Acute Pericarditis Following Acute Pulmonary Thromboembolism.

We describe the case of a 45-year-old Japanese man who developed acute pericarditis following an acute pulmonary thromboembolism. He had developed shortness of breath 7 days prior to hospitalization and was admitted with severe dyspnea. Echocardiography and laboratory results were compatible with acute pulmonary thromboembolism, which was confirmed by contrast-enhanced chest computed tomography. On the third hospital day, he experienced chest pain exacerbated by inspiration. On the fourth hospital day, his body temperature increased to 39°C and echocardiography revealed circumferential pericardial effusion. A diagnosis of acute pericarditis was made and the patient was treated with colchicine and aspirin. On the fifth hospital day, his symptoms largely subsided. Auscultation revealed pericardial friction rub. Electrocardiography demonstrated diffuse ST-segment elevations. Twenty-four days later, computed tomography revealed the disappearance of both the pericardial effusion and pulmonary arterial emboli. This case was thought to be one of acute pericarditis following acute pulmonary thromboembolism.

[USE OF QuantiFERON® TB-GOLD IN-TUBE IN A CONTACT INVESTIGATION TO DETERMINE THE ONSET OF TUBERCULOSIS WITH OR WITHOUT LATENT TUBERCULOSIS INFECTION TREATMENT].

PURPOSE: QuantiFERON® TB-Gold In-Tube (3G) testing was performed on tuberculosis-positive index cases and their contacts. The purpose of this study was to evaluate the relationship between 3G test results and the subsequent development of tuberculosis, and to identify effective strategies to prevent the onset of tuberculosis. METHODS: Index cases and their contacts were subjected to 3G testing in a contact investigation in Osaka City in 2011-2012. For index cases, sputum smears were tested, and the infecting organism was identified. For the contacts, the following information was collected: age, results of 3G testing, presence or absence of latent tuberculosis infection (LTBI) treatment, and onset of tuberculosis disease within 2 years of follow-up from the last contact with the index cases. RESULTS: (1) There were 830 index cases, including 774 subjects with pulmonary tuberculosis (93.3%) and 3 with laryngeal tuberculosis (0.4%). From sputum smear tests, 726 patients (87.5%) were determined to be 3G positive, and 83 (10.0%) were determined to be 3G negative. (2) In total, 2,644 contacts were subjected to 3G testing. Of these, 2,072 patients (78.4%) tested negative, 196 (7.4%) showed an equivocal result, and 375 (14.2%) tested positive. Their mean ages were 33.7, 38.0, and 38.8 years, respectively, showing significant differences in tuberculosis status according to age (P < 0.001). (3) Among the 2,072 3G-negative contacts, tuberculosis developed in 2 (0.1%) of 2063. None of these contacts was treated for LTBI. Among the 375 3G-positive contacts, tuberculosis developed in 36 (36.0%) of 100 subjects that were not LTBI treated, while tuberculosis developed in 3 (1.1 %) of 275 subjects that were LTBI treated. A significant difference in the incidence of tuberculosis between treated and untreated 3G-positive contacts was observed (P < 0.001). DISCUSSION: Tuberculosis developed in a high proportion of 3G-positive contacts that were not LTBI treated, suggesting the need for preventive management of 3G-positive contacts.

[PULMONARY TUBERCULOSIS TREATMENT OUTCOME AMONG FOREIGN NATIONALS RESIDING IN OSAKA CITY].

