Systemic Corticosteroids and Early Administration of Antiviral Agents for Pneumonia with Acute Wheezing due to Influenza A(H1N1)pdm09 in Japan

BACKGROUND: Pneumonia patients with wheezing due to influenza A(H1N1)pdm09 were frequently treated with systemic corticosteroids in Japan although systemic corticosteroid for critically ill patients with pneumonia caused by influenza A(H1N1)pdm09 has been controversial. Applicability of systemic corticosteroid treatment needs to be evaluated. METHODS/PRINCIPAL FINDINGS: We retrospectively reviewed 89 subjects who were diagnosed with influenza A(H1N1)pdm09 and admitted to a national hospital, Tokyo during the pandemic period. The median age of subjects (45 males) was 8 years (range, 0-71). All subjects were treated with antiviral agents and the median time from symptom onset to initiation of antiviral agents was 2 days (range, 0-7). Subjects were classified into four groups: upper respiratory tract infection, wheezing illness, pneumonia with wheezing, and pneumonia without wheezing. The characteristics of each group was evaluated. A history of asthma was found more frequently in the wheezing illness (55.6%) and pneumonia with wheezing (43.3%) groups than in the other two groups (p = 0.017). Corticosteroid treatment was assessed among subjects with pneumonia. Oxygen saturation was lower in subjects receiving corticosteroids (steroid group) than in subjects not receiving corticosteroids (no-steroid group) (p<0.001). The steroid group required greater oxygen supply than the no-steroid group (p<0.001). No significant difference was found by the Kaplan-Meier method between the steroid and the no-steroid groups in hours to fever alleviation from the initiation of antiviral agents and hospitalization days. In logistic regression analysis, wheezing, pneumonia and oxygen saturation were independent factors associated with using systemic corticosteroids. CONCLUSION: Patients with wheezing and a history of asthma were frequently found in the study subjects. Systemic corticosteroids together with early administration of antiviral agents to pneumonia with wheezing and possibly without wheezing did not result in negative clinical outcomes and may prevent progression to severe pneumonia in this study population

Dual Antiplatelet Therapy Can Be Discontinued at Three Months after Implantation of Zotarolimus-Eluting Stent in Patients with Coronary Artery Disease

Dual antiplatelet therapy (DAPT) after percutaneous coronary intervention increases the risk of bleeding. We studied the safety and clinical outcomes of switching from DAPT to aspirin monotherapy at 3 months after ZES implantation. We retrospectively evaluated 168 consecutive patients with coronary artery disease who had been implanted with a ZES from June 2009 through March 2010. After excluding 40 patients according to exclusion criteria such as myocardial infarction, 128 patients were divided into a 3-month DAPT group (67 patients, 88 lesions) and a 12-month conventional DAPT group (61 patients, 81 lesions). Coronary angiographic followup and clinical followup were conducted at more than 8 months and at 12 months after ZES implantation, respectively. Minor and major bleeding events, stent thrombosis (ST), and major adverse cardiac events (MACE) (death, myocardial infarction, cerebrovascular accident, target lesion revascularization, and target vessel revascularization) were evaluated. There were no statistically significant differences in the incidences of ST and MACE between the two groups. The incidence of bleeding events was significantly lower in the 3-month group than in the 12-month group (1.5% versus 11.5%, ). DAPT can be safely discontinued at 3 months after ZES implantation, which reduces bleeding risk

Early and Definitive Diagnosis of Toxic Shock Syndrome by Detection of Marked Expansion of T-Cell-Receptor Vβ2-Positive T Cells

We describe two cases of early toxic shock syndrome, caused by the superantigen produced from methicillin-resistant Staphylococcus aureus and diagnosed on the basis of an expansion of T-cell-receptor Vβ2-positive T cells. One case-patient showed atypical symptoms. Our results indicate that diagnostic systems incorporating laboratory techniques are essential for rapid, definitive diagnosis of toxic shock syndrome

Fas-Independent T-Cell Apoptosis by Dendritic Cells Controls Autoimmune Arthritis in MRL/lpr Mice

Background: Although autoimmunity in MRL/lpr mice occurs due to a defect in Fas-mediated cell death of T cells, the role of Fas-independent apoptosis in pathogenesis has rarely been investigated. We have recently reported that receptor activator of nuclear factor (NF)-kB ligand (RANKL)-activated dendritic cells (DCs) play a key role in the pathogenesis of rheumatoid arthritis (RA) in MRL/lpr mice. We here attempted to establish a new therapeutic strategy with RANKL-activated DCs in RA by controlling apoptosis of peripheral T cells. Repeated transfer of RANKL-activated DCs into MRL/lpr mice was tested to determine whether this had a therapeutic effect on autoimmunity. Methods and Finding: Cellular and molecular mechanisms of Fas-independent apoptosis of T cells induced by the DCs were investigated by in vitro and in vivo analyses. We demonstrated that repeated transfers of RANKL-activated DCs into MRL/lpr mice resulted in therapeutic effects on RA lesions and lymphoproliferation due to declines of CD4+ T, B, and CD4‾CD8‾ double negative (DN) T cells. We also found that the Fas-independent T-cell apoptosis was induced by a direct interaction between tumor necrosis factor (TNF)-related apoptosis-inducing ligand-receptor 2 (TRAIL-R2) on T cells and TRAIL on Fas-deficient DCs in MRL/lpr mice. Conclusion: These results strongly suggest that a novel Fas-independent apoptosis pathway in T cells maintains peripheral tolerance and thus controls autoimmunity in MRL/lpr mice

