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MAC Diagnosed with Gastric Aspirate / A. Takasa et al. 493 思われる。また,気管支鏡による診断はより確実だが, 胃液採取に比して患者へ与える苦痛や医療者の負担は大 きく,胃液検査で診断可能であれば,患者・医療者双方 にとってより有益である。  以上から今回の検討で,胃液培養検体は喀痰排出困難 例および気管支鏡施行困難例に対しては,その診断の一 助となる可能性が示唆された。

 著者の COI(confl icts of interest)開示:本論文発表内 容に関して特になし。

文   献

1 ) Saslaw S, Perkins R: The gastric smear for acid-fast bacilli in the presumptive diagnosis of tuberculosis. Am J Med Sciences. 1962 ; 243 : 470 474.

2 ) Pratt PC, Atwell RJ: The diagnostic reliability of acid-fast bacilli demonstrated in aspirated gastric contents. Am Rev Respir Dis. 1961 ; 83 : 96 99. 3 ) 倉島篤行:日本における非結核性抗酸菌症の動向. Pharma Medica. 2012 ; 30 : 43 48. 4 ) 日本結核病学会非結核性抗酸菌症対策委員会, 日本呼 吸器学会感染症・結核学術部会:肺非結核性抗酸菌症 診断に関する指針─2008年. 結核. 2008 ; 83 : 525 526. 5 ) Edwards LB, Palmer CE: Isolation of atypical

myco-bacteria from healthy persons. Am Rev Respir Dis. 1959 ; 80 : 747 749.

6 ) 杉原栄一郎, 檀原 高, 饗庭三代治, 他:高齢者非結核 性抗酸菌症の臨床的検討. 日老医誌. 2007 ; 44 : 503 506. 7 ) Mitarai S, Tanoue S, Sugita C, et al.: Potential use of

Amplicor PCR kit in diagnosing pulmonary tuberculosis from gastric aspirate. J Microbiol Methods. 2001 ; 47 : 339 344. 8 ) 中澤篤人, 萩原恵里, 池田 慧, 他:胃液培養で診断 し, 多剤併用化学療法が奏効した肺 Mycobacterium gor-donae症の1例. 結核. 2012 ; 87 : 727 731. 9 ) 土屋典子, 萩原恵里, 馬場智尚, 他:外科的切除にて最 終診断に至った Mycobacterium xenopi 肺感染症の1例. 日 呼吸誌. 2013 ; 2 : 139 142.

Abstract [Objectives] The diagnostic signifi cance of gastric aspirate culture has been established in pulmonary tubercu-losis, but not in pulmonary Mycobacterium avium complex (MAC) disease. This study aimed to verify the diagnostic signifi cance of gastric aspirate culture in pulmonary MAC disease.

 [Subjects and Methods] This retrospective study analyzed 77 cases of pulmonary MAC disease tentatively diagnosed through gastric aspirate culture in comparison with 308 cases diagnosed through sputum culture.

 [Results] There was no signifi cant difference in the clinical symptoms, laboratory data, or type of disease in both groups. Patients diagnosed through gastric aspirate culture had a signifi cantly lower chance of having underlying respiratory disease (26.0% vs. 46.8%), which indicates the diffi culty in obtaining sputum specimens from this group of patients. In 114 patients without chemotherapy intervention, more patients achieved spontaneous remission in the gastric aspirate group than in the sputum group. Among 271 patients treated with chemotherapy, there were no signifi cant differences in the course of radiological fi ndings and clinical symptoms between

both groups. During the observation period, a defi nitive diag-nosis through sputum culture or histological confi rmation was reached in 34 of 47 patients (72%). There was no signifi cant difference in the clinical characteristics, course of radiologi-cal fi ndings, and cliniradiologi-cal symptoms in the defi nitive group and tentative group.

 [Conclusion] Gastric aspirate is a minimally invasive, easy to conduct, and useful test for diagnosing pulmonary MAC disease.