UNLABELLED: Abstract PURPOSE: In this study, we analyzed pulmonary tuberculosis treatment outcomes among foreign nationals of different backgrounds. METHODS: The research was conducted between January 2006 and December 2011. One hundred fifty nine foreign nationals residing in Osaka city had pulmonary tuberculosis during this period. Patients were grouped according to treatment outcomes. We conducted three different types of comparisons. First, we compared backgrounds of patients with treatment success or default. Second, backgrounds of patients who continued treatment in Japan or who moved overseas (transfer out) were compared. Third, treatment outcomes of foreign nationals between 20 and 39 years of age were compared with those of age-matched Japanese patients registered between 2010 and 2011. RESULTS: (1) The treatment outcomes were as follows: cured, 53 cases (33.3%); treatment completed, 55 cases (34.6 %); treatment failure, 0 cases (0.0%); treatment default, 14 cases (8.8%); moved overseas, 17 cases (10.7%); moved to another location inside Japan, 13 cases (8.2%); died, 6 cases (3.8%); and under treatment, 1 case (0.6%). (2) Comparison of treatment success and default among foreign nationals with pulmonary tuberculosis revealed a default rate among smear-negative cases of 14.5%, significantly higher than in smear-positive cases (2.1%; P < 0.05). (3) We compared backgrounds between foreign nationals with pulmonary tuberculosis who continued taking treatment in Japan and those who moved abroad (transfer out). The rate of overseas transfer out (44.4%) was higher among patients not covered by health insurance. This was significantly higher than among patients covered by public insurance or assistance (9.0%; P < 0.01). (4) Comparison of foreign and Japanese nationals between 20 and 39 years of age revealed a default rate in foreign nationals with pulmonary tuberculosis of 13.6%. This was significantly higher than that of Japanese patients (4.0%; P < 0.01). The rate of transfer out among foreign nationals with pulmonary tuberculosis was 19.1%, also significantly higher than that of Japanese patients (5.3%; P < 0.001). DISCUSSION: The rates of treatment default and transfer out among patients between 20 to 39 years of age were significantly higher among foreign nationals than in Japanese patients. Lack of knowledge about treatment and language problems may contribute to this finding. This suggests that adequate support and definitive directly observed treatment short-course programs are needed for foreign nationals. Patients who moved abroad (overseas transfer out) may also be ultimately categorized as treatment default. However, it is difficult to determine final treatment outcomes of patients who moved abroad. Further measures are needed to ensure that foreign nationals continue to receive treatment when they transfer overseas.

[RATES OF COMPLETION AND TREATMENT OUTCOMES FOR TYPE OF COMMUNITY DOTS].

AIM: To investigate the relationship between completion rates for community directly observed treatment short-course (DOTS) and treatment outcomes, according to implementation tactics, to improve the treatment outcomes. METHODS AND SUBJECTS: We evaluated 529 newly registered patients with smear-positive pulmonary tuberculosis who underwent community DOTS (checking medication at least once per week) during 2010 and 2011 in Osaka City. DOTS completion was defined as checking medication 3 times or more per month, with checking medication missed less than 3 consecutive times. DOTS was implemented using the following 4 tactics: healthcare staff visited the patients' home or workplace (visiting type), the patients visited a health and welfare center (HWC type), the patients visited a pharmacy (P type), or the patients visited an outpatient department at a medical center (MC type). Regarding treatment outcomes, resolution of the tuberculosis or treatment completion was defined as "successful treatment", and treatment failure or default was defined as "unsuccessful treatment". We then analyzed the DOTS completion rate for each DOTS implementation tactic. RESULTS: DOTS was completed in 417 (78.8%) of the 529 patients. The completion rates were 79.7%, 75.4%, 75.9%, and 81.3% for patients who underwent visiting (n= 394), HWC (n = 61), P (n = 58), and MC (n = 16) DOTS, respectively; no significant difference was observed. The mean ages for each group were 62.8 years, 53.6 years, 45.0 years, and 56.6 years for patients who underwent visiting, HWC, P, and MC DOTS, respectively; patients who underwent P DOTS were significantly younger (P < 0.001). Among the 4 groups, the visiting DOTS group had the lowest percentage of full-time employees (16.2%) and the highest percentage of unemployed individuals (67.3%). In contrast, the percentage of full-time employees was 63.8% and 50.0% in the P and MC DOTS groups, respectively. The P DOTS group had the lowest unemployment percentage (19.0%) among the 4 groups. Thus, a significant correlation existed between the DOTS implementation tactics and the presence/ absence of the patients' occupations (P < 0.001). Among the 417 patients who completed DOTS, 99.8% achieved successful treatment. Among the 112 patients who did not complete DOTS, 89.3% achieved successful treatment, and this success rate was significantly lower than that for the group who completed DOTS (P < 0.00 1). Among the visiting, HWC, and P DOTS groups, the completion of DOTS resulted in a high treatment success rate. DISCUSSION: Patients who completed DOTS achieved better treatment outcomes; therefore, it is important to provide patients with medication support until their tuberculosis is resolved. The P DOTS group contained a higher percentage of full-time employees and had a significantly lower mean age; this was likely because pharmacies are accessible at night and during the weekend. There was no significant difference in the DOTS completion rates according to implementation tactic, which suggests that it is important to assist patients with their medication according to their needs.

