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In this multi-center prospective test-negative case-control study in Japan, the effectiveness of both BA.1-containing and BA.4/BA.5-containing bivalent COVID-19 mRNA vaccines against symptomatic infection during the BA.5-dominant period was high compared to no vaccination (65% and 76%) and moderate compared to monovalent vaccines administered over half a year before (46% combined).

Objective The coronavirus disease 2019 (COVID-19) pandemic has changed the inpatient treatment practice for bacterial pneumonia. Upon hospitalization, isolation is required while waiting for the polymerase chain reaction (PCR) test result, which may lead to limited access to medical resources and fewer room visits by medical staff. However, little is known about the relationship between isolation and the clinical outcomes of bacterial pneumonia. We hypothesized that isolation of suspected COVID-19 patients who are eventually diagnosed with bacterial pneumonia is associated with a prolonged length of hospitalization as compared with non-isolation. Patients This is a single-center, retrospective observational study of hospitalized adult patients diagnosed with bacterial pneumonia from January 2018 to September 2021. The patients were divided into a non-isolated (patients hospitalized between January 2018 and December 2019, who were not isolated at all) and an isolated group (patients hospitalized between January 2020 and September 2021, who were initially isolated because COVID-19 was suspected). The primary outcome was a prolonged length of hospitalization (≥14 days), and its relationship with isolation was analyzed using logistic regression analysis adjusted for age, sex, CURB-65, and the Charlson Comorbidity Index. Results Among 917 eligible patients, 214 (23%) underwent isolation. In the logistic regression analysis, the isolated group independently had a prolonged length of hospitalization as compared with the non-isolated group (odds ratio 1.49; 95% confidence interval 1.08-2.07, p=0.015). There was no significant difference in antibiotic use duration between the groups. Conclusion The isolation of bacterial pneumonia patients suspected of COVID-19 was associated with prolonged length of hospitalization.

Background: Effectiveness of restricting healthcare providers (HCPs) from working based on the coronavirus disease 2019 (COVID-19)-like symptoms should be evaluated. Methods: A total of 495 HCPs in a tertiary care hospital in Tokyo, Japan, participated in this study between June and July in 2020. Analysis of serum anti-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibody to identify infected HCPs, questionnaire surveys, and medical record reviews were conducted to evaluate the appropriateness of symptom-based work restriction for 10 days. Results: Five participants (1.0%) were identified as infected. Forty-six participants (9.3%) experienced work restriction and all five infected participants (10.8%) restricted working, even though the real-time reverse transcription-polymerase chain reaction was positive only in four participants (80.0%). There were no unexpectedly infected participants among those who did not experience work restriction. However, only 46 of 110 HCPs with COVID-19-like symptoms (41.8%) restricted themselves from working. Discussion: Symptom-based work restriction strategy successfully prevented infected HCPs to work, but showed low specificity to identify truly infected HCPs, and their low adherence to the strategy was revealed. Conclusions: HCPs with COVID-19-like symptoms should restrict working as the first step of infection prevention, but the strategy to identify truly infected HCPs is necessary.

Bronchoscopy is a recognized method for obtaining specimens for the diagnosis of nontuberculous mycobacterial pulmonary disease (NTM-PD). However, its diagnostic properties remain to be elucidated. The aim of this study was to determine the specificity of bronchoscopy for the diagnosis of NTM-PD, and to examine the diagnostic yield of bronchoscopy for detecting nontuberculous mycobacteria (NTM) when patients cannot expectorate sputum with NTM.This retrospective cohort study included 2657 patients who underwent bronchoscopy and mycobacterial culture between January 2004 and June 2018 in a tertiary care center in Tokyo, Japan. To examine the specificity of bronchoscopy, the first cohort comprised patients who underwent bronchoscopy for the diagnosis of lung cancer and mycobacterial culture. To investigate the diagnostic yield, patients with nodular bronchiectasis who underwent bronchoscopy for the diagnosis of NTM-PD were enrolled into the second cohort.In total, 919 patients were diagnosed with lung cancer, 19 patients showed positive culture for NTM, and 14 patients showed findings for NTM-PD. Accordingly, the specificity was calculated as 900/905 (99.4%). In addition, NTM-PD was suspected before bronchoscopy in 199 patients; the diagnostic yield was 105/199 (52.8%). Four factors were associated with NTM-PD: upper lobe examination, absence of specific bacteria, absence of connective tissue disease, and a higher total computed tomography score.Bronchoscopy has a high specificity for the diagnosis of NTM-PD. In addition, even when NTM is undetected in sputum, bronchoscopy may detect mycobacteria in approximately half of the patients suspected of having NTM-PD.