認知症高齢者の睡眠・覚醒状態を把握するための方法の検討 : 睡眠・覚醒観察法とアクチグラフの比較から

本研究の目的は,認知症高齢者の睡眠・覚醒状態の測定方法を検討することである.対象は,施設療養する中等症から重症の認知症高齢者10人のうち,アクチグラフ装着が継続困難な対象を除いた6人である.方法は,睡眠・覚醒観察法(30分と60分間隔)とアクチグラフによる連続3日間の同時測定を実施し,「一日の総睡眠時間」「夜間睡眠時間」「夜間睡眠率」「夜間中途覚醒回数」について比較分析した.結果,睡眠・覚醒観察法は,観察間隔よりも短い間隔で中途覚醒が起こる時や,臥床開眼状態で身体の動きや寝息がない時に睡眠・覚醒の判別を誤る可能性が示された.アクチグラムは不随意な動きや掻く,寝具をまさぐる動きを「覚醒」,身体活動性が著しく低いと「睡眠」と判別しやすい傾向にあった.以上より,認知症高齢者の睡眠・覚醒状態の把握にあたっては,身体活動性や不随意運動,睡眠の断片化の程度を考慮し測定用具を選択していく必要性が示された.This study investigated the assessment method of sleep-awake patterns of elderly with dementia. Ten elderly people in the level of moderate to severe dementia residing at a long-term care unit were recruited for subjects, and six of them were selected based on their capability of wearing actigraphs. The total sleep time, nighttime sleep time, nighttime sleeping ratio, and frequency of nighttime awakening were investigated for three days in a row, and comparative analyses were carried out. The result suggested possibility of observational method for making wrong assessment when subjects were staying in bed quietly with their eyes close, or when subjects\u27 awakening patterns were shorter than observational intervals. It was also found that actigraphs tend to detect involuntary movement such as scratching or fumbling blankets as awakening, and static activity as sleeping. It was suggested that subjects\u27 physical activity, involuntary movement, and sleeping fragmentation were needed to be concerned for selecting a method of assessing sleep-awake patterns among elderly with dementia

認知症高齢者の自発性を引き出す集団音楽療法における介入スキル

本研究の目的は,認知症高齢者の自発性を引き出す集団音楽療法における介入スキルについて明確化することである.認知症高齢者5人に対して8回の集団音楽療法を実施し,セラピストによる介入を帰納的に分析した結果,以下のことが示された.1)セッション中にみられた認知症高齢者の自発性の変化として,「覚醒時間が増加する」「演奏の始まりがスムーズになる」「演奏中のテンポやリズムの乱れを修正していく」「演奏後に満足感を表出する」「場を創造していく」の5つが見出された.2)セラピストが用いていた介入タイプは,「音楽への同調を促す」「注意・関心をひきつける」「巻き込む」「ほめる・支持する」「場の発展・拡張を期待して仕掛ける」の5つに分類された.3)認知症高齢者の自発性を引き出す集団音楽療法における介入スキルには,セラピストが楽曲ごとに(1)演奏に向かうまで,(2)演奏の始まり,(3)演奏中,(4)演奏の終わり,(5)演奏直後の5つの時点において5つの介入タイプを使い分け,参加者が音楽に同調していこうとする自発性を助けること,参加者自身が自分の演奏に満足し自尊心や自信が回復していく体験を積み重ねることで,自ら場を創造していく力を発揮できる機会を仕掛けていくことが見いだされた.The purpose of this study was to clarify therapeutic intervention skills for eliciting spontaneity of the elderly with dementia in a group of music therapy session. Subjects were five elderly persons with dementia guided by one music therapist. Group music therapy sessions focused on rhythm synchronization were held once a week during 8 weeks. The intervention types for eliciting the spontaneity of the elderly with dementia were extracted by the inductive method form description of spontaneous responses of the elderly and the therapist\u27s intervention. The following results were obtained. 1) The change of spontaneous responses among the elderly with dementia in the group music therapy session included (1) increasing time of awaking, (2) smooth participation to singing songs and playing instruments, (3) correcting the tempo of singing and playing, (4) expressing the gratification of playing music, and (5) creating a scene spontaneously in the session. 2) The intervention that the therapist used included (1) inducing synchronization to the rhythm and melody, (2) attracting to pay attention and interest, (3) involvement, (4) admiration and supporting, and (5) prompt to anticipation of evolvement in the group. 3) It is suggested that a music therapist should have a skill to select appropriate intervention for aiming 5 different timings of intervention when a therapist plays a tune, which is (1) before the execution, (2) at the beginning of the execution, (3) in the middle of the execution, (4) at the end of execution, (5) after the execution. It is also found that a skill to organize the combination of 5 types of interventions while focusing on these 5 points is important for a music therapist working for the elderly with dementia

Coexistence of transthyretin- and Aβ-type cerebral amyloid angiopathy in a patient with hereditary transthyretin V30M amyloidosis

金沢大学附属病院神経内科Embargo Period 12 month