I have investigated the following activities in national hospitals and sanatoriums as indicators of international cooperation: overseas dispatch of experts, participation in research programs, participation in related societies, participation in group-training activities, acceptance of overseas trainees, and dissemination of information. The former Ministry of Health and Welfare established the international medical cooperation network in 1999. It is clear that many national hospitals and sanatoriums outside this network have achieved satisfactory results of international cooperation. Those institutes are expected to join the international medical cooperation network and cooperate in a wide range of international medical cooperation activities including the travel clinic.

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Fifty bloody stool samples from pediatric patients were tested with the rapid Path-Stik O157, Novapath E. coli O157, and Novapath EHEC methods, and the results were compared with those of the conventional verotoxin detection test, a culture-based method.
One of the 9 specimens that tested positive using the Path-Stik O157 was found to contain E. coli O157, while the other 8 positive specimens contained Salmonella (7 cases) and normal flora (1 case). The other 41 specimens were negative. One specimen tested positive with Novapath E. coli O157 and after culturing it was shown to be an E. coli O157 case. The other 49 specimens were negative. Two specimens tested positive with the Novapath EHEC test, which detects verotoxin, and the culture method identified both E. coli O157 and E. coli O165. The other 48 specimens were negative. In addition, E. coli O157 (Verotoxin 1 and Verotoxin 2 producing strain) and E. coli O165 (Verotoxin 1 producing strain) were verified by the polymerase chain reaction method and microchip electophoresis analysis system which agreed with the results of both the culture method and the rapid diagnosis techniques.

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To examine the causes of long hospitalization we researched the schizophrenic patients who had been in the National Center Hospital for Mental, Nervous and Muscular Disorders on June 30 th 1992. We checked 71 patients, whose hospitalization had lasted for a maximum of 2 years, to see whether they continued their hospitalization or became outpatients. And we also examined the past history, psychiatric symptoms and the general rating scale, and compared the changes of the mental symptoms of patients who continued their hospitalization over a 5 year period (1992-1997). We used the Manchester Scale (MS) and the Ward Behavior Rating Scale (WBRS) as symptom rating scales and converted the drug dose into Haloperidol to examine. At the time of research, the group of patients who were discharged had a higher score than the group of patients who remained hospitalized in the MS and the WBRS scores which related to negative symptoms. But there were no significant differences in the scores of positive symptoms between the two groups. And in the group of patients who remained hospitalized the negative symptoms had became worse and the positive symptoms had still been serious. These results suggested that the highly scored positive symptoms and the related abnormal behavior were the part of the main reasons for un-discharged.

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‘Diagnosis Related Group/Prospective Payment System’ (DRG/PPS in Japan) has started on 1 November 1997 at 8 national and 2 social insurance hospitals. At that time, the system consisted of only 183 DRG and PPS was applied to all of them. (30% or less of in-patients were eligible for DRG/PPS) Then, based on 2 years of data, DRG were revised in April 2001 into 532 of which 267groups were linked to PPS, and the ICD-10 codes replaced ICD-9 codes.
In this symposium, Professor S. Matsuda, University of Occupational and Environmental Health, explained how DRG were used in France and other European countries, and presented the project on development of new DRG system suitable to health insurance scheme in Japan. I. Suzuki, MD, and K. Yoshida, MD, the vice directors of two national hospitals, showed from view point of hospital management that the effect of current DRG was difficult to assess because some DRG were inadequately classified and PPS were not always cost-related. However, they indicated that a small decrease in average period of hospitalization has led to improvement in balance of working revenues and expenses. K. Yoshida, MD, also added that adoption of clinical paths to DRG would be more useful. Mr. M, Anan, health information administrator, who has analyzed the clinical data provided by doctors, emphasized the importance of accurate application of the ICD-10 codesto each diagnosis with collaboration between doctors and information administrators.
DRG/PPS is now a vital factor that has begun to change health insurance scheme in Japan; therefore, we, as workers at national medical institutions should have stronger interest in the system for further understanding and actively participate in the project.