Background: Data regarding the quality of end-of-life care for patients with noncancerous illnesses are lacking. Objective: This study aimed to evaluate end-of-life care for patients with noncancerous respiratory disease from the perspective of bereaved family members and explore the factors associated with the quality of patient death and care. Design: This cross-sectional study included patients who had died of noncancerous respiratory disease in general wards of pulmonary department in Japan between 2014 and 2016 and conducted an anonymous self-report questionnaire survey for the patients' bereaved family members. Measurements: We evaluated overall satisfaction with care and the quality of death and end-of-life care using the Good Death Inventory (GDI) and Care Evaluation Scale (CES), respectively. A multiple linear regression analysis was performed to explore the factors associated with these outcomes. Results: In total, 130 questionnaires were distributed, and the effective response rate was 38% and 50 patients were included (median age: 82 [range 58–101] years; 37 men [74%]). Primary diagnoses at death included 29 cases of pneumonia (58%), 15 interstitial lung disease (30%), and 3 chronic obstructive pulmonary disease (6%). Of the bereaved family members, 26 (52%) were spouses, and 19 (38%) were children (median age [range]: 68 [33–102] years, 15 men [30%]). The overall CES and GDI scores (mean ± standard deviation) were 77 ± 15 and 79 ± 15, respectively. The presence of dementia was an independent factor associated with high CES and GDI scores in the multiple linear regression analysis. Conclusions: In patients who died of noncancerous respiratory disease, the presence of dementia could be associated with the higher quality of patient death and care. In dementia, an understanding of the terminal nature of this condition may lead to an appropriate end-of-life care.

Background: Corticosteroids have been reported to reduce the mortality rates in patients with coronavirus disease 2019 (COVID-19). Additionally, the role of high-dose methylprednisolone pulse therapy in reducing mortality in critically ill patients has also been documented. The purpose of this study is to identify patients with COVID-19 who are suitable for methylprednisolone pulse therapy. Methods: This was a retrospective study that included patients with COVID-19 receiving methylprednisolone pulse therapy (≥250 mg/day for 3 days) with subsequent tapering doses at our hospital between June 2020 and January 2021. We examined the differences in background clinical factors between the surviving group and the deceased group. Results: Out of 156 patients who received steroid therapy, 17 received methylprednisolone pulse therapy. Ten patients recovered (surviving group) and seven patients died (deceased group). The median age of the surviving and deceased groups was 64.5 years (range, 57-85) and 79 years (73-90), respectively, with a significant difference (p=0.004). Five of the deceased patients (71%) had developed serious complications associated with the cause of death, including pneumothorax, pneumomediastinum, COVID-19-associated pulmonary aspergillosis, cytomegalovirus infection, and bacteremia. On the other hand, out of the 10 survivors, only one elderly person had cytomegalovirus infection and the rest recovered without complications. Conclusion: Administration of methylprednisolone pulse therapy with subsequent tapering may be an effective treatment in patients with COVID-19 up to the age of early 70s;however, severe complications may be seen in elderly patients. ercial use only.

