Yellow Nail Syndrome Patients with Diffuse Panbronchiolitis-like Pulmonary Manifestation.

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.

Nationwide surveillance of bacterial respiratory pathogens conducted by the surveillance committee of Japanese Society of Chemotherapy, the Japanese Association for Infectious Diseases, and the Japanese Society for Clinical Microbiology in 2012: General view of the pathogens' antibacterial susceptibility.

The nationwide surveillance on antimicrobial susceptibility of bacterial respiratory pathogens from the patients in Japan was conducted by Japanese Society of Chemotherapy, Japanese association for infectious diseases and Japanese society for Clinical Microbiology in 2012. The isolates were collected from clinical specimens obtained from well-diagnosed adult patients with respiratory tract infections during the period between January and December in 2012 by three societies. Antimicrobial susceptibility testing was conducted at the central reference laboratory according to the method recommended by Clinical Laboratory Standard Institutes. Susceptibility testing was evaluated in 1236 strains (232 Staphylococcus aureus, 225 Streptococcus pneumoniae, 16 Streptococcus pyogenes, 231 Haemophilus influenzae, 147 Moraxella catarrhalis, 167 Klebsiella pneumoniae and 218 Pseudomonas aeruginosa). Ratio of methicillin-resistant S. aureus was 51.3%, and those of penicillin-intermediate S. pneumoniae was 0.4%. Among H. influenzae, 5.6% of them were found to be ß-lactamase-producing ampicillin-resistant strains, and 37.2% to be ß-lactamase-non-producing ampicillin-resistant strains. Extended spectrum ß-lactamase-producing K. pneumoniae and multi-drug resistant P. aeruginosa with metallo ß-lactamase were 4.2% and 3.2%, respectively. Continuous national surveillance is important to determine the actual situation of the resistance shown by bacterial respiratory pathogens to antimicrobial agents.

[Preoperative Arterial Embolization with N-butyl-2 Cyanoacrylate for Chronic Cavitary Pulmonary Aspergillosis with Trauma Induced Type â Diabetes Mellitus].

A 50-year-old man with hemoptysis, given a diagnosis of left upper lobe pulmonary aspergilloma with cavity and fungus ball by computed tomography. He has a history of typeⅠ diabetes mellitus due to traumatic injury of pancreas and underwent diaphragm plasty. Despite of systemic anti-fungal medication, symptom and radiological findings were not progressed and surgical intervention was planned. Before surgery we performed intercostal artery embolization, in order to minimize bleeding on dissecting adhesion between the chest wall and the lobe with aspergilloma. Left upper lobectomy with muscle-flap prombage was done safely with a blood loss of 450 ml. Postoperative course was favorable. Intercostal artery embolization with N-butyl-2cyanoacrylate is an effective way to minimize hemorrhage during surgical resection for pulmonary aspergillosis with sever adhesion.

Nationwide surveillance of bacterial respiratory pathogens conducted by the Japanese Society of Chemotherapy in 2008: general view of the pathogens' antibacterial susceptibility.