Key words: Nontuberculous mycobacteriosis, Gastric aspi-rate, Diagnosis, Mycobacterium avium complex

1Department of Respiratory Medicine, Kanagawa Cardio-vascular and Respiratory Center, 2Department of Internal Medicine, Japan Red Cross Tsukui Hospital

Correspondence to: Akiyuki Takasa, Department of Internal Medicine, Japan Red Cross Tsukui Hospital, 256 Nakano, Midori-ku, Sagamihara-shi, Kanagawa 252_ 0157 Japan. (E-mail: 98043at@jichi.ac.jp)

−−−−−−−−Original Article−−−−−−−−

CLINICAL FEATURES OF PULMONARY MYCOBACTERIUM AVIUM COMPLEX

DISEASE DIAGNOSED THROUGH GASTRIC ASPIRATE CULTURE

1, 2Akiyuki TAKASA, 1Eri HAGIWARA, 1Akimasa SEKINE, 1Hajime SASANO, 1Yoshihiro SUIDO, 1Hideya KITAMURA, and 1Takashi OGURA

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Abstract [Background and Objective] A directly observed treatment short course (DOTS) trial was launched in Japan in the late 1990s and targeted patients with social depression at urban areas. Based on these fi ndings, the Ministry of Health, Labour and Welfare established the Japanese DOTS Strategy in 2003, which is a comprehensive support service ensuring the adherence of tuberculosis patients to drug administration. DOTS services are initially provided at the hospital to patients with infectious tuberculosis who are hospitalized according to the Infectious Diseases Control Law. After being discharged from the hospital, the patients are referred to a public health center. However, a survey conducted in 2008 indicated that all the patients do not receive appropriate DOTS services at some hospitals. In the present study, we aimed to evaluate the protocols and workload of DOTS at hospitals that are actively involved in tuberculosis medical practice, including DOTS, to assess whether the hospital DOTS services were adequate.  [Method] We reviewed a series of articles on hospital DOTS from a Japanese journal on nursing for tuberculosis patients and identifi ed 25 activities regarding the hospital DOTS service. These 25 items were then classifi ed into 3 categories: health education to patients, support for adherence, and coordination with the health center. In total, 20 hospitals that had >20 authorized tuberculosis beds were selected ─while considering the geographical balance, schedule of this survey, etc. ─from 33 hospitals where an ex-trainee of the tuberculosis control expert training program in the Research Institute of Tuberculosis (RIT) was working and 20 hospitals that had collaborated with our previous survey on tuberculosis medical facilities. All the staff associated with the DOTS service were asked to record the total working time as well as the time spent for each activity. The data were collected and analyzed at the RIT.

 [Result] The working times for each activity of the DOTS service for nurses, pharmacists, ward clerks, head nurses, and doctors were 100, 90, 87, 86, and 63 min, respectively. For other professions, including medical social workers, nursing aids, nutritionists, and physical therapists, the working times

for each activity of the DOTS service were 31, 18, 10, and 8 min, respectively.

 The professionals who spent a longer time on health education, support for patient adherence, and coordination with the health center were pharmacists, doctors, and head nurses; nurses, pharmacists, and doctors; and head nurses, doctors, and ward clerks, respectively.

 [Discussion] Aging of tuberculosis patients was associated with problems on adherence in many patients, including patients who were not suited for a standard regimen, patients whose activity of daily life had deteriorated due to senile dementia, patients with diabetes mellitus, etc. Smoking cessation and mental care for cases of multi-drug resistant disease are new challenges in tuberculosis patient care. The present study clearly indicated that activities including patient education, support for patient adherence, and coordination with the health center─essential components of the hospital DOTS service according to the Japanese DOTS Strategy─ were performed by a team of professionals including doctors, nurses, pharmacists, medical social workers, etc., depending on the features and roles that they serve and the needs of each patient. For good practice of hospital DOTS, it is essential to not only provide DOTS, but also effectively provide individual or group health education and coordinate with health centers, thus aiming towards a better community DOTS service after patient discharge.

