Difference in electromyographic activity between the trapezius muscle and other neck accessory muscles under an increase in inspiratory resistive loading in the supine position.

The activity of the trapezius muscle is reportedly higher than that of other neck accessory muscles under a condition of increased inspiratory pressure in the standing position. The present study aimed to compare the activity of the trapezius muscle with those of the scalene and sternocleidomastoid muscles under a condition of increased inspiratory pressure in the supine position. This study included 40 subjects, and the muscle activity was measured using surface electromyography. Regarding the results, there was a significant difference in the muscle activity between the trapezius muscle and the scalene and sternocleidomastoid muscles (p = 0.003) in both men and women. Post-hoc analysis showed significant differences between trapezius and the other muscles. Moreover, there was no difference between the scalene and sternocleidomastoid muscles (p = 0.596). The increase in the change in electromyography activity of the muscle is greater in the trapezius muscle than in other muscles when the level of inspiratory pressure increases in the supine position.

Computerized data mining analysis of keywords as indicators of the concepts in AHA-BLS guideline updates.

INTRODUCTION: Cardiopulmonary resuscitation (CPR) guidelines have been updated every 5 years since 2000. Significant changes have been made in each update, and every time a guideline is changed, the instructors of each country that ratify the American Heart Association (AHA) must review the contents of the revised guideline to understand the changes made in the concept of CPR. The purpose of this study was to use a computerized data mining method to identify and characterize the changes in the key concepts of the AHA-Basic Life Support (BLS) updates between 2000 and 2015. METHODS: We analyzed the guidelines of the AHA-BLS provider manual of 2000, 2005, 2010, and 2015 using a computerized data mining method and attempted to identify the changes in keywords along with changes in the guideline. RESULTS: In particular, the 2000 guideline has focused on the detailed BLS technique of an individual health care provider, whereas the 2005 and 2010 guidelines have focused on changing the ratio of chest compressions and breathing and changing the BLS sequence, respectively. In the most recent 2015 guideline, the CPR team was the central topic. We observed that as the guidelines were updated over the years, keywords related to CPR and automated external defibrillators (AED) associated with co-occurrence network continued to appear. CONCLUSIONS: Analysis revealed that keywords related to CPR and AED associated with the co-occurrence network continued to appear. We believe that the results of this study will ultimately contribute to optimizing AHA's educational strategies for health care providers.

Successful conservative management of a case of caustic esophagitis based on computed tomography assessment.

Case: We describe the case of a female patient who ingested approximately 100 mL of toilet bowl cleaner containing 9.5% hydrochloric acid in a suicide attempt. Upon admission for hematemesis and epigastric pain, she was alert and oriented with stable vital signs. Initial contrast-enhanced computed tomography (CT) demonstrated edematous changes with no evidence of upper gastrointestinal tract perforation. Endoscopy was not performed owing to the high risk of perforation. We managed this patient conservatively. Repeat contrast-enhanced CT revealed mediastinal emphysema on day 2, which resolved by day 6. The patient was subsequently discharged with no apparent strictures of the upper gastrointestinal tract. Outcome: Surgical interventions are frequently required following the ingestion of large amounts of highly concentrated hydrochloric acid; however, this patient was successfully managed conservatively. Conclusion: Contrast-enhanced CT is useful in the assessment of the respiratory and digestive systems and the prediction of potential complications.

Association between cancer risk and drug-metabolizing enzyme gene (CYP2A6, CYP2A13, CYP4B1, SULT1A1, GSTM1, and GSTT1) polymorphisms in cases of lung cancer in Japan.

