TB Outbreak /M.Toyota 763

Dis. 2009 ; 13 : 486_493.20） Andre M, Ijaz K, Tillinghast JD, et al. : Transmission network

analysis to complement routine tuberculosis contact inves-tigations. Am J Public Health ; 2007 ; 97 : 470_477.

21） Gardy JL, Johnston JC, Ho Sui SJ, et al. : Whole-genome sequencing and social-network analysis of a tuberculosis outbreak. N Engl J Med. 2011 ; 364 : 730_739.

22） 和田崇之 , 長谷　篤：結核菌の縦列反復配列多型 （VNTR）解析に基づく分子疫学とその展望―大阪市の 例. 結核. 2010 ; 85 : 845_852.23） 松本智成, 岩本朋忠：第84回総会ミニシンポジウム. 「結核分子疫学の展望」. 結核. 2009 ; 84 : 783_794.

16） 高嶋哲也, 岩本朋忠：第81回総会シンポジウム「結核分子疫学の新展開」. 結核. 2006 ; 81 : 693_707.

17） Lambregts-van Weezenbeek CS, Sebek MM, van Gerven PJ, et al. : Tuberculosis contact investigation and DNA fin-gerprint surveillance in The Netherlands: 6 years experience with nation-wide cluster feedback and cluster monitoring. Int J Tuberc Lung Dis. 2003 ; 7 (12 Suppl 3) : 463_470.

18） Cook VJ, Sun SJ, Tapia J, et al. : Transmission network analysis in tuberculosis contact investigations. J Infect Dis. 2007 ; 196 : 1517_1527.

19） Jackson AD, Seagar AL, Reid ME, et al. : Characterising transmission of a tuberculosis genotype in Scotland: a quali-tative approach to social network enquiry. Int J Tuberc Lung

Abstract　[Purpose] To evaluate the various transmission routes of tuberculosis in an outbreak among young adults in order to develop an effective method for contact investigations. 　[Method] We reviewed the records of 21 tuberculosis patients involved in an outbreak of tuberculosis ; the records were collected by conventional epidemiological studies. Mycobacterium tuberculosis isolates were genotyped using IS6110-based restriction fragment length polymorphism (RFLP). 　[Result] The index patient was a 26-year-old man whose 32-year-old brother was identified as the source patient of tuberculosis through a contact investigation. Investigation of their contacts led to the identification of 10 tuberculosis patients. Further, 5 more patients with only casual contact with the index or source patients developed tuberculosis 18_25 months after identification of the index patient. The RFLP analysis of strains obtained from these 5 patients as well as the index and source patients revealed an identical pattern. Fur-ther, 4 persons, among those who had epidemiological links with some of the above-mentioned 5 patients, developed tuber-culosis 22_34 months after identification of the index patient.

All 21 patients were relatively young. In total, 15 strains ob-tained from these patients were sent for the RFLP analysis, all of which showed an identical pattern. The epidemiological links were categorized into a household environment, an enter-tainment area, a university, a music band, and a construction site.　[Conclusion] Molecular epidemiology can provide insights into the process of tuberculosis transmission, which may otherwise go unrecognized by conventional contact investiga-tions. Additionally, it can play an important role in identifying places of tuberculosis outbreaks and routes of transmission in a contact investigation.

Key words : Tuberculosis, Outbreak, Contact investigation, Young adult, RFLP, Molecular epidemiology

Kochi City Public Health Center

Correspondence to: Makoto Toyota, Kochi City Public Health Center, 1_7_45, Marunouchi, Kochi-shi, Kochi 780_0850Japan. (E-mail : kc-140200@city.kochi.lg.jp)

－－－－－－－－Original Article－－－－－－－－

EVALUATION OF TUBERCULOSIS TRANSMISSION ROUTES IN AN OUTBREAK AMONG YOUNG ADULTS FOR

DEVELOPING AN EFFECTIVE METHOD FOR CONTACT INVESTIGATIONS

Makoto TOYOTA

Tuberculous Peritonitis Accompanied by Lymphadenitis /T.Koga et al. 769

Abstract　A 62-year-old woman with liver cirrhosis devel-oped ascites. She had been previously treated with a com-bination of interferon and ribavirin therapy. The ascites was bloody and of exudative nature. Radiological examinations showed supraclavicular, axillar, and mediastinal lymphade-nopathy. Biopsy of the axillar lymph node was performed because of suspected malignancy, and the results showed that the lymph node had granulomatous infl ammation with caseous necrosis and Langhans giant cells, suggestive of mycobacterial infection. Furthermore, a DNA sequence specifi c to Myco-

