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Because of the diversity of cancer biology and multiple treatment options, which include focal therapy(surgical resection and radiotherapy)and systemic therapy, oncology practice is complicated and always challenging for oncologists and patients. To decide on an evidence-based optimal therapy, clinical guideline has a crucial role for physicians. However, there are discrepancies in the contents and accessibility to the guidelines among each. This article mentions the role of guidelines and how they are adapted into practice from the viewpoint of a medical oncologist working at a community hospital.

At small or mid-sized medical institutions, such as Japanese community hospitals, adequate infectious disease physicians (IDP) are lacking, mainly due to shortages of full-time pharmacists and IDPs who support antimicrobial stewardship team (AST) activities. With our hospital AST, we developed a multidisciplinary approach based on the interim reports of culture results or detected resistant bacteria for physicians, which are written by pharmacists and clinical laboratory technicians. At the AST conference, a pharmacist works as a chairman and reviews abstracts of cases which need to be discussed. We performed a retrospective analysis of the process and outcome of AST implementation, and introduced the use of reduction data for our hospital, obtained from Japan Surveillance for Infection Prevention and Healthcare Epidemiology (J-SIPHE). This program is important for pharmacists to promote the diagnostic process and comprehensive judgment necessary for bedside practice with infectious disease cases. We offer opportunities for pharmacy students to participate in the AST conference to learn how pharmacists consult with doctors about diagnosis and treatment. At present, the cooperation between AS and diagnostic stewardship (DS) has been emphasized, and improvements in a pharmacist's overall judgment regarding infectious disease cases are required to appropriate antimicrobial use. In addition, improving communication skills is essential for building a multidisciplinary approach. Regardless of the size of the facility, the role of pharmacists in AST should be implemented for the guidance of pharmacy students, which will help develop and secure future human resources at the facility.

There is a high rate of leakage after laparoscopic lower anterior resection(Lap-LAR).We examined the safety of Lap-LAR at community hospitals.We investigated 54 patients who underwent Lap-LAR at the 10 hospitals related to the Department of Surgery at Yokohama City University between April 2013 and March 2014.T he median patient age was 67 years, and 32 patients were men.Forty -eight(88%)cases were higher than pathological Grade T3, and 37(69%)patients had undergone D3 lymph node dissection.A diverting stoma(DS)was created in 13(24%)patients.An anus drain was placed in 23 (40%)patients.The clinical anastomotic leakage rate(13%)is comparable with the rate of the DS study(12.9%).The rate of anastomotic leakage was acceptable.Lap -LAR at a community hospital could be safely performed for rectal cancer by making appropriate case choices and implementing preventive measures against anastomotic leakage.

All the people have the right to die with dignity, but increase of elderly people and progress of the depauperation and isolation in Japan make it more difficult in this decade. As one of some solutions, we propose structuring the collaborative relationship between the critical care centers and the regional hospitals for the complicated patients. Patients inferred seriously ill should be transported first to the critical care center with substantial medical equipment and enough staff, diagnosed and stabilized in it. After those procedures, patients are transfered to and followed in the regional hospital for a certain period. These allotments of functions between hospitals are useful in the present condition.

Recently, reports of macrolide-resistant strains of Mycoplasma pneumoniae have been increasing. We examined the antimicrobial susceptibility and clinical significance in patients with M. pneumoniae. Seventy patients in whom M. pneumoniae was detected from 2008 to 2012 were included in the study, and compared with patients between 2003 and 2006. There were no macrolide-resistant strains detected in the 38 strains from 2003 to 2006, but from 2008 to 2012, out of the 70 strains 46 (65.7%) were positive for the macrolide-resistant 23SrRNA gene mutant (A2063G), which is consistent with recent trends. Comparison between cases of macrolide resistant strains and those with macrolide sensitive strains did not reveal a significant difference in the hospitalization period. The approximate duration of fever was 7 days; for both cases: those who received effective antimicrobials as the initial therapy, and for those with macrolide sensitive strains. It seems that the duration of fever depends on susceptibility to the initial antimicrobials regardless of macrolide resistance. There were some patients that improved without use of quinolone or minocycline, though macrolide-resistant strains were detected. These patients did not reveal extension of the hospital stay nor aggravation of pneumonia. This suggests that a macrolide drug might be the first choice drug for M. pneumoniae even now, and a change of drug should be considered when fever duration is long.