[EXAMINATION OF TUBERCULOSIS OUTBREAK INDEX CASES IN OSAKA CITY].

OBJECTIVE: To analyze tuberculosis outbreak index cases in order to improve preventative measures. METHODS: Outbreaks reported in Osaka City between 2008 and 2014 were investigated. The index cases were examined according to category group, sex, age, chest radiograph findings, sputum smear examination, patient delay, doctor delay, total delay in case finding, and adherence to regular health examinations. As controls, 467 patients in Osaka City with newly registered sputum smear-positive pulmonary tuberculosis in 2011 were included. RESULTS: Thirteen outbreaks occurred. The group categories included enterprises (9 outbreaks), preparatory schools (2), a junior high school (1), and other (1). The group of index cases consisted of 12 men (92.3%) and one woman (7.7%), with a mean age of 39.1 years; 11 (84.6%) were 30 to 50 years of age. Their ages ranged from 15 to 54 years. Of the control group of patients with sputum smear-positive pulmonary tuberculosis, 69.2% were 60 years or older, with a mean age of 65.4 years. These results suggest that the index case group was significantly younger (p < 0.001). There were ten cases (76.9%) of patient delay (initial visit 2 months or more after onset), and 8 (61.5%) of total delay (diagnosed 3 months or more after onset). These rates were significantly higher than those in the control group (p < 0.001). There were regular health examinations in four cases; among those, one did not see a doctor and another did not receive further examination. Chest radiographs revealed cavities in 12 cases (92.3%). All sputum smears were positive, with grades of 1 + in one case (7.7%), 2 + in two cases (15.4%), and 3 + in 10 cases (76.9%). These cases had a significantly higher rate of smear positivity than those in the control group (p < 0.001). DISCUSSION: The index cases were predominantly male, in their prime, and had higher infectivity rates. These findings suggest the importance of preventing delays in case findings and receiving regular and adequate health examinations.

[Evaluation of risk factors for failed/defaulted on treatment outcomes of pulmonary tuberculosis in Osaka City].

OBJECTIVE: In this study, we analyzed the relationship between the risk of discontinuing medication and patient outcomes. METHODS: Newly registered patients with pulmonary tuberculosis from Osaka City who required outpatient treatment in 2011 were included in the study. We assessed the number of patient cures and the number of patients who completed medication as outcomes for successful treatment and the number of failed treatments and the number of treatments that were discontinued by patients as outcomes for failed and discontinued treatments. As related factors, we examined the risk of discontinuing medication, implementation of directly observed treatments, short course (DOTS), and planned duration of treatment. To assess the risk of discontinuing medication, we examined the following medical risk factors: (1) drug resistance to isoniazid or rifampicin, (2) diabetes, (3) use of immunosuppressive/anticancer drugs, (4) use of adrenal corticosteroid, (5) artificial dialysis, (6) human immunodeficiency virus infection/acquired immunodeficiency syndrome, (7) liver damage, and (8) side effects. The social risk factors were (1) being without a fixed address at the time of registration, (2) a history of discontinuing treatment, (3) lack of assistance with medication, (4) being elderly and requiring nursing care, (5) alcohol/drug dependence, (6) serious mental disease, (7) financial problems, (8) lack of the awareness of being ill, (9) keeping irregular hours, and (10) others. RESULTS: We identified 568 cases of successful treatment and 41 cases of failed and discontinued treatment. Multiple logistic regression analysis was performed, with successful treatment considered as the dependent variable 0 and failed and discontinued treatment considered as the dependent variable 1. The medical/social risk factors, positive/negative sputum smear test results, the planned duration of treatment (6 months/9 months or more), and the implementation of B type or higher DOTS were included as independent variables. The significant medical risk factors were drug resistance to isoniazid or rifampicin, the use of immunosuppressive/anticancer drugs, and side effects, with odds ratios of 4.55, 4.68, and 2.68, respectively. Further, a planned duration of treatment of 9 months or more and the implementation of B type or higher DOTS were associated with odd ratios of 4.51 and 0.35, respectively. CONCLUSION: These results highlight the need to assess risk factors for discontinuing treatment and to adopt measures to overcome these factors, such as the type of DOTS being implemented, in each case.