bacterium tuberculosis was recovered from the same lesion, leading to a diagnosis of tuberculous lymphadenitis. The ascites and the lymphadenopathy subsided with anti-tubercu-losis chemotherapy. Although bacilli were not detected in the ascites, a high level of adenosine deaminase in the ascites, the coexistence of tuberculous lymphadenitis, and the response to anti-tuberculosis agents supported the diagnosis of tubercu-

lous peritonitis. Although tuberculous peritonitis is often diffi -cult to diagnose, lymph node biopsy was useful to establish the diagnosis in the present case.

Key words : Tuberculous peritonitis, Liver cirrhosis, Ascites, Tuberculous lymphadenitis, Adenosine deaminase, Lymph node biopsy

Departments of 1Respiratory Medicine, 2Gastroenterology, 3Sur-gery, 4Pathology, and 5Radiology, Asakura Medical Associ-ation Hospital

Correspondence to: Takeharu Koga, Department of Respira-tory Medicine, Asakura Medical Association Hospital, 422_1, Raiharu, Asakura-shi, Fukuoka 838_0069 Japan. (E-mail : koga.tk@asakura-med.or.jp)

－－－－－－－－Case Report－－－－－－－－

A CASE OF TUBERCULOUS PERITONITIS ACCOMPANIED BYLYMPHADENITIS IN A PATIENT WITH LIVER CIRRHOSIS IN WHICH

LYMPH NODE BIOPSY WAS USEFUL FOR ESTABLISHING THE DIAGNOSIS

1Takeharu KOGA, 2Kunihide ISHII, 3Ichiro SHIMA, 2,4Jun TAGUCHI, 1Tomoko KAMIMURA, 5Jun SAKOTA, and 2Takato UENO

結核 第87巻 第12号 2012年12月776

Abstract　A 67-year-old woman was referred to our hospital for persistent fever and dyspnea. Chest X-ray revealed diffuse reticulonodular shadows and high-resolution computed tomog-raphy showed randomly distributed small nodules. Examina-tion of sputum and urine revealed acid-fast bacilli, which were later confirmed as Mycobacterium tuberculosis sensitive to all drugs. Laboratory tests revealed thrombocytopenia, an ele-vated concentration of fibrin degradation products, and severe hypoxemia. We therefore diagnosed her with miliary tuber-culosis complicated by acute respiratory distress syndrome (ARDS) and disseminated intravascular coagulation (DIC). After admission, her status rapidly worsened and she required mechanical ventilation. Treatment with recombinant human soluble thrombomodulin (rTM) and high-dose methylprednis-olone was started in addition to the antituberculosis chemo-therapy. The patient s condition gradually improved and she was weaned from ventilation on day 30. She was discharged on day 92. It is generally thought that prognosis of miliary tuber-

culosis complicated by DIC and ARDS is very poor. A recent report suggested that rTM is effective for DIC and ARDS secondary to sepsis. This is the first report of miliary tuber-culosis complicated by DIC and ARDS successfully treated with rTM.

Key words : Miliary tuberculosis, Disseminated intravascular coagulation, Acute respiratory distress syndrome, Thrombo-modulin

1Department of Respiratory Medicine, 2Department of Infec-tious Diseases, Clinical Reseach Center, National Hospital Organization Kinki-chuo Chest Medical Center

Correspondence to: Katsuhiro Suzuki, Department of Respi-ratory Medicine, National Hospital Organization Kinki-chuo Chest Medical Center, 1180 Nagasone-cho, Kita-ku, Sakai-shi, Osaka 591_8555 Japan. (E-mail : ksuzuki@kch.hosp.go.jp)

－－－－－－－－Case Report－－－－－－－－

A CASE OF MILIARY TUBERCULOSIS COMPLICATED BY DISSEMINATED INTRAVASCULAR COAGULATION

AND ACUTE RESPIRATORY DISTRESS SYNDROME SUCCESSFULLY TREATED WITH RECOMBINANT HUMAN SOLUBLE THROMBOMODULIN

1Sachiko SHIRAISHI, 1Shinji FUTAMI, 1Yu KURAHARA, 1, 2Kazunari TSUYUGUCHI, 1Seiji HAYASHI, and 1Katsuhiro SUZUKI