Purpose: We evaluated usefulness of transcatheter arterial embolization (TAE) for deep renal injury, and investigated whether there is any difference in outcomes for transcatheter arterial embolization (TAE) performed for deep renal injury in a large-sized hospital (university hospital) in comparison with a middle-sized hospital (local hospital)., Methods: We retrospectively reviewed the outcomes of 42 patients with renal injury who were transported to the critical care center of Nippon Medical School (NMS) Hospital in Tokyo from April 2001 to April 2011 and 33 patients of renal injury transported to the critical care center of Ohtawara Red Cross (ORC) Hospital in Tochigi prefecture from April 2001 to April 2009. Therefore, a total of 75 patients, which is the sum of the patients presenting to both the hospitals for renal injury were reevaluated according to the guidelines developed by the Japanese Association for the Surgery of Trauma (JAST) and published in 2008., Results: Forty-two patients in NMS hospital included 6 women and 36 men who were 16 to 88 years old (mean 41.6), and they were divided into Type I (16), Type II (11), and Type III (15) and were treated with bedrest (30), TAE (7), or laparotomy (5). Five patients died, but no one succumbed solely due to the renal injury. On the other hand, 33 Patients in ORC Hospital included 8 women and 25 men who were 16 to 87 years old (mean 46.6). They were divided into Type I (9). Type II (12), and Type III (12) and were treated with bedrest (24) or TAE (9). Eight patients died, but no one succumbed solely due to the renal injury. Sixteen patients were treated successfully with TAE in the 2 hospitals, and 15 of these 16 patients were divided into type III renal injury. Therefore, we believe that nephrectomy should be avoided in such patients because of the benefits offered by TAE., Conclusion: TAE was found to be useful for the treatment of type III renal injury in both institutions, irrespective of the size of a hospital.

In cooperation with the clinical laboratory, our Department of Laboratory Medicine has established a novel logistic support system. The goal of this system is to improve the efficacy of laboratory medicine for both the clinician and patient through a new advisory service. Any abnormal patient laboratory data are detected by computer, printed and then checked and analyzed by medical technologists. The resulting comprehensive interpretation report is checked and confirmed by a clinical pathologist. After the results are analyzed, the clinical pathologist sends relevant clinical comments to a clinician via electric medical records. Additional comments are provided if further tests are needed. In serious cases, the clinical pathologist contacts the clinician directly by mobile phone. This system can benefit the clinician and patient in regards to both risk management and medical audit. In addition, other medical staff may become more aware of the role of the clinical laboratory and the Department of Laboratory Medicine. In a community hospital, specialists in laboratory medicine are gatekeepers for risk management and medical audits through advisory services. The day when the necessity and importance of specialists in laboratory medicine are properly recognized will surely come in the future.

Kohka Public Hospital(KPH), approved as a regional cancer base hospital in February 2008, has concentrated on cancer treatment and care. KPH developed a Division of Home Care Medicine last year. A home care doctor visited and treated various patients, including cancer patients by co-operating with the Visiting Nurse Station; this resulted in an increase in home care patients but not of home deaths. To increase the cases of home care medicine, we believe that collaboration with other institutes and the creation of a regional network conference consisting of doctors, nurses, pharmacists, dental doctors, home helpers, and regional administrators is necessary. Via the conference, we recognized the need to obtain more information and create a system of collaborative home medication and care for cancer patients.

We have been practicing palliative care for terminal cancer patients at outpatient sections, patient wards, by home care, and by visiting nursing stations for the last 4 years. After the establishment of our palliative care unit in June 2011, it became difficult for us to provide sufficient home care support by ourselves, because of the increasing number of the patients and their widespread locations. It is therefore necessary to cooperate with regional medical clinics in order to support the patients who need home care even after their condition deteriorates. To determine the extent to which the home care-supporting clinics perform palliative care, we used an original questionnaire. Twenty-five clinics agreed to the publication of their names as our cooperating clinics. The number of patients who received palliative care at home from home care clinics after visiting our hospital increased from 8% to 14%, and the rate of patients who died at home also increased from 10% to 13%. Information about cooperating with home care clinics is very important and the improvement of palliative care skills necessary for home care doctors to continue their support for End-Of-Life cancer patients. Furthermore, the hospital should offer a strict and timely backup when the condition of patients treated at home suddenly deteriorates.