Genetic polymorphisms of enzymes involved in the metabolism of carcinogens are suggested to modify an individual's susceptibility to lung cancer. The purpose of this study was to investigate the relationship between lung cancer cases in Japan and variant alleles of cytochrome P450 (CYP) 2A6 (CYP2A6*4), CYP2A13 (CYP2A13*1-*10), CYP4B1 (CYP4B1*1-*7), sulfotransferase 1A1 (SULT1A1*2), glutathione S-transferase M1 (GSTM1 null), and glutathione S-transferase T1 (GSTT1 null). We investigated the distribution of these polymorphisms in 192 lung cancer patients and in 203 age- and sex-matched cancer-free controls. The polymorphisms were analyzed using various techniques including allele-specific PCR, hybridization probe assay, multiplex PCR, denaturing high-performance liquid chromatography (DHPLC), and direct sequencing. We also investigated allele and genotype frequencies and their association with lung cancer risk, demographic factors, and smoking status. The prevalence of the CYP2A6*4/*4 genotype in lung cancer cases was 3.6%, compared with 9.4% in the controls (adjusted OR = 0.36, 95% CI = 0.15-0.88, P = 0.025). In contrast, there was no association between the known CYP2A13, CYP4B1, SULT1A1, GSTM1, and GSTT1 polymorphisms and lung cancer. These data indicate that CYP2A6 deletions may be associated with lung cancer in the Japanese population studied.

Functional characterization of CYP2B6 allelic variants in demethylation of antimalarial artemether.

Artemether (AM) is one of the most effective antimalarial drugs. The elimination half-life of AM is very short, and it shows large interindividual variability in pharmacokinetic parameters. The aim of this study was to identify cytochrome P450 (P450) isozymes responsible for the demethylation of AM and to evaluate functional differences between 26 CYP2B6 allelic variants in vitro. Of 14 recombinant P450s examined in this study, CYP2B6 and CYP3A4 were primarily responsible for production of the desmethyl metabolite dihydroartemisinin. The intrinsic clearance (V(max)/K(m)) of CYP2B6 was 6-fold higher than that of CYP3A4. AM demethylation activity was correlated with CYP2B6 protein levels (P = 0.004); however, it was not correlated with CYP3A4 protein levels (P = 0.27) in human liver microsomes. Wild-type CYP2B6.1 and 25 CYP2B6 allelic variants (CYP2B6.2-CYP2B6.21 and CYP2B6.23-CYP2B6.27) were heterologously expressed in COS-7 cells. In vitro analysis revealed no enzymatic activity in 5 variants (CYP2B6.8, CYP2B6.12, CYP2B6.18, CYP2B6.21, and CYP2B6.24), lower activity in 7 variants (CYP2B6.10, CYP2B6.11, CYP2B6.14, CYP2B6.15, CYP2B6.16, CYP2B6.20, and CYP2B6.27), and higher activity in 4 variants (CYP2B6.2, CYP2B6.4, CYP2B6.6, and CYP2B6.19), compared with that of wild-type CYP2B6.1. In kinetic analysis, 3 variants (CYP2B6.2, CYP2B6.4, and CYP2B6.6) exhibited significantly higher V(max), and 3 variants (CYP2B6.14, CYP2B6.20 and CYP2B6.27) exhibited significantly lower V(max) compared with that of CYP2B6.1. This functional analysis of CYP2B6 variants could provide useful information for individualization of antimalarial drug therapy.

Novel single nucleotide polymorphism of the CYP2A13 gene in Japanese individuals.

Cytochrome P450 2A13 (CYP2A13) is a human CYP enzyme that is selectively expressed in the respiratory tract. It plays an active role in the metabolic activation of a tobacco-specific procarcinogen. In this study, the entire coding sequence and the exon-intron junctions of the CYP2A13 gene obtained from 395 Japanese individuals were screened for genetic polymorphisms. Eight genetic polymorphisms were found, of which seven gave rise to known variant alleles: CYP2A13*2, CYP2A13*3, CYP2A13*4, CYP2A13*6, and CYP2A13*7. We identified a novel single nucleotide polymorphism (SNP), 5792T>C, in exon 7 that caused an amino acid substitution (Ile331Thr). One of the 395 individuals included in the study was heterozygous for the variant allele, and therefore, the frequency of the allele in the study population was 0.13%.

Immunopathological characteristics of immune reconstitution inflammatory syndrome caused by Mycobacterium parascrofulaceum infection in a patient with AIDS.

