compared with historical controls. Higher binarized levels of total periostin were associated with more favorable suppressive effects on decreased DLCO but not VC. In conclusion, higher periostin levels were independently associated with survival and better therapeutic effectiveness in patients with IPF treated with nintedanib. Periostin assessments may contribute to determining therapeutic strategies for patients with IPF.

Periostin Is a Biomarker of Rheumatoid Arthritis-Associated Interstitial Lung Disease.

Periostin was investigated as a biomarker for rheumatoid arthritis-associated interstitial lung disease (RA-ILD). This prospective study measured serum monomeric and total periostin, Klebs von den Lungen-6 (KL-6), surfactant protein D (SP-D), and lactate dehydrogenase (LDH) in 19 patients with RA-ILD, 20 RA without ILD, and 137 healthy controls (HC). All biomarkers were higher in RA-ILD than HC or RA without ILD. KL-6 accurately detected ILD in RA patients (area under curve [AUC] = 0.939) and moderately detected SP-D and monomeric and total periostin (AUC = 0.803, =0.767, =0.767, respectively). Monomeric and total periostin were negatively correlated with normal lung area and positively correlated with honeycombing, reticulation, fibrosis score, and the traction bronchiectasis grade but not inflammatory areas. Serum levels of SP-D, KL-6, and LDH did not correlate with the extent of those fibrotic areas on high-resolution CT. Serum monomeric and total periostin were higher in patients with RA-ILD with definite usual interstitial pneumonia pattern compared with other ILD patterns. Immunohistochemical analyses of biopsy or autopsy lung tissues from RA-ILD during the chronic phase and acute exacerbation showed that periostin was expressed in fibroblastic foci but not inflammatory or dense fibrosis lesions. Periostin is a potential biomarker for diagnosis, evaluating fibrosis, and deciding therapeutic strategies for patients with RA-ILD.

Acute eosinophilic pneumonia in twins.

The pathogenesis of eosinophilic pneumonia is currently poorly understood, and this disease has not been reported in twins since 1983. Herein, we report a case of acute eosinophilic pneumonia in twins, which appeared to be triggered by initial smoking at different times by both patients. One patient resumed smoking after recovering from eosinophilic pneumonia, with no observed recurrence. This study discussed the possibility of an association between susceptibility to eosinophilic pneumonia and genetic factors in twins.

Impact of Pseudomonas aeruginosa coverage on the prognosis of elderly patients with community-acquired pneumonia.

BACKGROUND: Although the 2019 American Thoracic Society and Infectious Diseases Society of America guidelines for community-acquired pneumonia (CAP) recommend the use of antibiotics with Pseudomonas aeruginosa coverage for patients with prior sputum isolation of P. aeruginosa, further research is needed to confirm its clinical outcomes. This study aimed to assess the impact of the use of antibiotics with P. aeruginosa coverage on mortality in elderly CAP patients with sputum isolation of P. aeruginosa. METHODS: We retrospectively included consecutive elderly patients who were hospitalized for CAP and P. aeruginosa-positive sputum culture. The association between the use of antibiotics with P. aeruginosa coverage and 28-day mortality was assessed based on propensity score to reduce selection bias. RESULTS: A total of 216 patients were included, and 68 (31%) of them were treated with antibiotics with P. aeruginosa coverage. The number of patients treated with antibiotics with P. aeruginosa coverage was significantly higher among nonsurvivors than among survivors. After adjustment using propensity score, the association between the use of antibiotics with P. aeruginosa coverage and the 28-day mortality was found to be statistically nonsignificant (odds ratio 2.182, 95% confidence interval 0.732-6.508, p = 0.162). CONCLUSIONS: The use of antibiotics with P. aeruginosa coverage in elderly CAP patients with sputum isolation of P. aeruginosa did not improve their prognosis. A randomized control study is required to identify cases that should be treated with antibiotics covering P. aeruginosa.