For the purpose of nationwide surveillance of the antimicrobial susceptibility of bacterial respiratory pathogens collected from patients in Japan, the Japanese Society of Chemotherapy conducted a third year of nationwide surveillance during the period from January to April 2008. A total of 1,097 strains were collected from clinical specimens obtained from well-diagnosed adult patients with respiratory tract infections. Susceptibility testing was evaluable with 987 strains (189 Staphylococcus aureus, 211 Streptococcus pneumoniae, 6 Streptococcus pyogenes, 187 Haemophilus influenzae, 106 Moraxella catarrhalis, 126 Klebsiella pneumoniae, and 162 Pseudomonas aeruginosa). A total of 44 antibacterial agents, including 26 ß-lactams (four penicillins, three penicillins in combination with ß-lactamase inhibitors, four oral cephems, eight parenteral cephems, one monobactam, five carbapenems, and one penem), three aminoglycosides, four macrolides (including a ketolide), one lincosamide, one tetracycline, two glycopeptides, six fluoroquinolones, and one oxazolidinone were used for the study. Analysis was conducted at the central reference laboratory according to the method recommended by the Clinical and Laboratory Standard Institute (CLSI). The incidence of methicillin-resistant S. aureus (MRSA) was as high as 59.8%, and those of penicillin-intermediate and penicillin-resistant S. pneumoniae (PISP and PRSP) were 35.5 and 11.8%, respectively. Among H. influenzae, 13.9% of them were found to be ß-lactamase-non-producing ampicillin (ABPC)-intermediately resistant (BLNAI), 26.7% to be ß-lactamase-non-producing ABPC-resistant (BLNAR), and 5.3% to be ß-lactamase-producing ABPC-resistant (BLPAR) strains. A high frequency (76.5%) of ß-lactamase-producing strains was suspected in Moraxella catarrhalis isolates. Four (3.2%) extended-spectrum ß-lactamase-producing K. pneumoniae were found among 126 strains. Four isolates (2.5%) of P. aeruginosa were found to be metallo ß-lactamase-producing strains, including three (1.9%) suspected multidrug-resistant strains showing resistance to imipenem, amikacin, and ciprofloxacin. Continual national surveillance of the antimicrobial susceptibility of respiratory pathogens is crucial in order to monitor changing patterns of susceptibility and to be able to update treatment recommendations on a regular basis.

[Investigation of optimal drug in moderate bronchial asthma].

BACKGROUND: Many drugs and the combinations of drugs are recommended for each treatment step in bronchial asthma. However, there are few issues examined about the optimal drug and combination of drugs in a long term prognosis. In this study, we investigated the optimal drugs and combinations of drugs from a point of view of prognosis. METHODS: One hundred and ninety four patients who visited our hospital for treatment from November, 2003 to October, 2004 and were managed according to GINA guideline were surveyed retrospectively. We compared the rate of step up and the frequency of urgent visit and urgent hospitalization in one year between drug groups in each treatment step. RESULTS: The rate of step up was significantly higher in leukotriene receptor antagonist (LTRA) group than in inhalation corticosteroid (ICS) group and theophylline group in Step 2. The frequency of urgent visit and urgent hospitalization was significantly higher in ICS+LTRA group than in ICS+theophylline group and ICS+long-acting beta 2-agonist (LABA) group in Step 3. CONCLUSION: There is a possibility that the prognosis becomes bad when we use LTRA in the practical treatment according to GINA guideline.

Pharmacoeconomics of antiviral therapy for influenza in a Japanese hospital setting.

OBJECTIVES: We constructed a cost-effectiveness decision model to determine a hypothetical 'best treatment' pathway for patients presenting at our institution with influenza virus infection when the choice of treatment was either oseltamivir, zanamivir or a control therapy not active against influenza. METHODS: The decision model was constructed using DATA 3.5 for evaluating the cost-effectiveness analysis of neuraminidase inhibitors from the perspective of the healthcare payer. The time horizon was set at 14 days based on the general duration of influenza infection in Japan. Clinical outcomes were mainly derived from reports and guidance published by the National Institute for Clinical Excellence in the UK. Japan-specific cost parameters incorporated into the decision model were taken from the Medical Fee Point Survey conducted at St Luke's International Hospital in accordance with medical fee receipts kept at our institution. The study included four professionals and a supporter who gathered information required for the analysis. RESULTS: In otherwise healthy adults, cost savings of yen831.6 (approximately $US6.72; 2002 values) in the oseltamivir group and an increment in cost of yen40.5 (approximately $US0.33) in the zanamivir group were achieved in comparison with the control group. In contrast, an incremental cost of yen288.4 (approximately $US2.33) was incurred in the oseltamivir group versus the control group when at-risk patients were assessed, but cost savings of yen159.8 (approximately $US1.29) were achieved in the zanamivir group. As a result of cost-effectiveness and cost-utility analyses in otherwise healthy adults, oseltamivir dominated the control therapy because cost savings in the oseltamivir group were made. In the zanamivir group the cost was incremental and the Incremental Cost-Utility Ratio (ICUR) compared with the control group was about yen13 000 (approximately $US107.34)/quality-adjusted life-year (QALY) gained. As a result of cost-effectiveness and cost-utility analyses in at-risk patients, in the oseltamivir group the cost was incremental and the ICUR compared with the control group was about yen230 000 (approximately $US2138.77)/QALY gained. As cost savings were made, zanamivir dominated the control therapy. CONCLUSION: While the cost effectiveness (from the perspective of a healthcare payer) of the neuraminidase inhibitors was superior to that of the control group in the treatment of otherwise healthy adults with influenza in our study, it seemed necessary to take other factors into consideration before recommending one agent over the other as a first-line therapy. On the other hand, we suggest that zanamivir is the drug of choice for use in at-risk patients, and we recommend, in the light of our results, that if zanamivir is not available another therapy should be given rather than oseltamivir. Since with influenza infections deaths and hospitalisations of at-risk patients impact on the Japanese community, decision-making on the appropriate therapy should take into account the particular patient group involved.

