Myasthenia gravis (MG) is a prototype of antibody-mediated autoimmune disease in which the immune pathogenesis seems to be well elucidated. However, the role of thymic abnormality in the pathogenesis remains uncertain. Thymectomy is effective for treatment in MG, but the theoretical evidence has not been established. In patients with MG with non-thymoma, it should be particularly important to show the rationale of thymectomy for treatment.
Acetylcholine receptor on thymic myoid cells was believed to trigger the autoimmune response in MG. However, subsequent studies have failed to support this hypothesis. Instead, thymic epithelial cells became important in the pathogenesis. The thymus of MG patients contains all cellular components required for the initiation of a myasthenogenic autoimmune reaction (i, e., antigen, antigenpresenting cells, autoreactive T and B cells, are present in the MG thymus), which is, so far, a major theoretical reason to support the thymectomy. The thymic abnormality is directory involved in the pathogenesis of MG, and the more elucidation of the details of complex interaction between the each element in the thymus should also lead to the further understanding of other autoimmune dis-orders.

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We have performed experimental studies to compare rates and time of positive blood culture in two culture systems. Each system had different antibiotic absorbents; BACTEC 9000 system/96F, 97F bottle-resin absorbent (Becton Dickinson) and Bact/Alert 120 system/FAN bottle-active carbon absorbent (Organon Technica). Eighteen groups were consisted of 6 bacterial and 1 fungal species and 10 antibiotics. Detection rates and time to positive cultures showed significant differences according to culture system and bottle. Antibacterial absorbents could not reveal perfect activities for some antibiotics and then blood samples should be taken at the time of low blood levels.

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In collaborative research for Longevity Sciences from the Ministry Of Health and Welfare, entitled “Research on Guidelines for Long-term Care of Elderly Patients with Intractable Neurological Diseases” (Chief Researcher: Susumu Shinno), the care time was examined in 31 patients hospitalized with amyotrophic lateral sclerosis (ALS) in five National hospitals (Toneyama, Chiba-Higashi, Higashi-Nagoya, Chubu and Minami-Kyushu). The relationship between the care time and the required care level was investigated. 99% of cases hospitalized with ALS were at required care levels 4 and 5. Care time for all ALS cases was 197 minutes per day, which is much longer than the standard time for determination of the required care level. No difference in care time was detected between patients in the required care levels 4 and 5. Much more care time is needed for meals and medical care in care levels 4 cases than in level 5. Patients with assistance for oral ingestion had much more care time than nasal feeding patients. Medical care is very important in all care and it took much time to suck for twenty-four hours. It is desirable that suction is reflective in required care level judgement.

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Critical path has now become popular among national hospitals all around Japan. In the symposium, Dr. Mukohara MD overviewed the situation as follows: according to the results of questionnaires answered by national hospitals and sanatoriums in the legislature of Regional Medical Office of Kyushu, the numbers of critical path have doubled from 330 in 1999 to over 600 in 2000. The results also pointed out the standardizing of quality of care, which was the primary common demand of both physicians and nurses. Secondary, physicians emphasized on improvement of practice efficiency and nurses did on patient's satisfaction.
Also, there are certain backgrounds associated with payment system of medical fee. Dr. Yoshida MD referred to the relationships between critical path and DRG/PPS, under tested at the National Hospital of Kyushu Medical Center and he stressed on the inevitableness of the combination: DRG/PPS and critical path. Dr. Yoshida MD found effects of DRG/PPS as foll owings: utilizing ICD code, reduce of unnecessary laboratory exam and medical treatments, reduce of hospital length of stay, submit of accurate discharge summary, increase of the numbers of out-patients, facilitating home health care, improvement on hospital workers' cost consciousness and encouragement of teamwork, and preventing increases on medical expen diture. Contrary, DRG/PPS was not applicable to those on cases using special material such as hip joint replacements. Also note that the critical path was introduced into the April 2000 revisions of the National Insurance Payment System in term of detailed in-hospitalization plan. This was one of the factors that helped the outbreak of critical path in Japan.
The clinical effects of critical path have been indicated as well. Dr. Iida MD indicated on diabetic patient using critical path showed significantly lower HBAIC than the unused cases. Mr. Tsurumi also stated positive effects of critical path as follows: the effects of nutritional assessments systemized by dietician and that he found significant low fasting blood sugar level at the discharge point. The reason of this was explained by the improvement of patients' self understandings, Ms Yamazaki RN described that she found improvement on lung resection cases with critical path. She noted the changes of operation should effect: however, in comparison of each 50 cases before and after the implementation of critical path, she found improvement in the hospital length of stay, lung capacity volume, and six-minuets-walk distance before and after the operations. Critical path totally lead improvement of patients physical condition.
Dr. Nomura MD emphasizes the needs of setting outcome at the point of starting of critical path and outcome evaluations. Especially he stressed the importance of milestone outcomeset ting and discharge criteria. With this, more sufficient result could be expected. In the case of hip joint replacement, time needed to achieve the milestone outcome hove shortened in comparison of before and after the critical path implementation. He added that they had improvements on shortening of hospitalization terms, patients' satisfaction, job efficiencies, and material costs down. As further task, Dr. Nomura cosidered how much degree they can take EBM to critical pathway, evaluations of critical path that combines outpatient and inpat Tent, critical-path connected with health care institute of local district and long-term outcomeeffect of critical path applied cases.
From the side of pharmacists: Ms. Wada mentioned that stadardizations on medication had positive merits. For example, preventing incorrect medication of drugs was one of them. As the result of clinical procedure standardized, comparison of clinical and economical effectiveness, and side effects on different drugs could become easy to be evaluated. Mr. Wako, as coordinator on day surgery center, described critical path was an inevitable tool. According to the survey, offec

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A 54-year old female was admitted to our hospital because of cough, hemosputum, and general fatigue. Her right salivary gland was swollen and chest radiograph and computed tomography scan showed bilateral multiple nodules with cavitation. A diagnosis of Wegener's granulomatosis was made from increased of erythrocyte sedimentation rate, leukocytosis, serum cytoplasmic antineutrophil cytoplasmic antibodies (C-ANCA), and necrotizing granuloma with giant cells in lung nodule and nasal mucosa. The patient's clinical findings, lung nodules and right salivary gland enlargement were improved after treatment with cyclophosphamid, predonisolon and trimethoprim/sulfamethoxazole. A salivary gland enlargement due to involvemnt of Wegener's granuloma is a rare case according to the recent reports.

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Paralytic ileus is a major complication of Duchenne muscle dystrophy (DMD) which is occasionally observed in advanced stage patients. However, in a search of the literature we could not find any previous cases in which a laparotomy was performed for mechanical ileus with DMD. We recently experienced a patient with DMD who showed flequent ileus. A 31-year old man who had been bedridden since 25 years of age presented complaining of vomitting, abdominal fullness and pain. Conservative therapy proved to be ineffective and therefore a laparotomy was performed. During the operation, the right quadrant of the intraperitoneal cavity was found to be flattened while the left quadrant had completely caved in due to severe lordosis and scoliosis. In addition, a dilated jejunum was also found in the left quadrant. A tube gastrostomy and two jejunostomies were made and the postoperative course was good. Thereafter, the tubes were clamped, narrowed down, and removed 18 months after the operation. In the present case, the rate of weight loss was over 10% during the six month period before ileus developed. Therefore, a severe curvature of the spine due to DMD accompanied by a flattened intraperitoneal cavity caused by emaciation, which was similar to that caused by paralytic ileus of DMD, was thus considered to have caused the ileus observed in this patient.

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