Extrathoracic subclavian venipuncture by using only the J-type guidewire for permanent pacemaker electrode placement.

Extrathoracic subclavian/axillar venipuncture is an accepted method for implanting pacemaker leads. Although several procedures have been reported, no standard method has been established yet. We evaluated the usefulness of a method in which only J-type guidewires are used. Between August 2011 and November 2012, 33 patients (20 men and 13 women; age, 77.5 ± 10.3 years) underwent permanent pacemaker lead insertion by extrathoracic subclavian venipuncture at our hospital. Thirty-two of the patients underwent primary implantation, whereas 1 patient required an additional lead because of lead fracture. The guidewires were inserted from the cubital vein to the subclavian vein. After the pacemaker pockets were created, we set the X-ray projection in the ipsilateral anterior oblique view. The distal edge of the guidewire was positioned on the ventral side of the first rib on fluoroscopy. The needle tip was positioned within the Ushaped distal tip of the J-type guidewire. The needle was held parallel to the X-ray angle and advanced towards the first rib until the tip entered the subclavian vein. The guidewire was inserted through the cubital vein in 31 patients, and through the femoral vein in 2 patients. Using this method, we successfully performed subclavian venipunctures in all 33 patients (total, 60 punctures) without any complications. Extrathoracic subclavian venipuncture using only a J-type guidewire is an easy, safe, and economical method for pacemaker lead implantation.

[Interpreting "equivocal" results obtained from the QuantiFERON-TB Gold In-Tube test in contact investigations].

OBJECTIVE: In this study, we demonstrate the interpretation of "equivocal" results by the QuantiFERON"-TB Gold In-Tube (QFT-GIT) test in contact investigations. METHODS: The participants of the contact examinations were assessed by the QFT-GIT test after 2 to 4 months from the last contact with smear-positive tuberculosis patients. The study was conducted between April 2011 and March 2012. We enrolled 79 contact participants whose QFT-GIT tests produced equivocal results. RESULTS: The average age of the enrolled contacts was 35.9 years and the average interval from the last contact to the first QFT-GIT test was 85.4 days (range 62-118 days). The second QFT-GIT test produced negative results in 42 (53%) participants, equivocal results in 28 (35%), and positive results in 9 (11%). These 9 positive contacts belonged to the group of contacts with an index case whose QFT-GIT positive rate was more than 15%. The contacts belonging to groups with a QFT positive rate higher than 15% in the initial test had significantly higher QFT positive rates in the follow-up test than those belonging to groups with lower initial QFT positive rates (p=0.011). CONCLUSIONS: After retesting contacts with initially equivocal QFT results, 65% demonstrated either negative or positive results. If a contact's second QFT-GIT test is positive, it is highly probable that he/she is infected with tuberculosis and adequate treatment for latent TB infection is indicated. Thus far, no guidelines have been established for the management of contacts with equivocal results by the QFT-GIT test; therefore, further investigations and discussions are mandatory.

[Medication support and treatment outcome in homeless patients with tuberculosis].

PURPOSE: We conducted a study on factors related to treatment outcome and medication support in homeless patients with tuberculosis. METHODS: Participants were 433 homeless patients with tuberculosis newly registered in Osaka City between 2007 and 2009. We investigated factors related to treatment outcome (e.g., length of hospital stay, scheduled duration of outpatient treatment, and type of DOTS). Controls were 3,047 non-homeless patients with pulmonary tuberculosis newly registered in Osaka City during the same period. RESULTS: Regarding medication support, 219 (70.4%) of the 311 patients with successful treatment received DOTS and completed the treatment during their hospital stay. Thirty-five (72.9%) of the forty-eight patients who did not complete treatment left the hospital at their own discretion, resulting in treatment failure/default. The rate of treatment failure/default in the homeless patients with pulmonary tuberculosis was 11.0%, significantly higher than that of non-homeless patients with pulmonary tuberculosis (6.5%; P < 0.001). Among the 102 patients receiving community DOTS, medication compliance occurred at least 5 days a week in 66 patients (64.7%) and treatments failed or were interrupted in 10 patients (9.8%). The mean hospital stay was 2.0 +/- 1.6 months in patients with failed/defaulted treatment and 4.4 +/- 2.5 months in those with successful treatment. The scheduled duration of outpatient treatment was 7.9 +/- 2.7 months in patients with failed/defaulted treatment and 3.6 +/- 2.1 months in those with successful treatment. Shorter length of hospital stay and longer scheduled duration of outpatient treatment were associated with a higher rate of treatment failure/default (P < 0.01). CONCLUSION: Homeless patients with tuberculosis had a higher rate of treatment failure/default, most likely due to leaving the hospital at their own discretion. Patients with successful treatment generally completed treatment during their hospital stay. In contrast, patients who received community DOTS after discharge from the hospital had a higher rate of treatment failure/default, despite receiving medication at least 5 days a week. This suggests the need for adequate support, particularly in patients with a shorter hospital stay and those with a longer scheduled duration of outpatient treatment.