[A case of mediastinal metastasis of renal small cell carcinoma, performing CHOP therapy for an acute respiratory failure by the air way obstruction under the mechanical ventilation].

A case of mediastinal metastasis of renal small cell carcinoma was reported. A 45-year-old female was admitted to our hospital complaining of worsening dyspnea. The chest radiograph and CT showed stenosis of the bronchi bilaterally due to the mediastinal mass. Prior to pathological diagnosis, CHOP therapy with cyclophosphamide, adriamycin, vincristine and prednisolone was performed under mechanical ventilation for the purpose of resuscitation. The therapy was effective; and the was weaned from the mechanical ventilator, resulting in complete remission. Transbronchial samples from the left main bronchus confirmed that the mediastinal mass was identical pathologically to the renal small cell carcinoma (RSCC) resected 5 years before. As a result, the mediastinal mass was diagnosed as a metastatic focus of RSCC. RSCC is known to have one of the most unfavorable prognoses among malignancies. Despite efforts with chemotherapy, almost all cases that appear in the literature died within 1 year after diagnosis. No standard treatment modality has yet been established. Thus, the present case is rare because an RSCC relapse after a long free period went into remission as a result of CHOP therapy. It is suggested that CHOP therapy may well be an effective tool against RSCC, and could be a valuable choice for a treatment regimen.

[Usefulness of clinical pathway for community-acquired pneumonia as both an educational and a cost-management tool--an intervention study to compare the usefulness of management with a critical pathway to historical control of conventional management].

To delineate the usefulness of a clinical pathway for community-acquired pneumonia (CAP) as an educational tool as well as a cost management tool, we conducted a prospective controlled trial including a historical control group. Consecutive CAP patients classified under Category 3 of the American Thoracic Society and admitted to our hospital were evaluated. Using the clinical pathway method, 42 patients were managed between April and December 2000 as the intervention group, and 33 patients received conventional management between April and December 1999 as a historical control. For the intervention group, the clinical pathway, which was a time-task matrix formatted with consideration for guidance for disease treatment, laboratory tests, physical examinations, oxygen saturation monitoring, ambulation, diet, education for the patient and clinical outcomes, was implemented. We determined (1) educational effect, measured using reduction of delay caused by physicians; (2) quality of clinical practice, measured using the success rate of the initial antimicrobial therapy and readmission rate; and (3) economic efficacy, measured using health care cost and length of hospital stay. The delay caused by physicians was reduced by 16% in the Intervention Group (5% vs. 21%; p = 0.045). The success rates of initial antimicrobial therapy in the two groups were similar (85.7% vs. 84.8%). In the intention-to-treat set, the median value of health care cost was reduced by yen 48,055 (yen 277,460 vs. yen 325,515; p = 0.017) and the median length of a hospital stay was shortened by 3 days (8 vs. 11 days; p = 0.0007) in the Intervention Group. In conclusion, the clinical pathway had an educational effect on physicians regarding the management of hospitalized patients with community-acquired pneumonia as well as on the cost management.