結核 第87巻 第12号 2012年12月782

Abstract　A 43-year-old man developed fever, systemic erythema, and hepatic dysfunction approximately 1 month after initiating treatment with oral allopurinol and anti-TB drugs. The high fever, skin rash, headache, vomiting, and general malaise aggravated even after discontinuation of the anti-TB drugs and allopurinol, and they continued for more than 2 weeks. Hence, the patient was diagnosed with atypical drug-induced hypersensitivity syndrome. Oral prednisolone was introduced at a dosage of 65 mg, and the systemic symp-toms rapidly subsided. Drug lymphocyte stimulation test was positive for isoniazid and oxypurinol, a metabolite of allopu-rinol. The prednisolone dosage was gradually reduced with 3_7 day intervals, and the patient was discharged on day 31 without any recurrence of the symptoms. Although high fever and erythema occurred again upon resumption of isoniazid,

the symptoms gradually improved with oral prednisolone. Finally, the patient was diagnosed with atypical drug-induced hypersensitivity syndrome caused by isoniazid.

Key words : Drug-induced hypersensitivity syndrome, Isoni-azid, Oxypurinol, Drug lymphocyte stimulation test

Department of Internal Medicine, Department of Medical On-cology & Respiratory Medicine, Shimane University Faculty of Medicine

Correspomdence to: Takeshi Isobe, Department of Medical Oncology & Respiratory Medicine, Shimane University Faculty of Medicine, 89_1, Enya-cho, Izumo-shi, Shimane 693_8501 Japan. (E-mail : isobeti@med.shimane-u.ac.jp)

－－－－－－－－Case Report－－－－－－－－

A CASE OF ATYPICAL DRUG-INDUCED HYPERSENSITIVITY SYNDROME CAUSED BY ISONIAZID

Shinichi IWAMOTO, Taeko SUZUKI, Akihisa SUTANI, Takashige KURAKI, and Takeshi ISOBE

TB Annual Report 2010 (7) 787

い。一方女性は，2010年 1年間の件数は25であり前年

の25と同じであった 2)。

　2007年から2010年までの 4年間を通してみた場合，

初回治療患者における多剤耐性率は，男性が20歳未満，

女性が20歳代で最も高く，男女共に1.8%であった。ま

た初回治療患者における INH耐性，RFP耐性は，いずれ

も男女共に50歳以上に比して50歳未満の各年代層で同

等かそれ以上高い傾向にあった。年齢区分でみていく

と，総じて年齢が上がるにつれて耐性の割合（多剤耐

性，INH耐性，RFP耐性，1剤以上耐性それぞれ）が男

女共に減少していく傾向がみられた。

　表 4は，特に外国人について，2007～2010年 4年間の

耐性率を性・年齢階層別にみたものである。初回多剤耐

性率は男性が2.9%，女性が4.2%であった。

お わ り に

　2007年以降の結核サーベイランスによって，中央集計

されるようになった HIV感染 ⁄糖尿病合併 ⁄薬剤耐性等の情報について概観した。

　結核における薬剤耐性のサーベイランスは対策立案だ

けでなく対策評価にも重要な役割を果たすが，現在わが

国では結核登録者情報システムからの薬剤耐性情報のみ

が唯一の公的なサーベイランスであり，その意味で非常

に重要な情報項目の一つである。2010年では培養検査

結果や薬剤感受性検査結果の入力率が前 3年に比して向

上しており，更なる向上に期待したい。

文　　　献

1） 結核研究所疫学情報センター：結核年報2008　Series 7. 診断時病状（2）. 結核. 2010 ; 85 : 495_498.

2） 結核研究所疫学情報センター：結核年報2009　Series 7. 診断時病状（2）. 結核. 2011 ; 86 : 883_887.