Unlabelled: background & aim: Elderly patients often suffer comorbidity, which leads to polypharmacy (≥ 6 concurrent medications). The extent of polypharmacy in very elderly patients in university hospitals has been reported, but not in community hospital outpatient units. We investigated polypharmacy in late-stage elderly patients at an outpatient unit of a community hospital., Methods: The study group comprised 159 patients who visited a community hospital during 6 consecutive days. We analyzed the number of consultations and the changeless prescriptions for the past three months or more in the medical records of these patients., Results: Patients took up to 15 types of medication (average 6.5 ± 3.5) and up to 36 tablets (average 12.4 ± 7.8 tablets/day) at the time of survey. Over 9 months, 76.1% of patients had multiple consultations. A total of 57.9% of patients received polypharmacy. Antihypertensive drugs were prescribed to 20.3% of patients. Inappropriate prescription accounted for 4.8% of a total of 1,031 prescriptions., Conclusion: A larger number of very elderly patients was receiving polypharmacy and multiple consultations in outpatient units of a community hospital than has been previously reported in university hospitals. It is important to prescribe appropriately for very elderly patients in teams which include pharmacists and nurses as well as doctors.

We require many types of jobs and a compact cooperation of an institution so that the terminal stage cancer patients undergo palliative care they hope. Even if the patient and family hope for palliative care at home, there are many cases with various limitations where they had to continue staying in the hospital. On the other hand, we experienced a case with a good use of surgeon's skills in which the patient was able to go back home. Another case was that the patient was able to go home from hospital for an overnight or two. One more case in point was that the patient's QOL had increased while he was alive, though the patient could not go back home. The palliative care that surgeon offers is not only provide a pain control, but he also has to give a thought that how the patient's QOL amelioration and daily clinical maneuverings(for stopping aggressive tumor invasions)by surgeon are balanced.

Confronted with treatment of leg ulcers and decubitus, a touch of arterial pulsation is necessary for diagnosis of peripheral arterial disease. Duplex scan reveals the site of arterial lesions, and if necessary, vascular reconstruction is done in order to promote peripheral circulation. Regardless of wound care which included irrigation and debridement, gangrene is worsening unfortunately, so we have to decide an amputation for life salvage. Some cases of decubitus, an operation of skin flap is effective for an early discharge. Vascular surgeons are familiar with these treatments so they are most adequate as an initiative leader for treating leg ulcers and decubitus.

In 2006, we reconfirmed Suwachuo hospital slogan as "When there is a need of community, we will do our best to meet it" and the department of home nursing care is officially established in our hospital next spring. A death rate at home is generally used to evaluate a home nursing care, and this rate at our department was 60.8% in 2008. However, community needs various options in addition to death at home. Keeping an eye on community opinions is of great importance.

Recently, there have been marked advances in the technological strategies employed in medical examinations. The educational concept to nurture highly capable medical technologists is considered to be a priority issue by not only educators but also employers, even though the medical educational levels have markedly improved in every college and university. It is commonly acknowledged that the results of any examination in the clinical laboratory should be accurate and fed back to medical doctors as soon as possible. The business outline of medical technologists in our hospital is becoming more extensive because we act as a core hospital in the area, and so knowledge regarding many kinds of chemical and transfusion examinations is required in operations performed around the clock. Furthermore, medical doctors, clerical workers, nurses, and volunteers comprise a team of sophisticated workers in our hospital. To accomplish our daily work, character traits such as accuracy, honesty, perseverance, and ability to follow instruction manuals, are the most fundamental and valuable. To nurture a highly career-oriented medical technologist, we propose that the following should be focused on: self-responsibility, reduction of malpractices, economic profitability, brainstorming, education of subsequent generations, and the spirit of cooperativeness and reconciliation. Additionally, it is another basic requirement of competent medical technologists to learn to adapt to laboratory-based changes in their work throughout their career. In conclusion, how to adapt to any social demand and learn strategies in any era should be taught in college or university as well as after graduation because each hospital and institute has a different philosophy and requirements of newcomers. It is important for medical technologists and doctors to develop flexible ways of thinking, although we sometimes might accede to traditional ways.

