Evaluation of community-acquired pneumonia guidelines of Japanese Respiratory Society: differentiation of atypical pneumonia and bacterial pneumonia]

To evaluate the usefulness of differentiation of atypical pneumonia and bacterial pneumonia in the community-acquired pneumonia guidelines of the Japanese Respiratory Society, we investigated 124 cases of three atypical pneumonias (Mycoplasma pneumonia, 62 cases; Chlamydia pneumoniae pneumonia, 46 cases; Chlamydia psittaci pneumonia, 13 cases) and 403 cases of bacterial pneumonia at our hospital over seven years. Overall, the sensitivity and specificity of the criteria in the guideline were 70.4% and 91.8%, respectively. High accordance was recognized in patients under 60 years old with atypical pneumonia. Items in the criteria that included subjective factors were considered inassessable. We found that the differentiation of pneumonias in the guideline is useful for the diagnosis of atypical pneumonia among younger patients, but it should be concise and objective. We therefore propose that the criteria would be more effective if they consisted of only 4 items: age under 60 years, no underlying disorders, presence of stubborn dry cough, and normal peripheral white blood cell count.     

Cost-effectiveness analysis of ambulatory treatment for adult patients with community-acquired pneumonia: according to Japanese Respiratory Society guidelines]

The Japanese Respiratory Society has recently formulated practice guidelines for the management of adult patients with community-acquired pneumonia. The guidelines recommend the use of various oral antibiotics at individual physicians' discretion. We compared the cost-effectiveness of amoxicillin/clavulanate (AMPC/CVA), azithromycin (AZM), clarithromycin (CAM), cefdinir (CFDN), levofloxacin (LVFX), and minocycline (MINO), when used on an ambulatory basis. We performed a formal cost-effectiveness analysis from the perspective of direct cost payers in the framework of the Japanese medical system. Outcomes considered were quality-adjusted life days (QALD), costs per patient, and incremental costs per quality-adjusted life year (QALY) gained. Under baseline conditions, the effectiveness of MINO, AZM, CAM, and LVFX were on a par and higher than that of AMPC/CVA or CFDN by 125-290.5 QALD. The least expensive antibiotic was MINO (55,070 to 59,208 yen), followed by AZM (56,049 to 60,188 yen), CAM (56,171 to 60,309 yen), LVFX (61,988 to 66,127 yen). AMPC/CVA (122,432 to 133,797 yen), and CFDN (123,375 to 134,649 yen). Thus, MINO, AZM, and CAM were cost-effective antibiotics for adults with community-acquired pneumonia. Sensitivity analyses revealed that the initial success rate of each antibiotic was crucial in determining cost-effectiveness. When the number of times antibiotics are taken in a day and the period of therapy were taken into account, AZM was most beneficial with 917,179-1,152,694 yen (US$ 7,643-9,606) per additional QALY over MINO in patients without comorbidity. This result, however, was not applicable to patients with chronic lung disease. MINO was the least expensive and the most cost-effective in empirically treating adult patients with community-acquired pneumonia on an ambulatory basis. AZM provides a higher quality of life for adults without comorbidity with generally acceptable marginal cost.     

Evaluation of the Japanese Respiratory Society guidelines for the identification of Mycoplasma pneumoniae pneumonia

Background and objective: Community‐acquired pneumonia (CAP) is a leading cause of morbidity and mortality worldwide. Mycoplasma pneumoniae is one of the major causative pathogens of CAP. Early diagnosis of M. pneumoniae pneumonia is crucial for initiating appropriate antibiotic therapy. The aim of this study was to determine whether the Japanese Respiratory Society (JRS) guidelines on CAP are effective for diagnosing M. pneumoniae pneumonia. Methods: Between August 2008 and July 2009, adult outpatients with CAP were consecutively enrolled. The aetiology of CAP was determined by culture and real‐time polymerase chain reaction (PCR) methods to detect M. pneumoniae, urine antigen tests to detect Streptococcus pneumoniae and Legionella pneumoniae, blood and sputum culture for bacteria and real‐time PCR for eight common respiratory viruses. The predictive value of the JRS guidelines for differentiating M. pneumoniae pneumonia from typical bacterial and viral pneumonias was determined. Results: Data from 215 adult CAP outpatients was analyzed. An aetiological diagnosis was made for 105 patients (48.8%), including 62 patients with M. pneumoniae pneumonia, 17 patients with typical bacterial pneumonia and 23 patients with viral pneumonia. According to the JRS criteria for differential diagnosis of atypical pneumonia, 55 of 62 patients were correctly diagnosed with M. pneumoniae pneumonia (sensitivity 88.7%), and 31 of 40 patients with bacterial and viral pneumonia were correctly excluded (specificity 77.5%). Conclusions: The JRS guidelines on CAP provide a useful tool for the identification of M. pneumoniae pneumonia cases and differentiating these from cases of typical bacterial or viral pneumonia.     