Immune reconstitution inflammatory syndrome (IRIS) caused by mycobacterium in patients with AIDS is often experienced in clinical practice. There is, however, a paucity of data documenting the histopathological findings and the pathogenesis. We determined the immunopathological characteristics of IRIS associated with Mycobacterium parascrofulaceum infection in an AIDS patient. A patient presented with pulmonary lymphadenitis and involvement of the pulmonary lingular segment. Portions of the involved lymph nodes and lung were excised, and the immunological properties were analyzed by immunohistochemical assays. The histological characteristics of lymph nodes showed a caseous necrosis. Histopathologically, the pulmonary lesion was composed of exudative and proliferative lesions. CD4(+), CD8(+), CD57(+), and CD25(+)/FoxP3(+) cells were observed in both types of lesions. Clusters of CD20(+) cells and GATA3(+) cells were predominantly observed in exudative lesions, while T-bet(+) cells were dominant in proliferative lesions. ROR-γ(+) cells were also observed in exudative lesions. These results indicate that the cellular immunity to mycobacteria was recovering in the lung tissue. In M. parascrofulaceum pulmonary infection, the exudative lesion had characteristics of Th2 and Th17-type immunities. In contrast, the proliferative lesion had characteristics of Th-1 type immunity. Our data provide the first evidence to reveal the status of the axis of distinctive immunity in the process of granuloma formation caused by a mycobacterium-related infection.

Hepatocyte growth factor levels in Legionella pneumonia: a retrospective study.

BACKGROUND: Hepatocyte growth factor (HGF) is known to be involved in the resolution of pulmonary inflammation and repair of acute lung injury. Legionella pneumonia is sometimes complicated by acute lung injury. Our study aimed to determine the role of serum HGF levels in Legionella pneumonia. METHODS: Sera from patients with Legionella pneumonia (42 cases), other bacterial pneumonia (33 cases), pulmonary tuberculosis (19 cases), and normal controls (29 cases) were collected. The serum HGF levels for each serum sample were determined by sandwich ELISA. Clinical and laboratory data were collected by reviewing the medical charts. RESULTS: Serum HGF levels were higher in patients with Legionella pneumonia than in those with other bacterial pneumonia, pulmonary tuberculosis, and controls. The HGF levels were compared with white blood cell counts, C-reactive protein, Alanine amino-transferase, and lactate dehydrogenase (LDH). The HGF levels were correlated to serum LDH levels. Moreover, serum HGF levels were significantly higher in non-survivors than in survivors. CONCLUSIONS: HGF levels increased in severer pneumonia caused by Legionella, suggesting that HGF might play a significant role in the Legionella pneumonia.

Pneumocystis jirovecii pneumonia and alveolar hemorrhage in a pregnant woman with human T cell lymphotropic virus type-1 infection.

Acute lung injury during pregnancy results in morbidity and mortality in both the mother and the fetus. Pneumocystis jirovecii pneumonia (PCP) is a rare disease but may occur in pregnant immune-suppressed women. Here, we describe a case of acute lung injury due to PCP and alveolar hemorrhage in a pregnant woman who was a human T lymphotropic virus type-1 (HTLV-1) carrier. PCP should be considered in the differential diagnosis of pulmonary complications during pregnancy in HTLV-1 endemic areas.

Pulmonary Mycobacterium parascrofulaceum infection as an immune reconstitution inflammatory syndrome in an AIDS patient.

Nontuberculous mycobacterial (NTM) infection in HIV (human immunodeficiency virus)-infected patients who have started highly active antiretroviral therapy (HAART) is well known to be one scenario of immune reconstitution inflammatory syndrome (IRIS). We encountered the first case in Japan of an HIV-infected patient with pulmonary Mycobacterium parascrofulaceum infection as IRIS. A 34 year-old man with acquired immunodeficiency syndrome (AIDS) was receiving highly active antiretroviral therapy. Lymphadenopathy was observed at the left pulmonary hilum. IRIS was suspected and thoracoscopic surgery was performed to diagnose the cause of lymphadenopathy. Granulomas were observed histologically, and M. parascrofulaceum was cultured. This organism was susceptible to Clarithromycin, rifampicin and levofloxacin. After the operation and without treatment, recurrence of M. parascrofulaceum infection was not observed. M. parascrofulaceum was isolated from several clinical specimens for the first time in 2004. To date, only five cases have been reported.