In the new post graduate training system, the 55% of interns in the Hokkaido area choosed the post graduate training at the general hospitals and 45% of them choosed the medical universities (Hokkaido university, Asahikawa medical university, Sapporo medical university). Furthermore, 23% of interns in Hokkaido area choosed the general hospitals and medical universities in Sapporo city. As to the post graduate training system in neurology, 5 hospitals included the neurology for at least 1 month to 3 months. On the other hand, in one general hospital in Sapporo city, the clinical training of neurology was not included in the post graduate training system. During 2 years of the new post graduate training system, only 25% of the interns could rotate the neurological department. Since the neurology training course is necessary for the post graduate training system, it is suggested to need to support the opportunity to rotate the neurology for the interns.

The Tama Nanbu-Chiiki hospital is a community health support hospital in the sphere of the Minamitama insurance medical treatment that consists of five cities of the Minamitama district in Tokyo. The cancer medical treatment and emergency care are assumed to be an emphasis in medical treatment at the hospital, and an acute short-term hospital has 306 beds. The community health support hospital is organized with a general manager, clerical workers, a nursing master of MSW and nurses, and they execute cooperation with a community health organization. In the fiscal year 2004, we handled a total of 240 terminal patients. Of these, the HPN introduction guidance was conducted to 87 patients, and 34 of the 87 patients were transformed to being homecare treatment. Here, we report the role of a nursing consultation master based on the cases we handled at this hospital. Meanwhile, we also introduce a home care adjustment procedure to home IVH induced patients who require advanced medical treatments for home recuperation, when they discharged from the hospital.

Tomo clinic is a special clinic for the handicapped. We have supported a day care center and a group home for persons with severe motor and intellectual disabilities (SMID) for over ten years. It seems that physical well-being declines dramatically in persons with SMID over 20-years old. We need special cooperation with the general hospital not only for the treatment of adult diseases including esophageal cancer, but also to backup the social activities of our clinic, because we support daily lives of persons with SMID and their families who want to live together in their own communities for as long as possible. The author reported the daily medical care activities in the day care center and the group home.

Background: In Japanese local hospitals there are not many persons who can give speedy and exact medical treatment in emergency. We investigated a role of anesthesiologists in the education of cardiopulmonary resuscitation (CPR) in local hospitals., Methods: A total of 3 doctors and 30 nurses completed the questionnaire about the education of CPR after training of advanced cardiac life support (ACLS) in a local hospital., Results: It showed that all doctors and nurses have had some anxiety about the emergency treatment of patients and could understand the importance of CPR. Moreover, most of them answered that they wanted to learn ACLS more, and that the training of ACLS simulation was the most impressive., Conclusions: It is important for anesthesiologists to teach ACLS and to promote the spread of ACLS in local hospitals.

We report an elderly advanced NSCLC patient effectively treated with vinorelbine on an outpatient basis in cooperation with his family doctor. A 79-year-old man was referred to our hospital for evaluation of a nodular shadow in his right lung. Chest CT scan showed a 2.0 cm tumor shadow in right S1, and small nodular shadows in right S4 and left S5. Neck lymph node biopsy yielded a diagnosis of adenocarcinoma. The clinical stage was IV, and he underwent chemotherapy of vinorelbine 25 mg/m2 on days 1 and 8. The regimen opted for a setup of a schedule, while the dose of vinorelbine and evaluation by CT were done in our hospital. This regimen was well tolerated and suitable. The patient could receive long-term continuation of the chemotherapy medication, and showed improvement in terms of prolongation of life and QOL.