Cigarette smoking in patients with asthma leads to poor symptom control. As patients who are current smokers have been excluded from enrollment in many clinical trials on asthma, there are few reports on the treatment in current smokers with asthma. In this study, we aimed to assess how respiratory physicians manage asthma in current smokers in Japan.Respiratory physicians in 16 Japanese hospitals answered a questionnaire on treatment for patients with asthma between December 2014 and February 2015. Medical records were reviewed for 1756 patients with asthma.The mean patient age was 61.1 years, and 62.9% of the patients were female. A total of 102 patients (5.8%) were current smokers, and 546 patients (31.1%) were former smokers. Long-acting muscarinic antagonists (LAMA) were prescribed more frequently for current smokers with asthma than for former smokers and never smokers with asthma (10.8% vs 4.6%, p = 0.01, 10.8% vs 3.8%, p0.01). In contrast, macrolides were prescribed more frequently for former smokers and never smokers with asthma than for current smokers with asthma (7.7% vs 1.0%, p = 0.01, 6.4% vs 1.0%, p = 0.03). Triple therapy, i.e., inhaled corticosteroids, long-acting beta agonists, and LAMA concomitantly, was prescribed for current smokers with asthma more frequently than for former smokers and never smokers with asthma (9.8% vs 4.0%, p = 0.01, 9.8% vs 3.3%, p0.01).According to this survey, current smokers with asthma received more intensive therapy, including LAMA, than did former smokers with asthma.

Objectives To determine the prevalence of burnout according to job category after the first wave of COVID‐19 in Japan and to explore its association with certain factors. Methods An online cross‐sectional survey of health care workers (HCWs) from June 15 to July 6, 2020, was conducted at a tertiary hospital in Tokyo, Japan. Demographic characteristics, results of the Japanese version of the Maslach Burnout Inventory‐General Survey, types of anxiety and stress, changes in life and work after the peak of the pandemic, and types of support aimed at reducing the physical or mental burden, were determined. Results Of 672 HCWs, 149 (22.6%) met the overall burnout criteria. Burnout was more prevalent in women (OR, 3.11; 95% CI, 1.45‐6.67, P = .003), anxiety due to unfamiliarity with personal protective equipment (PPE) (OR, 1.98; 95% CI, 1.20‐3.27, P = .007), and decreased sleep duration (OR, 1.96; 95% CI, 1.20‐3.20, P = .008). Conversely, participants who felt that the delivery of COVID‐19‐related information (OR, .608; 95% CI, .371‐.996, P = .048) and PPE education opportunities (OR, .484; 95% CI, .236‐.993, P = .048) and messages of encouragement at the workplace (OR, .584; 95% CI, .352‐.969; p = .037) was helpful experienced less burnout. Conclusions There is a need to focus on the above factors to maintain the mental health of HCWs. The delivery of COVID‐19‐related information and educational interventions for PPE and messages of encouragement at the workplace may be needed to reduce the mental burden.

Chest computed tomography (CT) has been used to complement coronavirus disease 2019 (COVID‐19) diagnosis due to its high sensitivity. However, owing to the low specificity of CT findings, differential diagnosis is essential. The typical CT findings of COVID‐19 include ground‐glass opacifications and consolidations with predominant distribution in bilateral, peripheral, and subpleural parts of the lung. These imaging findings are non‐specific and may resemble other lung conditions, including ultrasonic humidifier lung, which is a condition that develops on inhaling aerosols generated by ultrasonic humidifiers. We present two patients with initial symptoms similar to COVID‐19. CT examination revealed centrilobular nodules and consolidations with upper lobe‐predominant distribution, although atypical for COVID‐19, but key findings for ultrasonic humidifier lung. Therefore, ultrasonic humidifier lung could be a differential diagnosis for COVID‐19 in dry environments. Characteristic CT findings and a history of ultrasonic humidifier use are critical to the final diagnosis., We report two cases of patients diagnosed with ultrasonic humidifier lung with characteristic computed tomography (CT) findings of centrilobular nodules and consolidations with upper lobe‐predominant distribution, who were initially suspected of coronavirus disease 2019 (COVID‐19) infection.

Background Recently, virtual bronchoscopic navigation (VBN) has become frequently used for the pathological specimen collection of peripheral lung lesions using various VBN software packages. Herein, we examined the reproducibility of peripheral branches in VBN software using LungPoint and VINCENT versions 4.0 and 5.5. Methods This study included patients suspected of malignant peripheral lung lesions who underwent bronchoscopy at our hospital from February 2016 to April 2017. Computed tomography was taken at a thickness of 1.25 mm in all cases, and VB images were created based on the computed tomography data using LungPoint, or VINCENT version 4.0 or 5.5. One observer read the program-generated VB images and compared how many branches could be visualized with the lobe bronchus as the primary branch. Results A total of 129 patients (n = 131 lesions) underwent bronchoscopy, with 82 cases of primary lung cancer. Pathological bronchoscopic diagnosis was done in 63 cases, resulting to a diagnostic rate of 76.8%. VB images generated by LungPoint, and VINCENT versions 4.0 and 5.5 reproduced an average of 4.3, 3.47, and 5.12 branches, respectively, with significant differences (p Conclusions VINCENT version 5.5 exhibits better reproducibility of peripheral branches than LungPoint for VBN.