[Cost effectiveness of hypertension treatment based on the measurement of ambulatory blood pressure].

In recent years soaring medical costs have become a major social problem in developed countries. Ambulatory blood pressure (ABP) measurements have a stronger predictive power for cardiovascular events than clinic blood pressure (CBP) measurements. Therefore the introduction of ABP measurement for the diagnosis and treatment of hypertension should lead to a decrease in medical expenditure. This study presents calculations of the cost saving and life years associated with changing from CBP to ABP measurement as diagnostic tool. We constructed a Markov model using data from the Ohasama study and a Japanese national database. Study population was 7.042 million individuals aged 40 years and above living in Japan. The introduction of ABP for hypertension would result in a reduction of about 9.48 trillion yen per 10 years. We conducted a sensitivity analysis and found that the introduction of ABP was associated with at least a cost reduction of 47500 billion yen. But it did not provide significant extension of average life years. However the introduction of ABP for hypertension treatment would be a very effective method in perspective of public health because it reduced about 59600 individuals of stroke and about 18900 individuals of death. Given its cost-effectiveness, extensive application of ABP measurement in clinical practice is expected.

Active tuberculosis in patients undergoing hemodialysis for end-stage renal disease: a 9-year retrospective analysis in a single center.

OBJECTIVE: Tuberculosis (TB) in patients undergoing hemodialysis (HD) for end-stage renal disease (ESRD) is commonly thought to be associated with a very poor prognosis. Moreover, it is difficult to diagnose. This report was designed to describe this condition and to determine the mortality rate and risk factors associated with mortality. In addition, the study evaluated the usefulness of QuantiFERON TB-2G((R)) (QFT-2G). METHODS: Retrospective study PATIENTS: Patients with confirmed TB admitted between January 2001 and May 2009 were retrospectively identified and enrolled. The clinical, radiological, and bacteriological data at the time of admission were recorded. A multivariate analysis was performed to identify the predictive factors for mortality. RESULTS: A total 19 TB patients (6 females; median age, 73 years) were included. TB occurred in most cases within 1.3 years from the initiation of dialysis. Most patients presented with fever (84.2%) and extrapulmonary TB (57.9%). The mortality rate within 24 weeks of the initiation of TB treatment was 36.8%. The factors associated with mortality were: a short duration of dialysis (HR 8.86, 95% CI 1.03-75.7, p=0.04), and underweight (HR 10.88, 95% CI 1.28-92.6, p=0.02). The sensitivity of QFT-2G, acid-fast smear, and polymerase chain reaction was 50, 80, and 88.2% respectively. CONCLUSION: These data indicate a high incidence of TB in the early stages of HD and a high mortality rate among these patients. The clinical utility of QFT-2G was found to be limited. Hypoalbuminemia might therefore be related to either indeterminate or negative results of QFT-2G.

[Tuberculosis of the tongue initially suspected of tongue cancer: a case report--including the search for recent 16 cases in Japan].

A 56-year-old man, having no particular past history, was admitted to our hospital, with a 9-month history of painful ulcerated lesion of the tongue and a 6-month history of productive cough. A physical examination revealed swelling of his cervical lymph nodes, and a chest roentgenogram on admission showed cavities in the both upper lung fields and nodular shadows over the both lung fields. He was initially suspected of having both cancer of the tongue and pulmonary tuberculosis, but finally diagnosed as secondary tuberculosis of the tongue due to sputum smear-positive pulmonary tuberculosis by biopsy of the tongue and sputum examination. He was treated with isoniazid, rifampicin, ethambutol and pyrazinamide, and his pain and ulcerated lesion of the tongue rapidly improved. Due to our search for recent 16 cases of tuberculosis of the tongue in Japan, we found that the patients of tuberculosis of the tongue were more likely to have concurrently sputum smear-positive pulmonary tuberculosis. In some cases, the delay in diagnosis was seen. These cases suggest that refractory ulcerated cases of the tongue should be subjected to the biopsy and examination for acid fast bacilli of the tongue with suspicion of tuberculosis of the tongue, and then a chest roentgenogram with suspicion of pulmonary tuberculosis.