We previously reported a hospital-based retrospective study on community-acquired pneumonia (CAP) at Tagami Hospital, which was a community hospital, between 1994 and 1997. This study was designed to clarify the etiology of CAP diagnosed between 2000 and 2002. We analyzed a total of 124 cases of CAP in our hospital during the study period, and compared the results with the previous data. Identification of the causative organisms of CAP was based on gram staining, the morphology of the colonies, quantitative culture of the sputum, and the serological tests. During the study period, we determined the causative organisms in 42 cases (33.8%). Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis were the major causative organisms. The severity of the cases was classified into three groups according to the guideline for CAP, which was edited by the Japanese Respiratory Society. The survival rates in the moderate and severe groups were significantly (p < 0.001) higher than that of the mild group, as analyzed by the Kaplan-Meier method, as follows: 70% (moderate) vs 100% (mild); and 40% (severe) vs 100% (mild). In a total of 7 patients who died, we found the following risk factors: elderly male patients, bedridden status with cerebral infarction, and micro-aspiration, including recurrent pneumonia at short intervals of less than 17 days. Our study indicated that the JRS-edited guideline for CAP is a very useful tool for analyzing cases with CAP in Japan.

Tama Nambu-Chiiki Hospital is a secondary medical institution providing the acute short-term care centered on cancer treatment and emergency medical service, which few other medical institutions in the region provide. The hospital, which has no system to directly support home medical care by house visit or visiting nurses, needs to coordinate home medical care with other community medical institutions. 2 nurses serve as the Nursing Consultants who provide consultation services over the issues related to home medical care and other issues face to face or by phone and coordinate home medical care with other community medical institutions. Medical coordination based on trust and understanding of home medical care by hospital staffs are essential for the smooth transfer to home medical care. Activities of the hospital are studied to cope with the changes in healthcare trend.

Tama Nambu-Chiiki Hospital is a secondary medical institution providing the acute short-term care centered on cancer treatment and emergency medical service, which few other medical institutions in the region provide. The hospital, which has no system to directly support home medical care by house visit or visiting nurses, needs to coordinate home medical care with other community medical institutions. 2 nurses serve as the Nursing Consultants who provide consultation services over the issues related to home medical care and other issues face to face or by phone and coordinate home medical care with other community medical institutions. Medical coordination based on trust and understanding of home medical care by hospital staffs are essential for the smooth transfer to home medical care. Activities of the hospital are studied to cope with the changes in healthcare trend.

As clinical training has become a compulsory element of the training of physicians, all doctors are now required to undergo training in basic abilities of diagnosis and treatment. Clinical training has become possible in local medical organizations as well as university hospitals and large hospitals. There are full-time clinical pathologists in the laboratory staff of large hospitals, but they have little time for clinical trainees in the present educational system in the field of clinical laboratory. In mid-size and small hospitals, there is no clinical pathologist at the central diagnostic and treatment division, and clinical laboratory technicians are expected to play roles of trainers. It is important for the training administrator to prepare an environment in which clinical trainees can learn the selection of examinations, execution of examinations, interpretation of results, and actual handling of patients and, particularly in the execution of examinations, to cooperate with the director of the examination division and see that trainees can learn the necessary skills that they must acquire. The training administrator must also formulate a program to help clinical trainees to develop the abilities necessary for them to function as a member of team care. Such a program must not only be effective for the training of physicians but also contribute to the development of laboratory technicians and to improvements in the quality of medical care that is provided.

Since convulsions associated with the concurrent administration of enoxacin and fenbufen were reported in 1986, the concurrent administration of quinolones and anti-inflammatory drugs has been regulated to be contraindicated or carefully administered. However, the real incidence of the co-administration is not clear. We surveyed the incidence of co-administration of these drugs from the prescriptions in a community hospital. Quinolones were prescribed in 1% of the out-patients, and anti-inflammatory drugs were co-administrated in 16% of quinolone-prescribed patients. Among quinolones prescribed, levofloxacin was used most frequently. And acetaminphen (including acetaminophen-combination) was most frequently prescribed with quinolones, and anti-inflammatory drugs, which is regulated to be carefully administrated with quinolones, were frequently co-prescribed. In medical practice, quinolones were revealed to be co-administered with anti-inflammatory drugs. Since our recent report suggests that each quinolone and each anti-inflammatory drug has different activity in their drug interaction, it should be necessary to recognize the interaction of these drugs separately for their effective and safe use in clinical field.

