A nosocomial infection of pulmonary tuberculosis in a 320-bed general hospital was reported. In March 1997 when a 28 year-old physician developed pulmonary tuberculosis, 20 nurses under the age of 30 years were skin tested with PPD. Their chest x-rays were within normal limits. The skin test was repeated on 16 of the 20 in late May and 11 showed a subcutaneous induration of over 20 mm in diameter with redness. An ad hoc anti-tuberculosis committee was organized in the hospital and recommended a prophylactic administration of INH to the 11 strong reactors if they consented. Eight of them agreed but 3 refused. A 26 year-old nurse, one of the 3 not taking INH against advice developed pulmonary tuberculosis in a month. An emergency mass survey was performed on all hospital employees with chest x-rays and PPD skin tests in late July, 1997. Pulmonary tuberculosis was found in 4 nurses working in the same ward with the 26 year-old nurse and a laboratory technician. Two other nurses who refused to take INH for prophylaxis also developed pulmonary tuberculosis. Pulmonary tuberculosis developed in 9 hospital employees after all. The 7 of the 9 (6 nurses and the physician) worked in the same ward and 4 of the 7 were culture positive for mycobacterium tuberculosis. The DNA patterns of the tubercle bacilli of the 4 by RFPL's or finger-printing method were identical to that of a smear-positive patient who was hospitalized in the same ward for 8 days in late November 1996. This was the index case of the present episode of nosocomial infection of pulmonary tuberculosis of this hospital. The following are the lessons to have been learned; no patients with chest diseases should be directly admitted to a general ward before the smear-negativity of tuberculous bacilli is guaranteed and the PPD skin test should be performed at the time of employment.

View full abstract

“Health services research” aims to evaluate medical programs and health policy programs in order to improve the quality of current health delivery systems. In the United States, health system formats have dramatically changed for recent decades and many research projects have been done to make the current health systems more effective, more efficient, and equitable. This review introduced the contents and some examples of health services research, and discussed the importance of scientific evaluations of the current health programs in Japan through research. Health services research mainly assesses “access to care”, “cost for care”, and “quality of care”. Research for access to care describes potential enabling resources and utilization of health services. Cost research reflects efficiency of care programs delivered. Quality research evaluates the contents and outcomes of services. For Japanese health system, which is just faced with dynamic changes in the near future, quality evaluation through research must be an urgent task. Appropriate research on clinical base will enhance how we provide health care services.

View full abstract

In order to investigate the clinical features of dementia in super-aged patients, we examined the symptoms and troublesome behavior shown by nonagenarian patients who developed dementia in Alzheimer's disease with late onset (demented nonagenarian group). A total of 24 inpatients were selected from she National Shimofusa Sanatorium as subjects: these included 11 patients who were diagnosed as having dementia in Alzheimer's disease with late onset and 13 with dementia in Alzheimer's disease with early onset (early onset group). The GBS (Gottfries, Brane and Steen's) and DBD (Dementia Behavior Disturbance) scales were used for evaluation of symptoms and troublesome behavior, and the symptoms were compared between the two groups. Disturbances of orientation and memory were significantly milder in the demented nonagenarians than in the early dementia group, but reduced motivation, confusion, anxiety and accusational behavior were more severe in the demented nonagenarians. The present results suggest that the clinical features of dementia in the super-aged are more complex because not only intelligence disturbances (disorientation, memory impairment) but also symptoms related to physiological aging (delirium, depression, impaired fluency) and pathological aging (reduced motivation) are mixed.

View full abstract

We must introduce risk management for prevention of medical accidents in clinical examination. It is a useful method for prevention of patient's harm or injury to investigate and analyze various risk cases in many facilities. Though the main cause of medical troubles depend on medical accidents, unexpected incidents, and others, it is also useful for prevention of medical trouble to respond to patient's questions and complaints. So, we investigate and analyze various risk cases in the department of radiology. In this paper, we discuss medical troubles due to patient's question and complaint.

View full abstract

Collection of clinical data is the base of clinical research. In Japan, however, the data collec-tion from multiple medical institutions is not common. National Hospital and Sanatoriums are a group of hospitals located all over Japan. If they cooperate in data collection, a large scale clinical research becomes possible. Moreover, a computer network named HOSPnet, which started its operation in March, 1996 opened a possibility to collect clinical data from hospitals without having meetings of participants. In this study, a data collection system using HOSPnet was developed and 181 doctors from 79 institutions sent data through this system to prove the above possibility. The results showed that this method is feasible for the future clinical research. But at the same time, there still remained much to be solved for the use of this system in clinical trials of medical drugs.