Background The rapid spread of the COVID-19 pandemic has taken a considerable mental strain on frontline healthcare workers (HCWs). Although a number of studies have reported on burnout during the peak of the pandemic, few studies have analyzed it after the pandemic temporally subsided. This study aimed to identify which intervention or support was helpful to reduce the physical and mental burden during the pandemic. Methods An online cross-sectional survey of HCWs from June 15 to July 6, 2020, was conducted at a tertiary hospital in Tokyo, Japan. Demographic characteristics, results of the Japanese version of the Maslach Burnout Inventory-General Survey, types of anxiety and stress, changes in life and work after the peak of the pandemic, and types of support aimed at reducing the physical or mental burden, were determined. Results Out of 672 HCWs, 149 (22.6%) met the overall burnout criteria. Figure 1 showed the comparison of what helped reduce their physical and mental burden between the burnout group and the non-burnout group. After adjusted by the potential covariates, burnout was more prevalent in women (OR, 3.11; 95% CI, 1.45–6.67; p = .003), and had heightened anxiety due to unfamiliarity with PPE (OR, 1.98; 95% CI, 1.20–3.27; p=.007). Conversely, participants who reported that PPE education opportunities (OR, .484; 95% CI, .236–.993; p = .048) and messages of encouragement at the workplace (OR, .584; 95% CI, .352–.969; p = .037) helped reduce their physical and mental burden had less burnout. Figure 1. What factors helped reduce the physical or mental burden Conclusion The educational interventions for PPE and messages of encouragement at the workplace may be needed to reduce the mental burden for HCWs. Disclosures All Authors: No reported disclosures

We report the first case of disseminated nocardiosis due to trimethoprim/sulfamethoxazole-resistant Nocardia terpenica successfully treated with meropenem and clarithromycin. The patient travelled to Japan from Australia via Southeast Asia, which led to differential diagnoses of multiple lung nodules including miliary tuberculosis and melioidosis as well as nocardiosis. Because of variety of susceptibility depending on the Nocardia species, clinicians need to confirm the species and investigate its susceptibility.

A 51‐year‐old man attended our hospital with chief complaints of fever and diarrhoea for the past eight days. Chest computed tomography showed peripherally dominant ground‐glass opacity. Severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) RNA was detected by real‐time polymerase chain reaction, and the patient was diagnosed with coronavirus disease (COVID‐19). His clinical course included respiratory failure, acute kidney injury, and paralytic ileus. Systemic management was difficult, but he recovered with high‐dose steroids, temporary haemodialysis therapy, and a nasointestinal tube, without antiviral drugs. COVID‐19 can be associated with multiple organ failure due to vascular endothelial injury., Coronavirus disease (COVID‐19) may be associated with multiple organ failure due to vascular endothelial damage. Here, we report a case of COVID‐19 in which a patient suffered from ileus complications and was difficult to manage systemically. However, he recovered with high doses of steroids, hemodialysis, and the nasal intestine without the use of antivirals.

We report a case series of seven mechanically ventilated patients with acute respiratory distress syndrome (ARDS) caused by coronavirus disease (COVID‐19) who received early treatment with high‐dose, short‐term systemic corticosteroids to prevent cytokine overproduction. Of the seven patients, four were male and median age was 69 years. They were intubated within seven days after admission when their respiratory status rapidly worsened. At that time, we administered 1000 or 500 mg/day for three days of methylprednisolone intravenously, followed by 1 mg/kg and tapered off. The median duration for the total administration of corticosteroids was 13 days. This high‐dose, short‐term corticosteroid therapy enabled extubation of the patients within seven days. Many questions on the clinical management of COVID‐19 remain unanswered, and data on corticosteroid therapy as a choice of treatment are mixed. We present the clinical course of our cases, review the previous evidence, and discuss management., Many questions on the clinical management of coronavirus disease (COVID‐19) remain unanswered, and data on corticosteroid therapy as a choice of treatment are mixed. We present the clinical course of seven patients, review the previous evidence, and discuss management.