The area distribution of out-issued prescriptions for outpatients in Saiseikai Kurihashi Hospital was surveyed over 6 months from the first day of out-issue. Behavior patterns of outpatients in the selection of pharmacy were also investigated. Our survey included the out-issued prescriptions in eight surrounding newly established pharmacies together with the first out-issue. Computer simulation indicated that 70% of the outpatients selected the surrounding pharmacies when they received their out-issued prescriptions the first time. However, the percentage of surrounding pharmacies selected by the patients decreased to 60% the second time, and then again increased to 80% the third time. The results suggest that most outpatients use surrounding pharmacies, although they try to use the pharmacies near their homes for a time.

The clinical features of 8 patients with pulmonary tuberculosis under treatment in the Koebaru Central Hospital, a community hospital without restricted tuberculosis wards, between 1992 and 2000 were evaluated. The major findings in the present study were: i) recently, the number of elderly patients with reactivated pulmonary tuberculosis has increased, ii) none of the patients showed respiratory symptoms, and 3 patients had negative Mantoux skin tests, iii) only one patient showed cavities on chest radiography, and iv) none of the expectorated sputum samples was smear-positive for Mycobacterium tuberculosis. Smears of intrabronchial sputum sampled using a fiberoptic bronchoscope from pulmonary lesions in patients without any symptoms were useful for establishing the diagnoses. Considering all aspects, it is important to perform aggressive evaluations, even for elderly patients, utilizing a fiberoptic bronchoscope for early diagnosis of pulmonary tuberculosis and to prevent nosocomial infections.

Purpose: To examine the prevalence of diabetic retinopathy and the relationship between diabetic retinopathy and systemic risk factors., Methods: A cross sectional study of diabetic retinopathy was conducted on 1,826 eyes of 913 randomly selected patients with type 2 diabetes in 9 central hospitals in Aomori Prefecture and the surrounding district. Retinopathy levels and maculopathy were assessed by binocular funduscopy, fundus photography and, if necessary, by fluorescein angiography. Multiple logistic regression analysis was performed to determine independent effects of systemic risk factors on diabetic retinopathy., Results: The prevalence of background retinopathy was 31%, of preproliferative retinopathy 5%, and of proliferative retinopathy 5% in all patients. However, in 3 hospitals in which the patients were routinely examined by fluorescein angiography, background retinopathy was found to be present in 60%, preproliferative retinopathy in 5%, and prolifertive retinopathy in 7%. Maculopathy was found in 8% of diabetic patients and the prevalence was 11% in the eyes with background retinopathy, 40% with preproliferative retinopathy, and 50% with proliferative retinopathy. Multiple logistic regression analysis showed that retinopathy was significantly associated with duration of diabetes, methods of diabetic control, hypertension, nephropathy, and neuropathy., Conclusion: The detection rate of background diabetic retinopathy by fluorescein angiography was twice as sensitive as that by binocular funduscopy and fundus photography. The prevalence of maculopathy increases with the progression of retinopathy. Several systemic risk factors have significant association with diabetic retinopathy and maculopathy.

The doctor of clinical laboratory medicine in the core hospital at a local city should grasp the situation of the clinical laboratory under present medical institute and submit measures for renovation of the laboratory. Further, the doctor should take part in medical consultation based on the laboratory data.

To determine changes in the clinical features of recent patients with pulmonary tuberculosis in a community hospital without restricted tuberculosis wards, the clinical findings of 112 patients with pulmonary tuberculosis (containing miliary tuberculosis) during the past 15 years were compared by dividing the patients into three groups, each encompassing a five-year period. Recently, the number of patients with pulmonary tuberculosis was found to be increasing in a community hospital. In particular, the percentages of elderly patients and smear positive patients have increased. However, because of the improving awareness on tuberculosis, we have diagnosed TB cases correctly on admission and tended to perform the appropriate treatment. The comparative study between pulmonary tuberculosis patients diagnosed at the outpatients department and diagnosed after admission indicated that the patients diagnosed after admission showed pneumonia-like infiltrative shadows without cavity formation and lower smear positivity for tubercle. Fortunately, resistance to antituberculous drugs of isolated tubercle bacilli in our community hospital has not yet increased and the prognosis of the cases proved to be good when the appropriate treatment was performed at an early stage.