Revision of the severity rating and classification of hospital-acquired pneumonia in the Japanese Respiratory Society guidelines

Background and objective: Based on the results of a multicentre collaborative survey of hospital‐acquired pneumonia (HAP) conducted in Japan, the severity rating and classification of pneumonia in the Japanese Respiratory Society guidelines for management of HAP were examined. Methods: Parameters for the severity classification were selected from the factors associated with prognosis in the HAP survey and in other previous reports. Depending on the presence of the parameters listed below, patients with HAP were stratified into those with high, moderate or low‐risk. The high‐risk group was defined as patients with three or more of the following risk factors: ‘malignant tumour or immunocompromised status’, ‘impaired consciousness’, ‘requiring fraction of inspired oxygen (FiO₂) >35% to maintain SaO₂ >90%’, ‘man aged 70 years or older, or woman aged 75 years or older’ and ‘oliguria or dehydration.’ The moderate‐risk group was defined as patients with any of the secondary risk factors as follows: ‘CRP ≥ 200 mg/L’ and ‘extent of infiltration on CXR covers at least 2/3 of one lung’. The low‐risk group was defined as all other patients. Results: Application of this classification scheme to the patients enrolled in the HAP survey revealed a mortality rate of 40.8% (98/240) in the high‐risk group, which was significantly higher than the mortality rates in the moderate and low‐risk groups: 24.9% (69/277) and 12.1% (101/834), respectively. Conclusion: These results indicate that it is possible to classify patients using these parameters as prognostic indicators.     

The Japanese Respiratory Society guidelines for management of community-acquired pneumonia in adults: a review from the factor of elderly

There is little consideration about the elderly factor in JRS and other countries' guidelines for management of community-acquired pneumonia (CAP) in adults. However, there seem to be several important differences in clinical manifestation, managing methods and outcome of pneumonia between young and elderly persons. I hope that the detection, management, and strategies to protect against pneumonia in the elderly will be included in the next guidelines.     

Usefulness of the Japanese Respiratory Society guidelines for community pneumonia: a retrospective analysis of community-acquired pneumonia between 2000 and 2002 in a general hospital

OBJECTIVE: The aim of this study was to investigate the causative organisms of community-acquired pneumonia (CAP) diagnosed between 2000 and 2002 and to evaluate the Japanese Respiratory Society (JRS) guidelines. METHODOLOGY: A total of 124 cases of CAP diagnosed during the study period were analyzed, and the results were compared with those of a previous study by the authors' research group. Determination of the causative organisms of CAP was based on Gram stain, morphology of colonies, quantitative culture of sputum, identification of bacterial isolates, and serological tests. RESULTS: During the study period, the causative organisms were identified in 42 cases (33.8%). Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis were the major causative organisms. Patients were classified into three groups based on the severity of CAP according to the JRS guidelines. The survival rates of patients with moderate and severe CAP were significantly lower than those of the mild group as evaluated by the Kaplan-Meier method (moderate vs mild, 70% vs 100%; severe vs mild, 40% vs 100%; P < 0.001 for both). Seven patients died during the study, and the risk factors were old age, bedridden status with cerebral infarction, and microaspiration, which was associated with recurrent pneumonia within 17 days. CONCLUSION: This study indicates that the JRS guidelines for CAP are useful for treating patients with CAP in Japan.     

Results of a survey questionnaire concerning smoking conditions in 54 major Japanese pharmaceutical companies and among their employees]

BACKGROUND: Despite progress in the prohibition of smoking in many hospitals, some medical representatives (MRs) still visit hospitals smelling of tobacco smoke. As few broad studies of the actual smoking conditions in pharmaceutical companies and among their employees have been conducted, this issue warrants investigation. METHODS: A total of 54 area offices. 155 branch offices, and 4610 employees of 54 major Japanese pharmaceutical companies that conduct business in the Tohno area of Gifu Prefecture were investigated using a questionnaire survey regarding smoking conditions. RESULTS: The results of the survey questionnaire distributed to pharmaceutical companies (response rate, 100.0%) indicated that 12.4% and 43.5% of offices have already prohibited smoking in the entire building or in offices, respectively. In addition, 31.6% of the offices have established separate smoking areas. The results of the individual employee questionnaire (response rate, 98.2%) indicated that 1805 employees (39.9%) smoke (including 1759 male smokers, 44.8%). The smoking rate among MRs (41.0%) was significantly higher than among non-MRs (31.1%) (p< 0.0001), while the smoking rate among managers (42.8%) was also higher than among non-managers (39.1%) (p = 0.0041). Tobacco is most frequently consumed by MRs in their business cars (57.8%) and while driving (42.1%). CONCLUSION: 87.5% of the companies have already established efficacious non-smoking conditions. However, the smoking rate among employees of major Japanese pharmaceutical companies, including MRs, remains high, suggesting that appropriate actions should be taken in order to promote smoking cessation of all smokers.     