Factors associated with gravity-dependent distribution on chest CT in elderly patients with community-acquired pneumonia: a retrospective observational study.

Although lung involvement in aspiration pneumonia typically has a gravity-dependent distribution on chest images, which patient's conditions contribute to its radiological pattern has not been fully elucidated. This study was designed to determine the factors associated with the gravity-dependent distribution of community-acquired pneumonia (CAP) on chest computed tomography (CT). This retrospective study included elderly patients aged ≥ 65 years with CAP who underwent chest CT within 1 week before or after admission. The factors associated with lower lobe- and posterior-predominant distributions of ground glass opacity or airspace consolidation were determined. Of the 369 patients with CAP, 348 (94%) underwent chest CT. Multivariate analyses showed that impaired consciousness, a low Barthel index of activities of daily living, and high hemoglobin levels were associated with lower lobe-predominant distribution, while male sex and impaired consciousness were associated with posterior-predominant distribution. Cerebrovascular diseases were unrelated to these distributions. While male sex, impaired consciousness, high hemoglobin levels, low albumin levels, and the number of involved lobes were associated with in-hospital mortality, gravity-dependent distributions were not. Impaired consciousness might be the most significant predictor of aspiration pneumonia; however, the gravity-dependent distribution of this disease is unlikely to affect disease prognosis.

Methicillin-resistant Staphylococcus aureus among elderly patients with community-acquired pneumonia.

INTRODUCTION: The 2019 American Thoracic Society/Infectious Diseases Society of America guidelines for community-acquired pneumonia (CAP) recommend methicillin-resistant Staphylococcus aureus (MRSA) coverage for patients with prior sputum isolation of MRSA. This study aimed to determine the impact of MRSA coverage on in-hospital mortality in elderly patients with CAP among whom MRSA was isolated. METHODS: Consecutive elderly patients who were admitted for CAP and had positive sputum culture for MRSA were retrospectively included, and the association between MRSA coverage and in-hospital mortality was analyzed. RESULTS: Twenty (18%) of 111 patients received MRSA coverage. Although patients who received MRSA coverage tended to have more frequent prior isolation of MRSA compared to those who did not, no significant difference in in-hospital mortality was observed between both groups (2/20, 10% vs. 8/91, 9%). MRSA coverage was not associated with in-hospital mortality (odds ratio: 1.15; 95% CI: 0.23-5.89, p = 0.864); however, advanced age, hemoglobin level, a high A-DROP score, and C-reactive protein levels were associated with in-hospital mortality. MRSA coverage may not improve the prognosis of elderly patients with CAP who had positive sputum culture for MRSA. CONCLUSIONS: A randomized control study is required to determine the efficacy of MRSA coverage on the management of CAP in elderly patients.

Significant elevation of free itraconazole concentration at onset of adverse effects: A case report.

Free itraconazole and hydroxyitraconazole concentrations were markedly elevated despite almost no changes in total concentrations when itraconazole was discontinued due to adverse effects. Elevated free itraconazole concentration may have a causal relationship with the development of adverse effects.

Quantitative assessment of erector spinae muscles and prognosis in elderly patients with pneumonia.

Erector spinae muscle (ESM) size has been reported as a predictor of prognosis in patients with some respiratory diseases. This study aimed to assess the association of ESM size on all-cause in-hospital mortality among elderly patients with pneumonia. We retrospectively included patients (age: ≥ 65 years) admitted to hospital from January 2015 to December 2017 for community-acquired pneumonia who underwent chest computed tomography (CT) on admission. The cross-sectional area of the ESM (ESMcsa) was measured on a single-slice CT image at the end of the 12th thoracic vertebra and adjusted by body surface area (BSA). Cox proportional hazards regression models were used to assess the influence of ESMcsa/BSA on in-hospital mortality. Among 736 patients who were admitted for pneumonia, 702 patients (95%) underwent chest CT. Of those, 689 patients (98%) for whom height and weight were measured to calculate BSA were included in this study. Patients in the non-survivor group were significantly older, had a greater frequency of respiratory failure, loss of consciousness, lower body mass index, hemoglobin, albumin, and ESMcsa/BSA. Multivariate analysis showed that a lower ESMcsa/BSA independently predicted in-hospital mortality after adjusting for these variables. In elderly patients with pneumonia, quantification of ESMcsa/BSA may be associated with in-hospital mortality.