To clarify the characteristic features of nursing home-acquired pneumonia in our community hospital, we performed a clinical analysis of 86 patients with nursing home-acquired pneumonia. The patients were divided into young and elderly groups. In the young group cerebral palsy was the underlying disease. In the elderly group, it was cerebrovascular attack. Although there were no differences in ADL, the nutritional condition of the young group was comparatively good, the isolated microorganism consisted of mostly Mycoplasma pneumoniae and the prognosis was good. The elderly group where the nutritional condition was poor, the patients were detected by non-respiratory symptoms and risk factors such as obvious episodes of aspiration led us to be concerned about the risk factors for nursing home-acquired pneumonia. The microorganism isolated from the sputum of the elderly group was frequently a multi-drug resistant microorganism such as Methicillin-resistant Staphylococcus aureus (MRSA) and polymicrobial infection. Their prognosis was poor despite treatment with multiple antibiotics. In the comparative study between survivors and non-survivors in the elderly group, risk factors such as hypotension, consciousness disturbance, the extension of infiltration shadows, respiratory failure, multiple organ failure and metabolic acidosis were influenced for the prognosis, but the isolated microorganisms and the antimicrobial agents were not concerned.

A study was made to clarify to what degree the booster phenomenon was present when the employees in a community hospital in Japan received two-step tuberculin testing (PPD). Of the seventy-five employees, most of all BCG-vaccinated subjects, twenty-three showed strongly positive of more than 30 mm of induration at the first test (PPD/T1), and the remaining fifty-two subjects received a second (PPD/T2) after 2 weeks. The second PPD showed a marked increase in reactivity, sixteen subjects newly became strongly positive and six of eight who were initially PPD negative (< 10 mm) were converted positive, and the mean reaction size changed from 14.7 +/- 5.6 mm (PPD/T1) to 31.5 +/- 15.5 mm (PPD/T2). The degree of boosting, measured by the change in millimeters induration size between PPD/T1 and PPD/T2 (PPD/T2-PPD/T1), was correlated with neither the size of PPD/T1 nor the age of the study participants, and was not associated with the difference of the position in the hospital. Thus, we could not explain the factor why such a marked boosting was observed in this study. However, these results indicated that the two-step tuberculin testing is an essential means of distinguishing new tuberculous infection from booster phenomenon. We agree with the current recommendation for routine two-step testing of new employees in the hospital.

Yukiguni Yamato General Hospital (199 beds) is one of main local hospitals of Minamiuonuma area in Niigata prefecture. From June 1997, an anesthesiologist has been employed as a staff of this hospital instead of parttimers. We examined whether employment of an anesthetic staff was useful for a local hospital or not, in terms of clinical and cost advantages. There were benefits in explaining the nature of anesthesia, possible risks, operating room and pre-postoperative procedures to the patients. And there were advantages in reducing anesthetic management fee, in shortening the staying time in operating room. We conclude that there are many benefits in obtaining an anesthesiologist for a local hospital staff, but there are some drawbacks in having to work alone.