[Evaluation of the effect of DOTS on treatment outcomes in patients with smear-positive pulmonary tuberculosis in Osaka City].

PURPOSE: To investigate the possibility of improving the results of therapy, we analyzed the association between the performance of directly observed treatment short course (DOTS) and treatment outcomes in patients with tuberculosis. METHODS: Patients with sputum smear-positive pulmonary tuberculosis who were newly registered in Osaka City between 2007 and 2010 were included in the study. The patients' drug-taking was confirmed at least once a week during DOTS. RESULTS: (1) In total, 2,423 patients were enrolled in the study (676, 563, 631, and 553 in 2007, 2008, 2009, and 2010, respectively). Of these, patients who died, those who were transferred during treatment, and those who remained under treatment at the time of analysis, were excluded. In 2007, 2008, 2009, and 2010, 84.1%, 82.3%, 86.2%, and 92.0% of patients, respectively, underwent DOTS and 91.6%, 91.7%, 92.6%, and 95.1%, respectively, were considered to be cured or to have completed treatment, demonstrating increases in both the parameters. On the other hand, 8.4%, 8.3%, 7.4%, and 4.9% of patients, respectively, were considered to have failed to respond to treatment or defaulted, showing a decreasing trend. (2) We examined the results of treatment of the 2010 cohort of patients with respect to whether a patient was supported by the DOTS service. Four percent of the 377 patients who underwent DOTS failed or defaulted compared with 15.2% of the 33 patients who did not undergo DOTS, which was a significant difference (P<0.01). (3) In total, 131 patients failed to respond to treatment or defaulted between 2007 and 2010, with reasons for such including abandonment of treatment, departure from the hospital, or refusal of treatment in 61 patients (46.6%); premature discontinuation of treatment due to physicians instructions in 33 (25.2%); and side effects in 22 (16.8%). The absence of a DOTS partner was considered a risk factor for discontinuation of treatment in 31 (56.4%) of the 55 patients who failed to respond to treatment or defaulted in 2009 and 2010. CONCLUSION: An increase in the coverage of DOTS may be important for improving treatment outcomes. The most common reasons for patients failing to respond to treatment or defaulting were abandonment of treatment, earlier departure from hospital, or refusal of treatment. The absence of a DOTS partner accounted for more than 50% of cases of premature discontinuation of treatment. Thus, it may be mandatory to adequately evaluate the risk of treatment discontinuation in individual patients and to take appropriate action against it.

[The association between smoking and sputum smear-positive pulmonary tuberculosis in Osaka City].