Japanese Society of Dialysis Therapy treatment guidelines for secondary hyperparathyroidism

Impairment of renal function causes various abnormalities of bone mineral metabolism including secondary hyperparathyroidism. The Japanese Society of Dialysis Therapy proposed the guidelines for the treatment of secondary hyperparathyroidism in chronic dialysis patients (JSDT guidelines) in 2006. From the perspective of better survival rate, the control goal value was determined to be 3.5-6 mg/dl for phosphorus, 8.4-10.0 mg/dl for calcium, and 60-180 pg/ml for intact PTH levels. When the 3 items cannot be controlled by treatment with an active vitamin D preparation, treatment is considered to be a failure, and intervention treatment of the parathyroid gland is recommended. The adequacy of the JSDT guideline must be evaluated by its clinical application.     

Impact of coronavirus disease 2019 on respiratory care in Japan: A nationwide survey by the Japanese Respiratory Society

BackgroundCoronavirus disease 2019 (COVID-19) has spread worldwide since 2020, placing a huge burden on medical facilities. In the field of respiratory medicine, there has been a decrease in the number of patients. While many pulmonologists have been receiving patients with COVID-19, the actual effects on respiratory care have not been elucidated. Therefore, we conducted this study to clarify the effects of COVID-19 on medical care in the field of respiratory medicine.MethodsWe conducted a questionnaire survey among 749 hospitals belonging to the Board-Certified Member system of the Japanese Respiratory Society on the effects of COVID-19 from November 2021.ResultsResponses were obtained from 170 hospitals (23%), in approximately 70% of which the respiratory medicine department was the main department involved in managing COVID-19. The number of spirometry and bronchoscopy tests decreased by 25% and 15%, respectively, and the number of both outpatients and inpatients decreased in 93% of hospitals. Among respiratory diseases, the number of patients hospitalized for usual pneumonia, bronchial asthma, and chronic obstructive pulmonary disease decreased greatly by 30%–45%. In 62% of hospitals, the biggest effect of the COVID-19 pandemic was the greater burden in terms of the clinical workload due to COVID-19.ConclusionsAlthough the number of tests and non-COVID-19 outpatients and inpatients decreased in respiratory medicine departments during the COVID-19 pandemic, the workload increased due to COVID-19, resulting in a great increase in the clinical burden.     

The Japanese Respiratory Society guidelines may reduce unnecessary chest computed tomography in patients with pneumonia requiring hospitalization: A retrospective study

BackgroundWith the abundance of CT scanners in Japan, doctors can easily order CT scans to diagnose pneumonia. The Japanese Respiratory Society (JRS) guidelines uniquely recommend conditions for which additional CT scans should be considered at the time of diagnosis of pneumonia, a feature not found in other guidelines. In this study, we aimed to evaluate the usefulness of the recommendations in a bid to reduce the number of unnecessary CT examinations.MethodsWe retrospectively reviewed the electronic medical records of consecutive patients with pneumonia hospitalized between April 2016 and March 2017 to extract patients’ backgrounds and clinical courses. Conformity with the JRS guideline recommendations was also examined. In the patients who did not meet the recommendations, we investigated the proportion of them for whom an additional CT scan influenced the clinical decisions. Finally, we evaluated whether there was a difference in hospital stay depending on the additional chest CT at the time of admission.ResultsWe included 363 hospitalized patients with pneumonia. Chest CT scan was performed in 306 patients (84.3%), of whom 186 (60.8%) did not meet the JRS guideline recommendations. Chest CT revealed findings requiring a change in treatment strategy in only 14 (7.5%) of the 186 patients. Among the 240 patients (66.1%) who did not meet the recommendations, no statistically significant difference was observed in the hospital stay or mortality between patients with and without CT scans.ConclusionsAdherence to the JRS guideline recommendations may reduce the excessive use of CT scans in the diagnosis of pneumonia.     