Key words: Hospital DOTS, Workload, Education to patients, Support for adherence, Coordination

Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association

Correspondence to: Yoko Nagata, Research Institute of Tu-berculosis, Japan Anti-Tuberculosis Association, 3_ 1_ 24, Matsuyama, Kiyose-shi, Tokyo 204_ 8533 Japan.

(E-mail: nagata@jata.or.jp) −−−−−−−−Original Article−−−−−−−−

ANALYSIS ON WORKLOAD FOR HOSPITAL DOTS SERVICE

Yoko NAGATA, Minako URAKAWA, Noriko KOBAYASHI, and Seiya KATO

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結核 第 89 巻 第 4 号 2014 年 4 月 508

Abstract [Purpose] To confi rm the effectiveness of inter-feron-gamma release assays (IGRAs) in the tuberculosis (TB) contact investigation of elderly people, we analyzed the results of the QuantiFERON® TB Gold in tube (QFT-3G) test, which is a commercially available IGRA.

 [Methods] We analyzed the results of the QFT-3G test in 2,420 subjects who were in close contact with TB patients. We investigated subjects with latent TB infection and those showing the onset of TB among the QFT-3G-positive subjects.  [Results] The QFT-3G-positive rate was 7.3% (95% con-fi dence interval, 6.2%_8.3%). In addition, we demonstrated that the QFT-3G-positive rate increased with age (P<0.001).  [Discussion] The QFT-3G-positive rate was high, partic-ularly in elderly people (≧60 years), but the rate was signif-icantly lower than the predicted prevalence of TB infection. Therefore, it was assumed that the QFT-3G test does not always provide a positive result, even in cases of subjects with a previous TB infection. Furthermore, data from the QFT-3G-positive subjects indicated that approximately one half of

subjects aged 60_69 years, approximately one-third of those aged 70_79 years, and approximately one-quarter of those aged over 80 years have had recent TB infections. In conclu-sion, the results of the QFT-3G test in elderly people need to be carefully evaluated according to the contact situation with TB patients; nevertheless, the QFT-3G test is useful for the screening of latent TB infection in elderly people who were in close contact with TB patients.

Key words: QFT-3G, Elderly, Contact investigation, Previous TB infection, Recent TB infection

Yamagata Prefectural Institute of Public Health

Correspondence to: Junji Seto, Department of Microbiology, Yamagata Prefectural Institute of Public Health, 1_ 6_ 6, Toka-machi, Yamagata-shi, Yamagata 990_ 0031 Japan.

(E-mail: setoj@pref.yamagata.jp) −−−−−−−−Original Article−−−−−−−−

EFFECTIVENESS OF INTERFERON-GAMMA RELEASE ASSAYS

IN THE TUBERCULOSIS CONTACT INVESTIGATION

OF ELDERLY PEOPLE

Junji SETO and Tadayuki AHIKO

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Abstract An 85-year-old man with dementia fi rst visited our hospital 5 years ago, complaining of hemoptysis. He was hospitalized 2 years later owing to fever, cough, and dyspnea. A chest computed tomography scan showed infi ltration with a cavity in the left upper lobe. He was diagnosed with non-tuberculous mycobacterial lung infection on the basis of the presence of acid-fast bacilli in the sputum and repeated bronchoalveolar lavage specimens; however, we were unable to identify the isolate by DNA‒DNA hybridization. Although his general condition had slightly improved after treatment initiation, intermittent chemotherapy owing to the adverse effects of the drugs and dementia led to rapid disease progression and death. After his death, the isolated myco-bacterium was identifi ed as Mycomyco-bacterium kyorinense by

sequence analysis of the hsp 65 and rpoB genes.