PURPOSE: This study aimed to analyze and evaluate the association between tuberculosis (TB) and smoking in order to obtain basic information for the control of smoking. METHODS: Of the 637 patients with sputum smear-positive pulmonary tuberculosis who were newly registered in Osaka City in 2009, 581 patients whose smoking status was identified were selected as study subjects. Data on the following were collected: patient characteristics, presence or absence of underlying conditions, patient's delay and doctor's delay in the diagnosis of TB, presence or absence of cavities, and degree of smear positivity. The patients were divided into the following three groups according to their smoking status: (1) never smokers (those who have never smoked), (2) former smokers (those who had smoked, but quitted), and (3) current smokers (those who smoke currently). RESULTS: (1) PATIENT CHARACTERISTICS: The subjects consisted of 413 males and 168 females, with mean ages of 65.7, 55.4, and 70.2 years for never smokers, current smokers, and former smokers, respectively. (2) Comparison with the national adult smoking rate (National health and nutrition survey 2009, Ministry of Health, Labour and Welfare): The prevalence of current smoking among male patients with sputum smear-positive pulmonary TB in Osaka was 62.4-82.4% among men in their 20s to 60s, and 27.5% among men in their 70s, which is higher than the national average. For female patients, the prevalence of current smoking was 46.2% among women in their 20s and 45.5% among women in their 30s, which is clearly higher than the national average. This was also true for those aged 40 years or older. (3) Severity of TB disease and smoking status: The presence of a cavity was significantly associated with being a male patient, being a current smoker, and longer patient's delay. Sputum smear grades (2+) and (3 +) were significantly correlated with being under 59 years old, being a current smoker, and longer patient's delay. CONCLUSION: The prevalence of current smokers was significantly higher among sputum smear-positive pulmonary TB patients in Osaka than the national average. More smokers had cavitary lesions and a high degree of smear positivity, which may lead to poorer treatment outcomes, and may also expose more surrounding people to infection.

[Examination of onset cases in contact investigation].

OBJECTIVES: To analyze and evaluate onset cases of tuberculosis detected in contact investigations and to apply the results to future countermeasures. METHODS: Index and secondary cases in contact investigations in which the secondary cases occurred in Osaka City between 2005 and 2008 were enrolled. The tuberculin skin test or QFT (QuantiFERON-TB Gold) was conducted to diagnose whether the contacts were infected with tuberculosis. X-ray examination of the chest was conducted to determine whether tuberculosis had developed, immediately or 6 months, 1 year or 2 years after the contact investigation. RESULTS: (1) Index cases: Index cases followed by secondary cases numbered 131 patients. Regarding the chest X-ray findings, a cavity was observed in 67.7% of the index cases, and a sputum smear of 3 + was observed in 51.5% of the index cases. A 3-month or longer delay in index case-finding was noted in 50.4% of the index cases. (2) Secondary cases: Secondary cases numbered 177 patients, consisting of 107 patients who showed an onset of less than 6 months after their last contact with index cases. Of 70 secondary cases in whom tuberculosis was detected in the investigation conducted 6 months to 2 years after the contact investigation, 50% of them were not tested for infection due to their older age, consisting of 11 patients in their 40's, 8 in their 50's, and 16 in their 60's or over, and 17.1% of them refused or discontinued the treatment for latent tuberculosis infection, leading to onset. DISCUSSION: Many secondary cases were detected immediately after the contact investigation, suggesting the importance of reducing the delay in index case-finding. Regarding the onset of secondary cases who showed an onset 6 months after the last contact with index cases, many cases showed an onset without being tested for infection due to their older age. More attention should be paid to the cases who refused or discontinued the treatment for latent tuberculosis infection, leading to onset.

Primary Cardiac Lymphoma Arising from Both Sides of the Heart.

Primary cardiac lymphomas (PCLs) are extremely rare tumors with a poor prognosis. They usually involve the pericardium and the right side of the heart. PCLs arising from the left side of the heart are relatively rare, with bilateral cases being even rarer. We herein report a case of PCL arising from both the right and left sides of the heart in a 65-year-old man. Multiple imaging modalities clearly demonstrated the tumors at the initial evaluation. The pathological diagnosis was diffuse large B-cell lymphoma.

[Assessment of self-discharge of homeless patients with tuberculosis].