Respiratory manifestations of systemic lupus erythematosus: old and new concepts

SLE has a wide spectrum of pulmonary manifestations due to lupus itself and secondarily to other conditions. Pleuritis and pulmonary infections are the most prevalent respiratory manifestations of each type. ILD, ALP, DAH, PAH, acute reversible hypoxaemia, and SLS are infrequent. Even when current diagnostic tests contribute to an earlier diagnosis, the current treatment of these manifestations is based on clinical experience and small series. Controlled trials are needed to assess the role of the different therapies in the treatment of the lung manifestations of lupus. Overall malignancy is increased in SLE, and lung cancer is among the most frequent types of cancer found in SLE patients. As survival in lupus patients has improved over recent decades, attempts to avoid pulmonary damage are emerging as an important objective.

• some conditions must be excluded in lupus patients with interstitial lung involvement, including infections, pulmonary oedema, some types of cancer, and sarcoidosis

• other causes of lung infiltrates (infectious pneumonia, aspiration pneumonitis, congestive cardiac failure, pulmonary embolism, etc) have to be excluded; early bronchoscopy with BAL and biopsy are the main tools for searching for pathogens

• there are several causes of pleural effusion in patients with lupus, such as pulmonary embolism, infections (bacterial, tuberculosis, etc.), congestive heart failure or malignancy; in this context pleural fluid analysis is a priority to establish the aetiology of the effusion

• diffuse alveolar haemorrhage is a life-threatening complication of SLE that requires aggressive treatment with corticosteroids and immunosuppressive drugs

• even when there are modern vasodilators that may be useful for the treatment of lupus pulmonary hypertension, the most encouraging approach to treating this complication is based on the use of immunosuppressive therapy

• pulmonary embolism should be suspected in any lupus patient having chest pain, sudden dyspnoea or hypoxaemia of unknown cause

• pneumonia occurs frequently in SLE patients, and early detection and empirical treatment with broad-spectrum antibiotic are essential; atypical pathogens must be kept in mind, especially in patients with profound immunosuppression

• there is a need to carry out randomized controlled trials to assess the role of the different therapies in the treatment of interstitial lung disease, acute lupus pneumonitis, diffuse alveolar haemorrhage, pulmonary arterial hypertension, and shrinking lung syndrome

• further basic and epidemiological research is necessary to learn more about pathogenesis, genetic predisposition, and environmental risk factors for lung malignancy and pulmonary drug-induced toxicity

Empirical antibiotic usage and bacterial superinfections in patients with COVID-19 in Japan: A nationwide survey by the Japanese Respiratory Society

An internet questionnaire survey for investigating empirical antibiotic usage and bacterial superinfections in patients with coronavirus disease-2019 (COVID-19) in Japan was conducted among the chief physicians of respiratory disease departments of 715 Japanese Respiratory Society-certified hospitals using Google Forms between January 28, 2021 and February 28, 2021. Responses to the questionnaire survey were obtained from 198 of 715 hospitals (27.6%). The survey revealed that the complication incidences of community-acquired pneumonia; hospital-acquired pneumonia, including ventilator-associated pneumonia; and sepsis were 2.86, 5.59, and 0.99%, respectively, among patients with moderate/severe and critical COVID-19. Bacterial co-infection and secondary infection rarely affected patients with COVID-19 in Japan, and the isolated pathogens were not specific to these patients. Moreover, the anti-inflammatory effects of macrolides for COVID-19 were not observed in several studies. These results might be useful in clinical practice for COVID-19.     

《2015年日本肝胆胰外科学会指南:急性胰腺炎的管理》推荐意见

<正>日本急性胰腺炎的管理指南(下称日本指南)最初发布于2006年。随后,日本健康、劳动和福利省(the health,labor and welfare ministry,MHLW)在2008年修订了急性胰腺炎严重程度评估系统,并于2年后在其官方出版物上更新了日本指南(2010版)。2012年,随着急性胰腺炎亚特兰大分级标准的修订,胰腺炎局部并发症的分类被重新评定。同时,内镜介入治     

Treatment understanding and compliance in asthma of children. Results of a prospective survey]

Compliance with treatment is a crucial factor in the management of asthmatic children which depends on the understanding of the disease and its treatment. The understanding of, and compliance with treatment were evaluated by means of a questionnaire in 50 parents of asthmatic children. 50% of these parents used anti-histamines as maintenance treatment and 30% also used these drugs during attacks. Half the parents knew about the bronchodilator effects of theophylline and B2-agonists. 42% and 30% respectively of the parents thought that the side-effects of theophylline or corticosteroids were few or inexistent; 86% claimed regular attendance to out-patient clinics, but 30% confessed that they had forgotten such drugs as theophylline and antihistamines. 50% took the appropriate therapeutic measures when confronted with a moderate or severe attack of asthma. Each child received 2.3 drugs on average for his or her asthma. This study shows that parents have an insufficient knowledge of asthma treatments, and this may partially explain the poor compliance with therapy as well as the morbidity and mortality associated with childhood asthma.