Presumed Septic Shock Caused by Actinotignum schaalii Bacteremia.

We herein report a case of presumed septic shock due to Actinotignum schaalii bacteremia with urinary tract infection. A 65-year-old Japanese man suffering from a fever was diagnosed with septic shock due to urinary tract infection. A urine sample was additionally incubated under 5% CO2 and anaerobic conditions after A. schaalii was identified in a blood culture, but A. schaalii was not detected in the urine culture. If Gram-positive rods are observed on Gram staining of a urine sample in symptomatic patients with a predisposing urogenital condition, 5% CO2 and an anaerobic culture of a urine sample should be performed immediately.

Risk factors for disease-related deterioration following diagnostic bronchoalveolar lavage procedures in diffuse lung disease: a case-control study.

BACKGROUND: Although the risk factors for diagnostic bronchoalveolar lavage (BAL)-induced acute exacerbations in patients with idiopathic pulmonary fibrosis (IPF) have been previously reported, no study has assessed these in patients with non-IPF. We aimed to identify the risk factors for BAL-induced disease deterioration (BAL-DD) in all types of diffuse lung disease. METHODS: Patients with diffuse lung disease who underwent BAL at our hospital from April 2012 to November 2017 were retrospectively analyzed. The patient information, laboratory data, radiological findings, and BAL fluid analysis results in patients who developed BAL-DDs were compared with those in patients who did not. RESULTS: BAL-DDs occurred in 14 (3.3%) of the 429 patients included the study. The BAL-DD group had a significantly poorer performance status, higher C-reactive protein level, lower partial pressure of oxygen in the arterial blood at rest, greater proportion of desaturation on exertion and cases having followed a progressive clinical course before BAL, and more extensive consolidation and ground-glass opacity on chest high-resolution computed tomography (HRCT) than the non-BAL-DD group. A high total cell concentration and an increased number of eosinophils in the BAL fluid were more frequently found in patients with BAL-DD than in those without. CONCLUSIONS: Patients with decreased physical activity level, increased level of inflammatory markers, low oxygenation status, and extensive lung involvements on chest HRCT and following a progressive clinical course before BAL may be warned of the BAL-DD risk. Elevated eosinophil counts in the BAL fluid could be associated with the triggering of BAL-DDs.

Diffuse Large B-Cell Lymphoma Arising from the Lesion of Chronic Lobar Atelectasis.

Pulmonary lymphoma is rare, accounting for < 1% of primary lung cancers. Most primary pulmonary lymphomas (PPL) are low-grade mucosa-associated lymphoid tissue (MALT)-type, and among PPL, diffuse large B-cell lymphoma (DLBCL) is extremely rare. In contrast, there has been an increase in the incidence of DLBCL among patients with autoimmune disorders and recurrent or chronic bacterial infection. A subset of DLBCL has been reported to develop through transformation of preexisting or concurrent MALT. The respiratory symptoms are non-specific, and the chest X-ray findings demonstrate the presence of interstitial and mixed alveolar infiltrates, nodular lesions, and localized homogeneous consolidations; the diagnosis of pulmonary DLBCL is thus challenging and often leads to a misdiagnosis or delayed diagnosis. We herein report a case of DLBCL which was assumed to have arisen from the lesion of chronic atelectasis that was successfully diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). A 74-year-old woman with diffuse bronchiectasis and chronic atelectasis of the left lower lobe suffered from productive cough and high fever. Increased airway filling with mucoid secretion was repeatedly observed within the area of atelectasis with bronchiectasis, and left lower lobe atelectasis developed. Subsequently, the hilar and mediastinal lymph nodes gradually became enlarged, and DLBCL was pathologically confirmed. In the present case, DLBCL was considered to have arisen in the lesion of chronic atelectasis. Physicians should recognize that DLBCL may develop at the site of chronic atelectasis during disease course of diffuse bronchiectasis, and thus DLBCL may be misdiagnosed as superimposed infection of chronic atelectasis.