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A rapid progress of the treatment for patients infected with HIV-1 was made since highly active antiretroviral therapy (HAART), the combination therapy of reverse transcriptase (RT) and protease (P) inhibitors, has been established. The development of anti-HIV-1 compounds supports this progress, in addition, well understanding of the clinical status of HIV-1 infected patients became possible by measuring CD4 cell count and plasma viral load. Recently, a drug-resistance test has been developed to evaluate the “quality” of a virus in addition to the measuring of HIV-1 “quantity”, and has become clinically utilized. Therefore, if the amino acid mutations associated with a drug-resistance could be detected by determining the sequence of pol-region HIV-1 cDNA, we can choose more effective drugs based on the genetic information of HIV-1 isolate even in such case. As drug resistant HIV-1 can emerge with high frequency, especially in the case when the concentration of anti HIV-1 drug in blood is lower than effective, it became important not only to complete the drug-adherence, but to monitor the plasma drug concentration. The final aim of the therapy for patients infected with HIV-1 is to eradicate the HIV-1 from their bodies. We also reported the simple and sensitive method for quantify HIV-1 provirus in infected cells, including latent reservoir, to ascertain the eradication of the virus.

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A survey of conditions and a workload analysis were conducted to understand the reasons for anesthesiologist shortages at National Centers for Advance and Specialized Medical Care, National Hospitals, and National Sanatoriums. The mean number of anesthesiologists employed in 82 anesthesiology departments in the national hospital group was 2.61±1.6. Sixty percent of current anesthesiology department heads have considered transferring from the national hospital group. The three most cited reasons, which account for 81% of the total, were salary, government service regulations, and treatment.
In a survey of university anesthesiology departments, which are the source of supply for anesthesiologists, 41% said that the national hospital group was unpopular, and 11% said these were the worst places to be sent. The reasons cited were the same as those mentioned in the survey of current heads of anesthesiology departments in the national hospital group.
A comparison of facilities with 500 beds or more revealed that anesthesiologist staffing in the national hospital group was approximately half that of other public hospitals (national hospital group: 3.3±1.8; other public hospitals: 7.2±3.2). Workload was significantly higher in the national hospital group, as the annual number of anesthetized cases per anesthesiologist was 516.2±199.6 in the national hospital group, compared with 351.4±118.3 in other public hospitals. Salary and government service regulations are difficult to change, but the first steps to improving these conditions should be increasing staffing levels and improving work conditions.

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A 55-year-old man was admitted to the hospital whose chief complaint was a fever and cough. During the two weeks before admission, his temperature rose intermittently. Two years prior, he had been admitted for the first time with tuberculosis and now a recurrence of the tuberculosis had occurred, so he was readmitted for further therapy. About twenty years ago, the patient was treated for Buerger disease. The patient knows he has had diabetes mellitus for several years, and there is a history of severe alcohol consumption. The present case was considered valuable for clarifying the epidemiologic study of tuberculosis.

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Rapidly progressive interstitial pneumonia (RPIP) in amyopathic dermatomyositis (ADM) usually does not respond to steroid therapy. Furthermore, neither cyclophosphamide pulse therapy nor cyclosporine are consistently effective. We report successful outcomes of intravenous γ-globulin infusion therapy in two patients with ADM including RPIP. The patients were Japanese men aged 33 and 62 years. Both showed similar symptoms prior to treatment including dry cough, dyspnea on exertion, fever, and polyarthralgia. Although both patients showed a typical Gottron's sign and atypical periorbital heliotrope discoloration, neither patient had proximal muscle weakness or an elevated serum creatine kinase concentration. Dyspnea, abnormal pulmonary densities in chest radiograph and computed tomograms, and arterial oxygen levels showed rapid deterioration in both patients 3 to 4 weeks after appearance of symptoms. We diagnosed both patients with RPIP associated with ADM and initiated high-dose intravenous immunoglobulin therapy (freeze-dried sulf onated human normal immunoglobulin, 25g/day, every 5 days). At the same time, pulse steroid therapy (methylprednisolone, 1000mg/day i. v. for 3 days) and cyclosporine (200mg/day i. v.) were given. With this combined treatment, clinical, radiologic, and blood gas abnormalities showed an immediate response.

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[in Japanese]

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