94 patients with tuberculosis were identified in a 236-bed community general hospital without a dedicated tuberculosis ward from June 1986 to February 1998. 69 patients had bacteriological proof of tuberculosis, and the remaining 25 had clinical evidence thereof. The mean age of all patients was 63.0 years (range: 23-89 years), and the male to female ratio was 2:1. 70 of these cases were admitted. During this same period of time, the total number of inpatients admitted to the internal medicine ward reached around 11,000. Excluding 6 cases who were referred to other hospitals with a tuberculosis ward, the mean duration of hospital stay of the remaining 64 cases was 51.6 days. Among all 94 cases, 62 had pulmonary tuberculosis and the other 32 had extrapulmonary manifestations. The latter group was comprised of 11 with miliary dissemination, 8 pleuritis, 4 osteomyelitis, 2 peritonitis, 2 urinary tract disease, 1 pericarditis, 1 intestinal disease, 1 meningitis, 1 intracranial tuberculoma and 1 genital disease. 3 cases of miliary tuberculosis with dissemination died with antemortem diagnoses of fever of unknown origin, pneumonia, and lung cancer with brain metastasis. These 3 cases illustrate the importance of heightened suspicion of tuberculosis among our patient population. Referral of patients with positive sputum smears to hospitals with a tuberculosis ward has occasionally been difficult because of inaccessibility. Critical comorbid diseases such as chronic renal failure requiring hemodialysis and malignancies are additional limiting factors to transfer to such facilities. Therefore, because of the prevalence and extent of this disease, its myriad clinical presentations, challenges associated with establishing an early diagnosis, and need to prevent spread to family, other patients, and staff, dedicated beds for care of tuberculosis in general hospitals are mandatory.

To clarify the characteristic features of nosocomial pneumonia in a community hospital, we performed a clinical analysis of 147 patients (155 episodes) with nosocomial pneumonia. The following results were obtained. 1, Regarding the risk factors for nosocomial pneumonia, factors such as the patient whose age was over 65 years, a duration of admission of over one month, performance status 4 and underlying respiratory diseases associated with the appearance of nosocomial pneumonia. 2, The causative microorganism isolated from the sputum of the patient with nosocomial pneumonia was frequently a multi-drug resistant microorganism such as Methicillin-resistant Staphylococcus aureus (MRSA). 3, regarding treatment, although several antibiotics were administered for a long time, mechanical ventilation was used on 31% of the patients, and steroid pulse therapy was carried out on 24%. The clinical efficacy was poor with a 50% mortality rate. The reason why treatment of nosocomial pneumonia was difficult is thought to be been related to the general condition of these inpatients and to the appearance of a multi-drug resistant, polymicrobial microorganisms.

In Japan, sleep-related disorders (SRD) have been handled by only a few university teams, and mainly on a research basis, because polysomnography (PSG) is labor-intensive, expensive, and unprofitable. Although public consciousness of SRDs has been raised by mass-media campaigns, the situation is far from ore that would meet patient's demands. We have done 1476 PSG tests over about five years, and diagnosed more than 600 cases of SRDs. Therapy included nasal continuous positive airway pressure in 170 cases, prosthetic mandibular advancement in 55 cases, and uvulopalatopharyngoplasty and related operations in 97 cases. We describe how we set up a sleep laboratory and a care system, and how to circumvent problems. Several points related to the selection of patients for PSG in daily clinical practice can be clarified with our data. Computerized sleep respiratory analyser might save time and money, but their advantages and disadvantages should be studied. The approach to SRDs should be comprehensive and systematic, and polysomnographers play an important role. We need programs organized by scientific institutions to train polysomnographers. Research should continue not only on scientific aspects of SRDs but also on the way patients with SRDs are cared for. Reasonable insurance coverage of the costs of nosal continuous positive airway pressure and of PSGs is essential for widespread access to these services.

Fifty patients with extrapulmonary tuberculosis were diagnosed at 4 community hospitals in Tokyo during 1981 to 1992. The percentage of extrapulmonary tuberculosis among the all types of tuberculosis was 10.5% as a whole, and 16% in females and 7.9% in males. The number of patients older than fifth generation was about two times more than that of younger generations. And the patients were more in males than in females under the forties, but were more in females than in males over the sixties. On chest radiogram, there was no pathological findings in 52% of the patients and active pulmonary tuberculosis was detected in 32% of the patients. The majority of the extrapulmonary tuberculosis (30 cases, 60%) was of lymph nodes, especially of cervical lymph nodes, and the remaining were 10 cases of tuberculosis in bone and joint, 4 each in intestine and pericardium, 2 each in liver, peritoneum, kidney, urinary bladder, epididymis and skin. Among 30 cases with tuberculous lymphadenopathy, the disease were observed in cervical lymph nodes by 19 cases, in pulmonary hilar and axillary node by each 4 cases and in abdominal cavity by 3 cases.