3） API-Net平成22年エイズ発生動向年報　発生動向の分析結果. (http://api-net.jfap.or.jp/status/2010/10nenpo/bunseki.pdf)

－－－－－－－－Report and Information－－－－－－－－

TUBERCULOSIS ANNUAL REPORT 2010─ (7) Tuberculosis Characteristics upon Diagnosis_2 ─

Tuberculosis Surveillance Center (TSC), RIT, JATA

Abstract　From 2007 to 2010, 229 newly notified tuberculo-sis (TB) cases with HIV infection were reported. These cases were detected in 204 (89.1％) male and 25 (10.9％) female patients ; 50 (21.8％) of these patients were foreigners. The present TB surveillance system does not provide reliable data on whether HIV tests were performed for TB cases; therefore, we report only those TB patients with HIV infection. 　In 2010, the proportion of newly notified TB cases with diabetes mellitus was 13.3％ (3,085/23,261); diabetes was observed in 15.4％ of male patients and 9.7％ of female patients.　In 2010, drug susceptibility test (DST) results were obtained for 8,380 (72.9％) of 11,495 culture-positive pulmonary TB cases through the TB surveillance system. The proportion of multi-drug resistant TB (MDR-TB), isoniazid resistance, and rifampicin resistance among the newly identified cases was 0.5％, 4.1％, and 0.7％, respectively. Among previously tested

cases, the proportion was 3.9％, 11.4％, and 5.2％, respectively. Resistance thus appears to have remained stable over the past 4 years (2007_2010). From 2007 to 2010, among the new pulmonary TB cases in foreign nationals, MDR-TB was observed in 2.9％ of male patients and 4.2％ of female patients.

Key words : Tuberculosis, Sex, Age, Foreigner, HIV, Diabetes mellitus, Anti-tuberculosis drug susceptibility test, Multi-drug resistance

Research Institute of Tuberculosis (RIT), Japan Anti-Tuber-culosis Association (JATA)

Correspondence to : Tuberculosis Surveillance Center (TSC), Research Institute of Tuberculosis (RIT), JATA, 3_1_24, Matsuyama, Kiyose-shi, Tokyo 204_8533 Japan. (E-mail : tbsur@jata.or.jp)

結核 第87巻 第12号 2012年12月794

Abstract　As the incidence of active tuberculosis in Japan declines and the healthcare environment changes, restructur-ing of the medical care system for tuberculosis is required. According to a questionnaire survey in Hiroshima Prefecture, experiences in tuberculosis (TB) care and knowledge, such as standard treatment and DOT, is insufficient in the local medical institutions designated for tuberculosis care. Regional coordination between the tuberculosis hospital and the regional private practitioners will be one of the important issues in proper TB care. In order to strengthen coordination, Higashi-hiroshima Medical Center (HMC) collaborated with Onomichi Medical Association and the health center having jurisdiction over the area (Tobu Health Center) to create liaison clinical paths for doctors, a booklet for patient education and a med-ication record named DOTS note . These liaison paths were provided to the regional practitioner from the health center on discharge and referral from HMC. After the start of regional cooperation, treatment outcome of the cohort of sputum smear positive pulmonary tuberculosis in the region were improved:success; 37.0％ to 53.3％ (cured; 0％ to 40.0％, completed;37.0％ to 13.3％), treatment more than 12 months; 17.4％ to 6.7％, died 37.0％ to 26.7％. It is considered from experience of the regional cooperation in Hiroshima that regional medical cooperation using liaison paths is helpful to provide proper TB care. 　Treatment of patients with serious complication(s) is

another issue in TB care. For example, only a few TB hospitals can treat the patient who needs hemodialysis, on the other hand, most general hospitals do not treat TB patients, because they have no beds and little knowledge.　I think the following measures are effective and necessary for the future TB care: 1) one or more of the general hospitals in each region should provide one or more air-controlled bed(s) to treat TB patients, which can be also used for pa-tients with suspected airborne infectious disease, 2) coopera-tion between tuberculosis experts and general physicians is necessary to provide standard TB care, 3) Rapid communica-tion between TB experts and regional health centers to provide concrete information such as liaison clinical paths, and finally, 4) government commitment is needed to promote the above measures.