Yellow nail syndrome (YNS) is a rare clinical syndrome characterized by a triad of yellow thick nail, lymphedema and respiratory diseases. We experienced 2 cases of YNS with diffuse panbronchiolitis (DPB)-like pulmonary manifestation. Since YNS might be hidden to those who have been diagnosed with DPB, physicians should be alert to recognize nail signs of YNS in case of DPB refractory to macrolide therapy. We hereby review previous case reports of YNS and discuss its pulmonary manifestations.

Introduction: The prevalence of asthma in the elderly has been increasing due to the aging of the global population. Appropriate treatment for asthma in the elderly is now a major issue, as the disease is often fatal and incurs high medical costs in the elderly population. There have been few recent reports on asthma treatment for the elderly in the real-world clinical settings. Objectives: This study was performed to assess how respiratory physicians manage asthma in elderly patients in clinical settings in Japan. Methods: Respiratory physicians in 16 Japanese hospitals responded to a questionnaire survey on asthma and COPD treatment between December 2014 and February 2015. The analysis was performed using data collected from medical records on 2041 asthma patients. Results: The mean patient age was 61.2 years, and 36.6% of the patients were men. In the breakdown by age, 1018 (49.9%) of the patients were elderly (≥ 65 years). Compared to the non-elderly, the elderly patients had a significantly lower BMI, greater smoking history in pack-years, and poorer pulmonary function. There were no significant differences between the elderly and non-elderly in the prescription rates of common medications such as inhaled corticosteroids, long-acting beta-agonists (LABA) administered via inhaler or transdermal patch, long-acting muscarinic antagonists, or leukotriene receptor antagonists. In contrast, mucoactive drugs (18.7% vs. 12.3%, P P P = 0.02). Conclusions: According to this survey, the prescription rates of mucoactive drugs, macrolides, and transdermal LABA were significantly higher in the elderly than in the non-elderly.

Small cell lung cancer (SCLC) is a neuroendocrine tumor, and the median age of onset is about 70 years old. A 20-year-old non-smoking man with known systemic sclerosis presented with discomfort in his left chest. Chest X-ray showed a mass shadow in the left upper zone. A transbronchial lung biopsy revealed small cell carcinoma, and imaging studies reached the diagnosis of extensive disease small cell lung cancer. He had concurrent interstitial lung disease with a non-specific interstitial pneumonia pattern and anti-Scl-70 antibodies. He died eight months after the diagnosis during fifth-line chemotherapy. We herein report the youngest case to date of SCLC with systemic sclerosis.

Background and Aims: Prompt diagnosis and staging of lung cancer are important to rapidly determine treatment options. The feasibility of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and bronchoscopic sampling of peripheral lesions in a single procedure was evaluated. Methods: This was a retrospective observational study on patients who underwent bronchoscopy at our hospital from January 2015 to December 2018 for suspected cancer. We compared the diagnostic yields among bronchoscopy procedures for both peripheral and coexistent mediastinal lesions in a single procedure (group 1), for peripheral lesions alone (group 2), and for mediastinal lesions alone (group 3). Results: During the study period, a total of 1,131 patients underwent bronchoscopy; 366 were for peripheral lesions alone (group 2) and 195 were by EBUS-TBNA (49 in group 1 and 85 in group 3). The diagnostic yield for mediastinal lesions was not significantly different between groups 1 and 3 (95.9% vs. 92.9%, respectively, p = 0.71), but the diagnostic yield for peripheral lesions was significantly higher in group 1 than in group 2 (77.6% vs. 62.6%, p Conclusion: Bronchoscopic sampling of both peripheral and mediastinal lesions in a single procedure was feasible and may increase the diagnostic yield.

