ObjectivesSome patients with nodular/bronchiectatic Mycobacterium avium complex lung disease (NB MAC-LD) deteriorate and die. The main aim of the study is to evaluate the prognostic factors and radiographic outcomes in patients with NB MAC-LD.SettingRetrospective single-centre review.Participants782 HIV-negative patients with NB MAC-LD treated at our institution in Japan.Primary and secondary outcome measuresAll-cause and MAC-LD progression mortality rates and the prognostic factors, and radiographic deterioration rates and the prognostic factors.ResultsMean age was 68.1 years, and median follow-up period was 4.3 years. Death from any cause and progression of MAC lung disease (MAC-LD) occurred in 130 (16.6%), and 19 (2.4%) patients, respectively. All-cause and MAC-LD progression 10-year mortality rates were 27.4% and 4.8%, respectively. In 536 patients with MAC-LD who were followed-up for more than 1 year, radiographic deterioration occurred in 221 (41.2%) patients and median time-to-radiographic deterioration was 9 years. A multivariate Cox proportional hazard model showed male sex, older age, body mass index <18.5 kg/m2, absence of bloody sputum, hypoalbuminaemia and erythrocyte sedimentation rate >40 mm/h to be negative prognostic factors for all-cause mortality, and the presence of idiopathic pulmonary fibrosis, haemoglobin <11.3 mg/dL, C reactive protein >1.0 mg/dL and the presence of cavity to be negative prognostic factors for radiographic deterioration.ConclusionsOnly 2.4% of patients with NB MAC-LD died from MAC-LD progression. As clinical trials testing the effectiveness of drug therapy in patients with NB MAC-LD are being designed and implemented, the primary end point could be time-to-radiographic deterioration, and trial patients need to be stratified according to these prognostic factors before randomisation.

A 73-year-old man developed diplopia after the administration of pembrolizumab for lung adenocarcinoma. He had ptosis and external ophthalmoplegia without general muscle weakness. Serum CK levels were elevated. Although autoantibodies to acetylcholine receptor and muscle-specific kinase, the edrophonium test, and the repetitive nerve stimulation test were all negative, anti-titin autoantibody was positive, leading to the diagnosis of myasthenia gravis (MG). Muscle pathology showed necrotizing myopathy with tubular aggregates. Unlike previously reported cases of pembrolizumab-associated MG, the present case showed ocular MG. This is the first case of pembrolizumab-associated MG with anti-titin antibody, as well as the first case with tubular aggregates.

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: Factors contributing to mortality in healthcare-associated pneumonia HCAP have not been investigated fully. We reviewed the etiology and identi ed prognostic factors of HCAP in hospitalized patients. We conducted a retrospective study of 500 Japanese patients with HCAP to assess these factors, with special emphasis on microbial etiology. Patients with HCAP were older 73.4 11.4 years , more predominantly male 74.4 , and had more smoking history and comorbidity than did community-acquired pneumonia CAP patients. Microbes were identi ed in 52.8 of HCAP patients. The most frequent causative microbial agents were Streptococcus pneumoniae n 108, 21.6 , influenza virus n 47, 9.4 , and Pseudomonas aeruginosa n 40, 8.0 . Multiple drug-resistant MDR pathogens were more frequent in HCAP patients 9.8 than CAP patients. Overall, 47 HCAP patients 9.4 died, with mortality being higher in HCAP than CAP patients. The three leading causes of non-survival from HCAP were S. pneumoniae, in uenza virus, and P. aeruginosa. MDR pathogens accounted for 21.3 of non-survivors. Multivariate analysis revealed disease severity on admission and treatment failure of initial antibiotics as independent factors for 30-day mortality. Among patients with treatment failure of initial antibiotics, 29.9 had received appropriate antibiotics. The most frequent pathogens in HCAP were S. pneumoniae, in uenza virus, and P. aeruginosa, in both survivors and nonsurvivors. Disease severity on admission and treatment failure of initial antibiotics were independent factors for mortality. MDR pathogens are important therapeutic targets to mitigate negative results, and treatment strategies other than antibiotic selection are also required.