Key words : Regional coordination, Liaison clinical path, Community DOTS, Tuberculosis beds

National Hospital Organization Higashihiroshima Medical Center

Correspondence to: Eriko Shigeto, National Hospital Orga-nization Higashihiroshima Medical Center, 513 Jike, Saijo-cho, Higashihiroshima-shi, Hiroshima 739_0041 Japan. (E-mail : eshigetou@hiro-hosp.jp)

－－－－－－－－The 87th Annual Meeting President Lecture－－－－－－－－

PRESENT AND FUTURE OF TUBERCULOSIS CARE IN REGIONS

Eriko SHIGETO

Symposium/Patient-Centered Medicine for TB 807

ま　と　め

　国内では，結核がすでに過去の疾患と思いがちである

が，世界に目を向けてみると依然として感染症としては

対策が必要な疾患のひとつである。また先進国の中でも

日本の罹患率が低いわけではない。今後，合併症を有す

る結核患者の増加，外国籍患者への早期発見・早期治療

への啓発と普及，地域格差や結核病床の減少による医療

アクセスの悪化が引き起こす諸問題に対しても，継続し

た対策が必要であるものと考える。

文　　　献

1） http://www1.mhlw.go.jp/houdou/1107/h0726-2_11.html

2） http://www.who.int/gho/tb/en/index.html3） Global Tuberculosis Control WHO Report 20114） 平成23年結核登録者情報調査年報集計結果（概況）（5_1 年次別・年齢階級別 新登録結核患者数）

5） 平成23年結核登録者情報調査年報集計結果（概況）（5_2 年次別・年齢階級別 菌喀痰塗抹陽性肺結核新登録患

者数）

6） http://www.mhlw.go.jp/bunya/kenkou/kekkaku-kansenshou03/dl/11sankou.pdf#page=13

Abstract　The 2011 edition of Specific Guiding Principles for Tuberculosis Prevention calls for a streamlined medical services system capable of providing medical care that is customized to the patient s needs. The new 21st Century Japanese version of the Directly Observed Treatment Short Course (DOTS) expands the indication of DOTS to all tuber-culosis (TB) patients in need of treatment. Hospital DOTS consists of comprehensive, patient-centered support provided by a DOTS care team. For DOTS in the field, health care providers should select optimal administration support based on patient profiles and local circumstances. 　In accordance with medical fee revisions for 2012, basic inpatient fees have been raised and new standards for TB hospitals have been established, the result of efforts made by the Japanese Society for Tuberculosis and other associated groups. 　It is important that the medical care system be improved so that patients can actively engage themselves as a member of the team, for the ultimate goal of practicing patient-centered medicine. We have organized this symposium to explore the best ways for practicing patient-centered medicine in treating TB. It is our sincere hope that this symposium will lead to improved medical treatment for TB patients.

1. Providing patient-centered TB service via utilization of collaborative care pathway: Akiko MATSUOKA (Hiroshima Prefectural Tobu Public Health Center)　We have been using two types of collaborative care pathway as one of the means of providing patient-centered TB services since 2008. The first is the clinical pathway, which is mainly used by TB specialist doctors to communicate with local

practitioners on future treatment plan (e.g. medication and treatment duration) of patients. The clinical pathway was first piloted in Onomichi district and its use was later expanded to the whole of Hiroshima prefecture. The second is the regional care pathway, which is used to share treatment progress, test results and other necessary patient information among the relevant parties. The regional care pathway was developed by the Tobu Public Health Center. It is currently being used by several other public health centers in Hiroshima.　Utilization of these two pathways has resulted in improved adherence, treatment being offered at local clinics, shorter hospitalization and better treatment outcomes.

2. Patient-centered DOTS in Funabashi-city: Akiko UOZUMI (Funabashi-city Public Health Center)　In Funabashi-city, all TB patients, including those with LTBI, are treated under DOTS which recognizes and tries to accommodate the various different needs of each individual patient. For example, various types of DOTS are offered, such as pharmacy-based DOTS and DOTS supported by caregivers of nursing homes. This enables public health nurses to take into consideration both the results of risk assessment and conve-nience for the patient, and choose DOTS which most effectively support the patient. Furthermore, DOTS in principle is offered face-to-face, so that DOTS providers may not only build relationship of trust with the patient, but also to collect and analyze the necessary information regarding the patient and respond timely when problems arise. Such effort has directly contributed to improved default and treatment rate.