View full abstract

We performed a thoracoscopic surgery for right lung cancer under a mini-thoracotomy and mediastinal lymphnode dissection using video-assisted mediastinoscopy through thoracotomy (reverse mediastinoscopy). A 67-years-old male was admitted with an abnormal shadow of right lower lobe on chest X-ray. Pathologic diagnosis of the bronchoscopic biopsy specimens was an adenocarcinoma. The patient underwent video-assisted right low lobectomy and mediastinal lymphnodes dissection using reverse mediastinoscopy. We inserted mediastinoscope into the subcarinal space displacing the lung, the left atrium and the esophagus, and dissected the subcarinal nodes completely. We also inserted the mediastinoscope into upper mediastinum and dissected upper mediastinal, pre-tracheal and tracheo-bronchial nodes. The subcarinal and pre-tracheal nodes were completely dissected and others were not, which we dissected through mini-thoracotomy. We concluded that reverse mediastinoscopy might be useful for dissecting the pre-tracheal and subcarinal nodes under a video-assisted thoracoscopy.

View full abstract

Acute renal failure due to ureteral obstruction by the gravid uterus is rare. This condition may lead to a fatal outcome in a pregnant patient with a solitary kidney. We report a patient of con-genital solitary kidney presented with anuria during pregnancy course. This was relieved by nephrostomy followed by a successful vaginal delivery at 36 weeks of pregnancy.

View full abstract

Air travel can cause severe respiratory decompensation in patients with Duchenne muscular dystrophy (DMD) due to reductions in total barometric pressure and inspired oxygen partial pressure We report four such patients who experienced air travel. Two of the patients underwent mechanical ventilation during sleep. Arousal blood gas analysis indicated mild hypoxemia and hypercapnia (Pao₂; 83.4 and 83.1mmHg, Paco₂; 51.4 and 56.9mmHg). Blood gas parameters in the other two were within normal limits. Spot₂ was measured in these patients during commercial flights, and three of them showed decreased Spo₂ during air travel. No symptoms attributable to hypoxemia occurred. We conclude that careful preparation, some ventilatory support using an Ambue bag or a mechanical ventilator, and oximetric monitoring are necessary for patients with DMD who intend to undertake air travel.

View full abstract

Between 1993 and 1995, the SMON Research Group (director Mitsuo IIDA; the author) had been very actively examining and interviewing SMON patients. The group picked up about 1200 cases each year, but about one third of the patients overlapped in the annual examinations. Excluding the redundant overlapping cases, we examined 1672 patients with a ratio of male to female of 1:3. The majority of this group was examined at the regional public health center and hospital, and 208 cases (12.4%) were examined by home visits. Most of the patients showed relatively normal physical conditions, but we could observe visual disturbance in 40%, motor disability in 45% and sensory deficit with dysesthesia in over 60%. Sixty-five percent of the patients demonstrated reduced severity of dysesthesia in comparison with that at the onset of SMON. Studying the severity of the illness, severe or mild cases increased a little, whereas cases in the moderate state decreased. The causes of the present severity were SMON itself in 44.7% and SMON with complications in 41.1%. The major complications were cataracta (42.8%), hypertension (31.6%), vertebral diseases (25.1%) and joint diseases (19.2%). Psychiatric disease and dementia in patients of ages over 70-years increased gradually. Accordingly, demand for the cure and care of SMON and its complications has been aris-ing as a prominent problem in a long-term strategy for SMON patients.

View full abstract

To construct large-scale database for clinical perinatal research, Clinical Obstetric Information Network: COIN started among 5 national hospitals (Hirosaki, Kure, Okura, Sendai, Zentsuji) in 1996.
1. Participants were 18 national hospitals (Cardiovascular Center, Chiba, Fukuyama, Hirosaki, International Medical Center, Kanazawa, Kobe, Kochi, Kofu, Kure, Kyoto, Nagoya, Narashino, Okura, Otake, Sendai, Yokohama-higashi, Zentsuji) in 1997.
2. Total births were 7, 895 cases, 473 (5.99%) of those were preterm deliveries. Maternal mortality rate was 12.56 (per 100, 000 live births).
3. Total neonates were 7, 960 cases, 464 (5.83%) of those were preterm between 28-36 weeks, and 32 (0.40%) were between 22-27 weeks. Neonatal mortality rate was 4.02 (per 10, 000 live births), and early neonatal mortality rate was 3.27 (per 10, 000 live births). Fetal death rates after 22 weeks of pregnancy was 4.13 (per 1, 000 total births), and perinatal mortality rate was 7.38 (per 1, 000 total births).

View full abstract