Cost-effectiveness of the introduction of home blood pressure measurement in patients with office hypertension.

OBJECTIVE: Cost-effectiveness of hypertension treatment is an important social and medical issue in Western as well as in Eastern countries, including Japan. Home blood pressure (HBP) measurements have a stronger predictive power for cardiovascular events than casual clinic blood pressure (CBP) measurements. Therefore, the introduction of HBP measurement for the diagnosis and treatment of hypertension should lead to a decrease in medical expenditure. This study presents calculations of the cost savings likely to take place when HBP is implemented for newly detected hypertensive subjects in Japan. DESIGN AND METHODS: We estimate the cost savings from the perspective of a Japanese healthcare system. To estimate the costs associated with changing from CBP to HBP measurement as the diagnostic tool, we constructed a simulation model using data from the Ohasama study. These calculations are based on current estimates for cost of treatment, prevalence of white-coat hypertension at baseline, and varying the incidence of new hypertension after the initial screening. RESULTS: When HBP measurement is not incorporated into the diagnostic process, the medical cost is estimated at US$10.89 million per 1000 subjects per 5 years. When HBP measurement is incorporated, the medical cost is estimated at US$9.33 million per 1000 subjects per 5 years. The reductions in medical costs vary from US$674,000 to US$2.51 million per 1000 subjects per 5 years for treatment of hypertension, when sensitivity analysis is performed. CONCLUSIONS: The introduction of HBP measurement for the treatment of hypertension is very useful for reducing medical costs.

The relationship between O-antigens and pathogenic genes of diarrhea-associated Escherichia coli.

To evaluate the serogrouping-based diagnosis of diarrheagenic Escherichia coli, a total of 1,130 strains of E. coli isolated in several countries were studied. The strains were regarded as enterovirulent on the basis of their O-antigens determined using a commercially available kit containing 43 antisera, and the presence of diarrhea-associated genes (eae, stx, aggR, est, elt, ipaH) was evaluated by PCR. Two hundred sixty-three strains of 1,130 (23.3%) were identified as diarrheagenic based on the presence of at least one pathogenic gene. The probability that E. coli identified as diarrheagenic on the basis of serogrouping actually possessed some pathogenic gene was highest for serogroup O119 (78.4%); other serogroups with a positive rate for pathogenic genes higher than 60% were O111 and O126. No target genes were detected among the strains belonging to serogroups O1, O29, O112ac, O143, O158 and O168. Our results suggest that, in practice, serogrouping is useful for the identification of diarrheagenic E. coli in a very limited number of serogroups.

[A case of loxoprofen-induced pneumonitis pathologically resembling hypersensitivity pneumonitis].

A 66-year-old woman was admitted to our hospital because of high fever, general fatigue, hypoxemia and liver dysfunction. Chest radiographs showed diffuse interstitial shadows in both lungs. We suspected drug-induced pneumonitis because of her history of drug administration for upper respiratory infection. Her symptoms and findings were markedly decreased by discontinuation of the drugs. Transbronchial lung biopsy specimens showed infiltration of eosinophils and lymphocytes to the alveolar septa, granuloma with Langhans' giant cells, and Masson bodies in a manner suggestive of hypersensitivity pneumonitis. Drug lymphocyte stimulation tests were negative except for loxoprofen. There was no recurrence of systemic or respiratory symptoms during overnight stays at home. On the basis of these findings, we arrived at a diagnosis of drug-induced pneumonitis caused by loxoprofen.