3. Hospital DOTS and clinical path for the treatment of

－－－－－－－－The 87th Annual Meeting Symposium－－－－－－－－

PATIENT-CENTERED MEDICINE FOR TUBERCULOSIS MEDICAL SERVICES

Chairpersons: 1Akira FUJITA and 2Tomoyo NARITA

808 結核 第87巻 第12号 2012年12月

tuberculosis : Kentaro SAKASHITA, Akira FUJITA (Tokyo Metropolitan Tama Medical Center)　We introduced a version of hospital DOTS at Tama Medical Center (formerly Fuchu Hospital) in 2004. As part of this three-stage version, patients are allowed to progress to the next stage if they meet the step-up criteria. Following the introduction of this hospital DOTS, the occurrence of drug administration-related incidents decreased and support for patient adherence became easier for health care workers than before. In 2006, we developed a clinical path based on this hospital DOTS with consistent eligibility criteria for patients. This clinical path helped increase the efficiency of medical services in the TB ward. In conclusion, a patient s initiative for tuberculosis treatment can be supported through our hospital s TB treatment system.

4. Survey of TB patients understanding and satisfaction of hospital DOTS : Yoko NAGATA, Minako URAKAWA, Noriko KOBAYASHI, Seiya KATO (Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association)　We surveyed the satisfaction and understanding of recently discharged TB patients regarding DOTS to analyze how to better implement DOTS. The questionnaire consisted of nine items covering knowledge of TB, comfort in talking to and asking questions of the medical staff, explanations given to family members, and motivation for continuing medication. Two hundred and eight of the 228 patients who accepted the questionnaire responded (response rate: 91.2％). 　The level of understanding and satisfaction tended to be higher among patients in hospitals that employed a primary

nursing system, more coverage and duration of DOT, and audiovisual materials for patient education. The level of under-standing and satisfaction also tended to be slightly higher among institutions that conducted in-hospital conferences and collaborated with public health centers more frequently.

5. Medical cooperative system against tuberculosis elimina-tion: Dai YOSHIZAWA (Tuberculosis and Infectious disease control division, Ministry of Health, Labour and Welfare)　There are 3 points we should consider. First, despite one of the intermediate burden countries, emphasis for infectious incidence is insufficient. Besides new incidence decreases gradually, increased ratio of the elderly causes necessity of implementation against each complications. The second is how find infectious one, especially from high burden countries, before they spread it. Final, unspecific symptoms suffer the patients and medical staff. It s the key of implementation that spread of tuberculosis must be caused by delayed diagnosis.

Key words : DOTS, Patient-centered medicine, Hospital DOTS, Regional partnership

1Tama-Hokubu Medical Center (Tama Medical Center), 2Bureau of Social Welfare and Public Health, Tokyo Metro-politan Government

Correspondence to: Akira Fujita, Tama-Hokubu Medical Center, 1_7_1, Aoba-cho, Higashimurayama-shi, Tokyo 189_

8511 Japan. (E-mail : akira_fujita@tamahoku-hp.jp)

818 結核 第87巻 第12号 2012年12月

Abstract　The Japan Tuberculosis Society organized sympo-sia on restructuring the medical-service system at the 84th and 86th annual meetings. These symposia clarifi ed the following issues and concerns. 　It is becoming diffi cult to maintain tuberculosis beds in wards in many areas, since beds required for tuberculosis are declining due to the decreasing incidence of tuberculosis and shortened hospitalization periods. The extremely poor profi t-ability of medical practices has caused closure of tuberculosis wards. A highly urbanized area may have a shortage of tuber-culosis beds, while some rural areas have the problem of poor access to hospitalization. Aging of tuberculosis patients causes an increase in the number of patients with serious complica-tions that are sometimes diffi cult to treat within a prefectural jurisdiction. Infection control for multi-drug resistant tuber-culosis needs to be solid. To address these issues and chal-lenges, it will be necessary to restructure the medical-service system for tuberculosis. 　The Prevention Guideline addressed in May 2011 by the Ministry of Health, Labour, and Welfare mentions that the medical-service system should seek to ensure enough tuber-culosis beds and to realize patient-centered medical service. The future directions should be 1) ensuring a core hospital for tuberculosis treatment at the prefectural level, 2) ensuring a principal hospital for treating tuberculosis patients with serious complications in an area, 3) ensuring the treatment environ-ment is suitable to individual patient conditions, 4) formulat-ing a regional coordination mechanism with a core hospital at the center in each area, and 5) achieving complete infection control. This symposium was organized based on discussions in the previous symposia to present points necessary to realize the future medical-service system described in the Prevention Guideline.　When constructing a new hospital or renovating a ward, attention must be paid to infection control and amenities for tuberculosis patients whose hospitalization is often longer than patients of other diseases. There is no offi cial standard for a facility with tuberculosis beds at this moment. Professor Atsuo Kakehi, a hospital architectural expert, discussed the points in a draft of the standard he proposed in his report.　Aging of tuberculosis patients increases the number of patients with serious complications. Ensuring medical service for such patients is a major challenge. The new National Hospital Organization Hokkaido Medical Center was built in March 2010 with tuberculosis wards. Dr. Arisu Kamada reported on infection control and medical practice for patients with serious complications in a general hospital.　Psychiatric diseases including senile dementia are among

