[A DRG/PPS simulation in the medical care of tuberculosis].

PURPOSE: To study the expected usefulness of the introduction of the DRG-PPS (Diagnosis-Related Group/Prospective Payment System, in which an insurer pays a fixed medical fee per hospitalization) into the current medical care of tuberculosis (TB) in Japan. METHOD: The medical fees were reviewed for all TB inpatients at 19 hospitals under the National Hospital Organization who were discharged in either June 2007 or February 2008. The sum of the fixed fee by the DRG was assumed based on the bivariate regression analysis of each patient's hospital days and his or her total actual fees during the hospital stay under the current (fee for care) system, since it was difficult to directly calculate the daily fees for every patient that would be the basis of DRG-PPS. RESULTS: Linear regression analysis estimated that the medical fees (including fees for the medical examinations and the treatments) for a hospital stay of 60 days, which is the standard for TB treatment, was 1,192,470 yen (19,870 yen per person per day) in June 2007, and 1,167,600 yen (19,460 yen per person per day) in February 2008. DISCUSSION: If we assume an average medical fee of about Y1.1-1.2 million yen for the standard hospital care of TB, the economic balance of the hospitals is negative, with a deficit of 0.6-0.7 million yen, given the estimated expenses of 1.8 million yen (i.e., 30,000 yen per person per day x 60 days). CONCLUSION: If the DRG-PPS is to be implemented based on the current medical fee rating system, the hospital administrators could not accept its introduction to the TB medical care service as it is, because it may undermine the economic management of hospitals.

[Exhaled breath-generated aerosols of mycobacterium tuberculosis in patients with active pulmonary tuberculosis during normal breathing].

OBJECTIVE: It has been understood that cough-generated aerosols act as an important vector for the spread of pulmonary tuberculosis. Humans commonly exhale aerosols during the normal respiration process that contain small droplets of the airway lining fluid. We aimed to determine whether aerosols exhaled by active pulmonary tuberculosis (AP-TB) patients may contain droplets with Mycobacterium tuberculosis (M-TB) during normal breathing. METHODS: Preliminarily, the collection efficiency of M-TB that was suspended in normal saline or distilled water was examined after subjecting the suspension to centrifugation at 3,000 g for 20 minutes. Better collection efficiency was observed in case of M-TB suspended in distilled water than that suspended in normal saline after centrifugation. Therefore, we selected distilled water instead of normal saline to prepare the fluid that was bubbled with exhaled breath. AP-TB patients with smear positive pulmonary tuberculosis who were being treated with anti-TB drugs for less than 7 days or those before the initiation of therapy expired into a 50-ml tube containing 10 ml distilled water for 30 minutes. We also prepared an exhaled breath condensate by cooling exhaled air through the tubing apparatus. RESULTS: In case of 20 AP-TB patients, the distilled water bubbled with the exhaled breath were negative for M-TB on smear, culture, and PCR (polymerase chain reaction) detection methods. The exhaled breath condensates were also negative in 24 AP-TB patients. CONCLUSION: These results suggest that exhaled breath-generated aerosols from AP-TB patients during normal breathing do not act as a vector for the spread of pulmonary tuberculosis.

[Achievement of sputum culture negative conversion by minocycline in a case with extensively drug-resistant pulmonary tuberculosis].

A 33-year male was readmitted to our hospital for the treatment of multi-drug resistant pulmonary tuberculosis in February 1993. Six years after the treatment, the left pleuropneumonectomy was done because of the enlargement of cavitary lesions with formation of fluid. Four years after the operation, M. tuberculosis from the patient was resistant to all first- and second-line anti-tuberculosis drugs. Apical lesion and cavitary lesion on the upper lung were still seen on chest X ray and sputum smear and culture were continuously positive. Minocycline and gatifloxacin were prescribed after five years of the operation. Sixteen months after changing the regimen sputum smear and culture converted negative. Chemotherapy was terminated in August 2007, two years after the negative conversion. One year after the termination of treatment no relapse occurred. We considered minocycline was effective in this case, because gatifloxacin was resistant by the drug susceptibility test and was previously used.

Long-term follow-up of a pouching operation after pancreaticoduodenectomy using a double-jejunal pouch.

A 63-year old male was referred with intraductal papillary adenocarcinoma of the pancreas. The patient had been treated previously with a distal gastrectomy for duodenal ulceration. This surgery left the patient with esophagitis, residual gastritis, and decreased appetite. A modification of the Imanaga reconstructive method using a double-jejunal pouch was performed for the pancreatic carcinoma. This method allows a better quality of life by not only preventing reflux esophagitis and residual gastritis but also increasing a food volume. Here we illustrate the usefulness of a pancreaticoduodenectomy using the pouching operation.

Systemic lupus erythematosus associated with massive ascites and pleural effusion in a patient who presented with disseminated intravascular coagulation.

A case of systemic lupus erythematosus (SLE) associated with serositis presenting with disseminated intravascular coagulation (DIC) is reported. A 53-year-old woman was admitted because of a fever. Laboratory tests revealed increased plasma levels of fibrinogen degradation products (FDP) and FDP-D-dimer, high titers of anti-nuclear antibody, high serum levels of anti-DNA antibody, immune complexes, decreased serum complements, and persistent proteinuria. A CT scan showed massive ascites and pleural effusion, marked edema and swelling of the mesenterium. The patient's condition and immunological abnormalities improved after steroid therapy. The association of DIC and lupus serositis has never been described in the literature.

Therapeutic effects of various initial combinations of chemotherapy including clarithromycin against Mycobacterium avium complex pulmonary disease.

BACKGROUND: The objective of this study was to find an optimal initial combination chemotherapy that includes clarithromycin (CAM) for treatment-naive patients with Mycobacterium avium complex (MAC) pulmonary disease, as assessed by microbiological conversion using a Mycobacterium growth indicator tube (MGIT). METHODS: Thirty-four patients with treatment-naive MAC pulmonary disease (determined using 1997 American Thoracic Society criteria) were evaluated retrospectively. They demonstrated a nodular and bronchiectatic pattern without cavity on high-resolution CT (HRCT) scans. The following three regimens were administered: regimen A (n = 9) consisted of CAM (400 mg/d), ethambutol (EB) [750 mg/d], and rifampicin (RFP) [450 mg/d]; regimen B (n = 12) consisted of CAM (800 mg/d), EB (750 mg/d), and RFP (450 mg/d); and regimen C (n = 13) consisted of CAM (800 mg/d), EB (1,000 mg/d), and RFP (600 mg/d) during the first 2 months followed by a reduction of the dosage of EB from 1,000 to 750 mg/d. Gender, age, BMI, and HRCT scan finding scores were not significantly different among the three groups. Chemotherapy was continued for 18 months. Sputum culture was periodically assessed by MGIT. RESULTS: Culture conversion at 18 months in regimen A (55.6%), which included a daily dosage of 400 mg of CAM (9.5 mg/kg), was significantly inferior to that in regimen B (91.7%), which included daily 800 mg of CAM (17.6 mg/kg; p < 0.05), but regimen B and C (92.3%) showed no between-group difference after > 18 months of chemotherapy. CONCLUSIONS: The higher dose of CAM allowed for better culture conversion. Daily combination chemotherapy that includes CAM (800 mg) seems appropriate as an initial treatment against treatment-naive patients with nodular and bronchiectatic MAC pulmonary disease.