OBJECTIVES: Factors responsible for the premature self-discharge of homeless tuberculosis (TB) patients from the hospital and the association between the self-discharge and treatment interruption were assessed. METHODS: A total of 205 homeless patients with TBs who were newly registered between January, 2007 and June, 2008 were evaluated. The subjects were divided into two groups (those who were discharged themselves from the hospital prematurely ["case" group] and those who were not [control group]), and the difference between the groups regarding the factors possibly responsible for the self-discharge was evaluated. RESULTS: i) Patient's characteristics: The subjects were all men; there were 45 in the "case" group and 160 in the control group. The proportion of subjects aged under 60 years was significantly higher in the "case" group (84.4%) than in the control group (52.5%). The proportion of subjects who consumed 360 mL or more of sake a day was significantly higher in the "case" group (64.4%) than in the control group (38.8%). ii) Questionnaire survey on admission: All of the patients were hospitalized for treatment of TB. In the interview on admission, more "case" group patients reported "I do not know much about TB" or "I am dissatisfied with my hospitalization", as shown by multiple logistic regression analysis. A review of troubles with inmates or healthcare workers over alcohol drinking or smoking showed that the proportion of subjects who had such troubles was significantly higher in the "case" group (55.6%) than in the control group (5.0%). iii) The association between the treatment outcomes and the self-discharge: The proportion of subjects with treatment outcomes of "cured" or "treatment completed" was significantly lower in the "case" group (46.7%) than in the control group (78.8%). The proportion of subjects with a treatment outcome of "defaulted" was significantly higher in the "case" group (42.2%) than in the control group (3.8%). CONCLUSION: The patients who were aged under 60 years or who consumed 360 mL or more of sake a day were shown to be significantly more likely to discharge themselves prematurely, which warrants a more careful handling of such problems. The poor understanding of disease necessitates more adequate explanation of TB, or education, considering each patient's level of understanding. In addition, the patients' dissatisfaction with their hospital stay, as seen in the case group, should be more carefully addressed in order to avoid the higher rate of trouble.

[Comparative performance of tuberculin skin test and QuantiFERON TB-gold in contact investigations for tuberculosis].

OBJECTIVES: To evaluate the performances of the QuantiFERON TB-Gold assay (QFT) and tuberculin skin test (TST) and to examine how a latent tuberculosis infection (LTBI) should be diagnosed in contact investigations of children aged 6 to 17 years. METHODS: A total of 232 boys and girls aged 6 to 17 years who were in contact with 134 culture-confirmed pulmonary tuberculosis patients (index cases) were examined both with QFT and TST. Factors influencing the results of the tests and their interactions were evaluated with multivariate analyses. RESULTS: Two variables (whether household contact and with/without contact with a cavitary disease patient) were found to significantly predict a positive QFT result. Positive TST defined with erythema being either greater than 20 mm or 30mm correlated significantly with two variables (whether household contact and with/without contact with a smear positive patient). There was moderate agreement between QFT and TST (positivity defined as with erythema greater than 30mm), with kappa=0.49, for contacts aged 6 to 11 years. Among contacts aged 6 to 11 years, 14 had a negative QFT result and TST with erythema greater than 30 mm. Of these 14, 7 contacts (50%) of smear positive index case were not indicated for LTBI treatment. CONCLUSIONS: When diagnosing LTBI among contacts aged 6 to 11 years who show negative QFT and strong TST reactions, we should take into consideration the factors related with a higher probability to the risk of infection. Because a history of past BCG vaccination is more likely to affect TST results in those aged 12 to 17 years than in younger subjects, greater care must be taken when evaluating the TST of these contacts.

[Examination of latent tuberculosis infection treatment status].

OBJECTIVE: To clarify factors involved in the refusal or discontinuation of treatment for latent tuberculosis infection (LTBI), we reviewed LTBI treatment. METHOD: The subjects were 193 patients for whom LTBI treatment was indicated on a family contact investigation in 2006. We examined the subjects' backgrounds and reasons for treatment refusal or discontinuation. In addition, we investigated the incidence of the onset of tuberculosis within 2 years after the final contact with the source of infection. RESULTS: i) Patient background: The state of treatment could be evaluated in 185 patients. Of these, drug therapy was completed in 138 (75%), whereas 47 (25%) refused or discontinued treatment. The mean ages of the former and latter were 21.0 and 26.2 years, respectively, showing a significant difference. Concerning the state of contact, 9 (8%) of 114 patients who had lived with and 12 (17%) of 71 who had lived apart from the source of infection refused treatment, showing a significant difference. ii) Onset within 2 years: We analyzed 180 patients for whom follow-up was possible. Drug therapy was completed in 137 patients. No patient developed tuberculosis onset. On the other hand, drug therapy was not completed in 43 patients, and 6 (14%) developed tuberculosis onset. iii) The reasons were investigated in 47 patients who did not complete drug therapy. There were 15 episodes associated with side effects, followed by 14 related to personal circumstances, such as being busy, disliking medicines, and the absence of confidence regarding the completion of drug therapy, and 6 associated with either insufficient explanations regarding the diagnosis or an absence of symptoms. CONCLUSION: Treatment refusal/discontinuation was more frequent in the more advanced age groups and patients who had lived apart from the source of infection. It may therefore be necessary to more closely explain the importance of treatment to these patients. Most reasons for treatment refusal/discontinuation were associated with side effects or insufficient explanations, suggesting the necessity of providing sufficient information to aid in patient understanding.