the largest problems among tuberculosis complications. The National Hospital Organization Kamo Psychiatric Center, which has model beds for tuberculosis, produced successful outcomes by collaborating with the National Hospital Organi-zation Higashihiroshima Medical Center tuberculosis hospital. Dr. Masahiro Nomura reported on the implementation of DOT and regional collaboration as well as medical practice in his hospital.　An important point in the National Guideline is regional collaboration. Dr. Tadatoshi Suruda from the National Hospital Organization Wakayama National Hospital discussed the status and outcomes from their regional collaboration system in Wakayama Prefecture, the top runner in this area. 　Thanks to solid presentation from the speakers and thought-ful comments from the fl oor, the symposium was very useful for promoting patient-centered medical service, a keyword in the National Guideline.

1. Environment of hospital beds for treating TB patients :Atsuo KAKEHI (Department of Architectural Design, School of Architecture, Kogakuin University)　It is becoming more diffi cult to confi gure wards since the number of tuberculosis beds is decreasing. It is therefore necessary to mix general beds and tuberculosis beds in one ward, making it necessary to develop criteria for designing facilities as part of a general ward for isolated space. This paper describes the current care environment of tuberculosis patients and the draft guidelines for a more appropriate hos-pital environment.

2. Treatment to complications in the patients in the tuberculo-sis hospital : Arisu KAMADA (National Hospital Organiza-tion Hokkaido Medical Center)　Recently, many patients with tuberculosis, especially the elderly, have been exhibiting various complications. It is often diffi cult to treat complications at a tuberculosis hospital, espe-cially at the old sanatorium hospital. Our hospital is both a tuberculosis hospital and a general hospital in which various complications can be treated. However, such general hospitals are very rare in Japan. Many patients passed away immediately after transferring to a tuberculosis hospital due to inadequate treatment of complications. To avoid repeating such tragedies, continuing treatment of complications without transferring to a tuberculosis hospital should be considered.

3. Tuberculosis care in psychiatry: Masahiro NOMURA (Department of Internal Medicine, National Hospital Organi-zation Kamo Psychiatric Center)

－－－－－－－－The 87th Annual Meeting Symposium－－－－－－－－

FOLLOW-UP DISCUSSION ON RESTRUCTURING THE MEDICAL-SERVICE SYSTEM

Chairpersons: 1Seiya KATO and 2Arisu KAMADA

Symposium/Medical Service System 819

　Kamo Psychiatric Center has eight model beds for tuber-culosis patients with psychiatric diseases. We retrospectively studied 71 cases of hospital DOTS from 2006 to 2011. There were 33 dementia cases and 30 schizophrenia cases. The standard regimens (A or B) were performed for 68 of the 71 cases. The median duration of hospitalization was six months. Some schizophrenia cases taking antipsychotic medications experienced worse mental symptoms when they started tuber-culosis treatment.

4. Medical collaboration for tuberculosis patients care in region: Tadatoshi SURUDA (National Hospital Organization Wakayama National Hospital)　Complete medical collaboration for tuberculosis patients care is possible by close cooperation utilizing coordination tools such as the regional critical path among TB hospitals, other medical facilities, welfare organizations, and health cen-ters that function as a coordinator in an area. TB hospitals and

health centers, both major role players in the collaboration scheme, should maintain good ties and share responsibilities. Through establishing close collaboration, medical service for TB patients will be a part of primary practice. It is expected to raise TB awareness among general medical staff and result in early case detection in the area.

Key words : Tuberculosis, Facility standard, Complication, Regional-collaboration system

1Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association, 2National Hospital Organization Hokkaido Med-ical Center

Correspondence to: Seiya Kato, Research Institute of Tuber-culosis, Japan Anti-Tuberculosis Association, 3_1_24, Matsu-yama, Kiyose-shi, Tokyo 204_8533 Japan.(E-mail : kato@jata.or.jp)