Factors associated with false negative interferon-γ release assay results in patients with tuberculosis: A systematic review with meta-analysis.

Which factors are related to false negative results of the interferon-γ release assay (IGRA) is unclear. This systematic review described the risk factors associated with false negative IGRA results. Two authors independently identified studies designed to evaluate risk factors for false negative IGRA results from PubMed, the Cochrane Register of Control Trial database, and EMBASE, accessed on October 22, 2018. Meta-analyses were conducted with random-effect models, and heterogeneity was calculated with the I2 method. Of 1,377 titles and abstracts screened, 47 full texts were selected for review, and we finally included 17 studies in this systematic review. The most commonly studied risk factor (14 studies) was advanced age, followed by low peripheral lymphocyte counts (7 studies), and these factors were associated with false negative results even with different tuberculosis incidences (pooled odds ratio 2.06; 95% CI, 1.68-2.52 in advanced age and 2.68; 95% CI, 2.00-3.61 in low peripheral lymphocyte counts). Advanced age and low peripheral lymphocyte counts may be common risk factors for false negative IGRA results, suggesting that people with these factors need to be carefully followed, even if they have negative IGRA results.

Asthma Exacerbation Coincident with Saddle Pulmonary Embolism and Paradoxical Embolism.

Saddle pulmonary embolism (PE) and paradoxical embolism (PDE) are life-threatening disorders carrying a risk of sudden death, and their prompt diagnosis is extremely important. Saddle PE is a radiologic definition and refers to a thrombus that straddles the bifurcation of the pulmonary artery trunk, carrying a risk of sudden hemodynamic collapse. PDE is defined as a systemic arterial embolus due to the passage of a venous thrombus though a right-to-left shunt, such as patent foramen ovale (PFO). We herein present the rare case of asthma exacerbation coincident with saddle PE and PDE. A 69-year-old woman with asthma was suffering from dyspnea, pulse attenuation of the left radial artery and left upper limb pain. An arterial blood gas analysis revealed hypoxemia, and a pulmonary function test demonstrated an obstructive pattern. Enhanced computed tomography (CT) revealed saddle PE, right popliteal venous thrombosis, and left brachial artery occlusion. After the treatment with edoxaban, an anticoagulant, and aspirin, the PE was significantly alleviated, and the brachial artery occlusion was recanalized. Subsequently, the right-to-left shunt through PFO was confirmed, and PDE was suspected of inducting her brachial artery embolism. In the present case, the pulse attenuation of the radial artery and upper limb pain prompted us to consider peripheral vascular disease or coagulation disorders. Physicians should keep in mind that patients with asthma are at considerable risk of PE, and it is important to be aware of possible PFO in patients presenting with the coexistence of PE and systemic arterial embolism.

A Pitfall of Treatment with Tosufloxacin for Pneumonia That Might Be Lung Tuberculosis.

Tosufloxacin, which is not used to treat Mycobacterium tuberculosis, is a fluoroquinolone recommended for pneumonia when the possibility of tuberculosis infection cannot be excluded. In the present case, symptoms and chest infiltrative shadow initially improved by tosufloxacin. Therefore, we regarded this patient as having general pneumonia and did not perform follow-up chest X-ray until the infiltrates had completely disappeared. However, a few weeks later, the symptoms and the infiltrates had worsened, so M. tuberculosis was isolated from the patient's sputum. This case suggests that patients suspected of having pulmonary tuberculosis should be monitored carefully, even if antibiotics without antituberculous activity are initially effective.