Key words : Mycobacterium kyorinense, Nontuberculous mycobacterial disease, Fatal disease, Elderly, Compliance 1Department of Respiratory Medicine, Tokyo Medical and Dental University, 2Department of Respiratory Medicine, Toshiba General Hospital, 3Department of Respiratory Medi-cine, Toho University Ohashi Medical Center

Correspondence to: Yumi Sakakibara, Department of Respi-ratory Medicine, Tokyo Medical and Dental University, 1_ 5_ 45, Yushima, Bunkyo-ku, Tokyo 113_ 8519 Japan. (E-mail: ysaka.pulm@tmd.ac.jp)

−−−−−−−−Case Report−−−−−−−−

FATAL NONTUBERCULOUS MYCOBACTERIAL LUNG DISEASE

CAUSED BY MYCOBACTERIUM KYORINENSE :

A CASE REPORT WITH FIVE YEARS OF FOLLOW-UP

1, 2Yumi SAKAKIBARA, 2, 3Kumiko KISHIMOTO, 2Kaoru KOJIMA, 1, 2Toshihide FUJIE,

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結核 第 89 巻 第 4 号 2014 年 4 月 520

Abstract [Objective] To contribute to measures against hospital-acquired infections by analyzing and evaluating tuberculosis contact investigations in hospitals.

 [Methods] This study included 202 tuberculosis cases between January 2010 and September 2011 in which contact investigations were requested from the Public Health Offi ce in Osaka City.

 [Results] 1) To assess the necessity for contact investigation and the demographics of index cases, contact investigations were conducted for 66 of the 202 cases. Index cases with higher rates of contact investigation included those with higher degree of sputum smear positivity, respiratory symp-toms, period from hospitalization to tuberculosis diagnosis of 8 days or longer, and high-risk procedures (including endotracheal intubation, endotracheal aspiration, and broncho-fi berscopy). 2) A total of 632 contact persons from the follow-ing professions underwent QuantiFERON®-TB (QFT) testing: 59 doctors, 492 nurses, 60 other hospital staff members, and 21 patients, and the positive QFT rates were 18.6, 10.8, 13.3, and 14.3%, respectively. 3) Among the 66 index cases for which contact investigations were conducted, there were 0 QFT-positive contact persons in 37 cases (56.1%), 1 or more in 29 (43.9%), and 2 or more in 18 cases (27.3%). Assuming the dependent variable to be 0 and 1, respectively, for index cases with 0 and 2 or more QFT-positive contact persons,

we performed a multiple logistic regression analysis with independent variables that included the presence or absence of high-risk procedures, period from hospitalization to diagnosis either within 7 days or 8 or more days, presence or absence of cough and cavity, and the degree of sputum smear positivity (1+/2+/3+). Among these variables, those signifi cantly associated with cases with 1 and 2 or more QFT-positive persons included the presence of high-risk procedures and period from hospitalization to diagnosis of 8 days or longer (P<0.05).

 [Discussion] Our results suggest that early diagnosis and appropriate responses during high-risk procedures may be necessary measures to prevent hospital-acquired infections. Key words: Tuberculosis, Nosocomial infection, Contact investigation, Doctor’s delay, Tracheal aspiration, QFT 1Osaka City Public Health Offi ce, 2Health Bureau, Osaka City, 3Health and Welfare Center of Nishinari Ward, Osaka City Correspondence to: Kenji Matsumoto, Osaka City Public Health Offi ce, 1_2_7_1000, Asahimachi, Abeno-ku, Osaka-shi, Osaka 545_ 0051 Japan.

(E-mail: ke-matsumoto@city.osaka.lg.jp) −−−−−−−−Field Activities−−−−−−−−

TUBERCULOSIS CONTACT INVESTIGATION IN HOSPITALS

1Kenji MATSUMOTO, 1Jun KOMUKAI, 1Sachi KASAI, 1Satoshi HIROTA,

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