[Tuberculosis infection by tuberculin skin test or QuantiFERON and related factors in contact investigations].

OBJECTIVE: We investigated the factors related to secondary infections in contact group investigations. METHOD: From March, 2008 to February, 2009, a total of 457 tuberculosis (TB) notifications were reviewed by the Health Examination Committee of the Health Centers of Osaka City over indications of a contact investigation. A contact investigation was considered necessary for 92 cases with 620 contacts. For the contacts of these cases, the tuberculin skin test (TST) or/and QuantiFERON-TB 2nd Generation (QFT) was used. The contacts testing positive for QFT were classified as "infected". The contacts with "doubtful" QFT were classified as either "infected" or "non-infected" according to the QFT-positive rate of the group as a whole. Those with blisters in TST were classified as "infected". RESULTS: Among the total of 84 "infected" cases thus defined, 56 were QFT-positive, 17 were doubtful, and 11 had blisters with TST. On the other hand, among the total of 515 "uninfected" cases, 18 were doubtful on the QFT test, 323 were QFT-negative and 174 were cases with TST of erythema less than 30 mm without QFT test. The relationship between characteristics of index cases and whether a contact was infected or not was as follows: Severe chest X-ray findings, sputum smear positivity, and a cough persisting for more than two months were significantly associated with infection of the contacts. The closeness of contact was also significantly related with a higher risk of infection, so that contact with an index case for more than 100 hours, and contact in a space less than 100 square meters were more likely to cause transmission of infection. CONCLUSION: Severity of chest X-ray findings, degree of smear positivity and period of cough were confirmed to be important in judging whether investigations are necessary. The time and space of contact were also considered to be important factors. We should consider these factors comprehensively in order to decide on indications for a contact investigation.

[Discussion on incidence of tuberculosis patients among nurses in Osaka City].

PURPOSE: To analyze conditions of developing TB among nurses and to discuss preventive measures. METHODS: TB patient cards of nurses and other health workers registered in Osaka City from 1999 to 2003 were studied. RESULTS: Incidence rate of TB among female nurse/ assistant-nurse was 3.0 times higher than that of all female population. The route of case finding were as follows with descending order, visit to medical facilities with symptoms (55.8%), regular health check (35.8%), individual health check (5.8%), and contact examination (2.5%). Among risk factors related to the development of TB work in hospitals account for 55.0% in nurse patients of all ages, 72.5% in 20s, 47.4% in 30s, 37.5% in 40s, 36.4% in 50s and 0% in 60s. Individual risk factors were identified as follows in descending order, "TB patients diagnosed in the hospital." (10.0%), "examined at TB contact examination." (9.2%), "history of TB treatment at 18 years of age and over" (7.5%), "working experience in TB hospital/TB ward." (6.7%), "TB patients diagnosed among colleague." (5.0%), "increased reaction of tuberculin skin test after employment." (2.5%), "diagnosis of 'healed TB lesion" at regular health check." (1.7%), "default of chemoprophylaxis" (1.7%). Among various risk factors, "examined at TB contact examination" and "TB patients diagnosed in the hospital" are the two most common factors and occupied 38.8% in patients in 20s. DISCUSSION: Therefore it is important to promote further nosocomial TB infection control with a view to lower incidence rate of TB among nurses, which is 3 times higher than that of all female population.

A patient with Graves' disease accompanied by bloody pericardial effusion.

A hyperthyroid patient with bloody pericardial effusion is presented. He was hospitalized for severe dyspnea. Pericardiocentesis yielded 1.2 liters of bloody fluid. Biochemical, cytologic, and radiologic examinations failed to identify the etiology of the effusion. Upon normalization of thyroid function using antithyroid drugs, the pericardial effusion resolved without recurrence. The patient was diagnosed as Graves' disease, which rarely is complicated by bloody pericardial effusion. As it is rarely reported and not widely known, this association may be underdiagnosed.