Objective Adult patients with pertussis rarely show typical symptoms, such as paroxysmal coughing, inspiratory "whoop", or post-tussive vomiting. While a culture is regarded as the gold standard for diagnosis, the sensitivity is very low. Therefore, the diagnosis of pertussis in adults in clinical practice is mostly based on single-sample serology using an enzyme-linked immunosorbent assay (ELISA) with the pertussis toxin antigen. Various cut-off values for the anti-pertussis toxin IgG (PT-IgG) have been proposed. It has been reported that concentrations of PT-IgG fall below the defined cut-off about 4.5 months after infection on average, and within 1 year in most patients. We investigated the distribution and time course of the PT-IgG levels. Methods The data were collected from the medical records. Patients The study retrospectively identified subjects who had visited Ikebukuro Otani Clinic, which is a specialized clinic for patients with cough. We retrospectively reviewed 406 patients with PT-IgG measurements to investigate the age distribution of PT-IgG levels. The changes in PT-IgG levels over time were assessed in the 205 patients who had more than one PT-IgG measurement. Results PT-IgG levels were ≥100 EU/mL in more than 15% of subjects. The PT-IgG levels of a few subjects had diminished over a long period of time. Conclusion A PT-IgG level greater than the defined cut-off value simply indicates past infection or immunization in most subjects. As such, a single measurement of PT-IgG using the cut-off values might lead to overdiagnosis of pertussis. Further data collection and analysis are required.

Background. Although digital clubbing is a common presentation in patients with interstitial lung disease (ILD), little has been reported regarding its role in assessing patients with ILD. This study evaluated patients with ILD for the presence of clubbing and investigated its association with clinical data. Methods. We evaluated patients with ILD who visited the teaching hospital at which the study was conducted, between October 2014 and January 2015. Clubbing, evaluated using a Vernier caliper for individual patients, was defined as a phalangeal depth ratio > 1. We examined the association of clubbing with clinical data. Results. Of 102 patients with ILD, we identified 17 (16.7%) with clubbing. The partial pressure of oxygen in arterial blood was lower (65.2 ± 5.9 mmHg versus 80.2 ± 3.1 mmHg; p=0.03), serum Krebs von den Lugen-6 (KL-6) levels were higher (1495.0 ± 277.4 U/mL versus 839.1 ± 70.2 U/mL; p=0.001), and the percent predicted diffusing capacity of carbon monoxide was lower (50.0 ± 6.0 versus 73.5 ± 3.1; p=0.002) in these patients with clubbing. Conclusions. Patients with clubbing had lower oxygen levels, higher serum KL-6 levels, and lower pulmonary function than those without clubbing.

Background Previous reports have documented the efficacy of an early switch from intravenous to oral antimicrobials in community-acquired pneumonia, but not aspiration pneumonia. Therefore, we assessed the feasibility and efficacy of these newly developed criteria for community-acquired pneumonia in patients with aspiration pneumonia. Methods This prospective observational study included consecutive patients admitted with aspiration pneumonia over a 10-month period at St. Luke's International Hospital; we excluded patients that required intensive care. The criteria for an early switch were stability of vital signs (temperature≤38°C; respiratory rate≤24breaths/min; pulse rate≤100beats/min for >24h) and a successful swallow evaluation (repetitive saliva swallowing test score≥2; modified water swallowing test score≥4). Our primary endpoint was successful completion of antimicrobial treatment 30 days after the switch, without reversion to intravenous antimicrobials. Our anticipated success rate was set as 60–75%, based on a previous study. Results Of the 70 patients admitted with aspiration pneumonia, 32 (45.7%) were excluded, and 38 (54.3%) met the inclusion criteria. Of these 38 patients, 29 (76.3%) met the switch criteria. The median duration of hospital stay for the included patients was 16 (5–30) days and 30 (12–68) days, respectively ( P =0.03). Among patients who met the switch criteria, 26 (89.7%) completed oral treatment successfully while 3 (10.3%) reverted to intravenous antimicrobials. Conclusions Approximately 75% of patients met the switch criteria; of these, nearly 90% underwent safe conversion to oral therapy. These results demonstrate the efficacy and feasibility of our switch criteria.