70歳,男性。数日で体重が13kg増加し,低Alb血症(1.4g/dL)が出現し,当科に入院した。入院時,リウマチ因子・抗核抗体・抗SS-A抗体陽性および補体低値で,体幹部造影CT検査で腹部大動脈に壁在血栓を認めた。99mTc標識ヒト血清Albシンチグラフィ検査を行い,胃下部～上部空腸にradioisotopeの集積があり,自己免疫性蛋白漏出性胃腸症と診断した。プレドニンを開始したが,その10日後,強い上腹部痛が出現した。D-dimerが著明な高値で,体幹部造影CT検査で腹部大動脈,上腸管膜動脈等に血栓が多発していた。ヘパリンによる抗凝固療法を開始し,腹痛は軽快,D-dimerは低下した。血清Albも上昇傾向に転じ,その後,体幹部造影CT検査で血栓は消失した。動脈硬化性疾患の危険因子を有している蛋白漏出性胃腸症の症例においては,血栓症の精査を行い抗凝固療法の導入を検討すべきである。(著者抄録)

COVID-19患者に対応した医療者の職種と身体・精神症状の関連について検討した。対象は当院(3次医療機関)で本症患者の診療に従事した71名(医師27名、看護師25名、技師19名)である。患者との接触の程度や身体・精神症状の有無などを質問紙で週2回確認した。接触頻度は多い時で平均4.2日/週であった。身体症状の有訴率は28.2%で、鼻水・鼻づまりと頭痛が多かった。精神症状の有訴率は31.0%で、不安と神経過敏が主であった。看護師は医師に比べ、気分の落ち込み(36.0% vs.0%)および不安(52.0% vs.7.4%)の有訴率が高かった(各P<0.01)。多変量解析による精神症状出現の予測因子は、看護師(オッズ比4.90、P=0.04)と身体的愁訴(4.66、P=0.02)であった。身体症状を有する医療者、特に看護師の身体面と精神面の健康管理に一層配慮する必要があることが示唆された。

DOI： 10.1016/j.ijantimicag.2023.106767

PubMed

Authorship：Last author   Publishing type：Research paper (scientific journal)   International / domestic magazine：International journal  

BACKGROUND: Hypervirulent Klebsiella pneumoniae (hvKp) infections confer notable morbidity and mortality. Differential diagnosis to determine whether the infections are caused by either the hvKp or classical K. pneumoniae (cKp) strain is particularly important for undertaking optimal clinical care and infection control efforts. AIM: To identify and assess the potential predictors of hvKp infections. METHODS: PubMed, Web of Science, and Cochrane Library databases were searched for all relevant publications from January 2000 to March 2022. The search terms included a combination of the following terms: (i) Klebsiella pneumoniae or K. pneumoniae and (ii) hypervirulent or hypervirulence. A meta-analysis of factors for which risk ratio was reported in three or more studies was conducted, and at least one statistically significant association was identified. FINDINGS: In this systematic review of 11 observational studies, a total of 1392 patients with K. pneumoniae infection and 596 (42.8%) with hvKp strains were evaluated. In the meta-analysis, diabetes mellitus and liver abscess (pooled risk ratio: 2.61 (95% confidence interval: 1.79-3.80) and 9.04 (2.58-31.72), respectively; all P < 0.001) were predictors of hvKp infections. CONCLUSION: For patients with a history of the abovementioned predictors, prudent management, including the search for multiple sites of infection and/or metastatic spread and the enforcement of an early and appropriate source control procedure, should be initiated in consideration of the potential presence of hvKp. We believe that this research highlights the urgent need for increasing clinical awareness of the management of hvKp infections.

DOI： 10.1016/j.jhin.2023.02.005

PubMed

DOI： 10.1002/jgf2.538

PubMed

Publishing type：Research paper (scientific journal)   International / domestic magazine：International journal  

BACKGROUND/PURPOSE: Klebsiella pneumoniae bacteremia-induced sepsis is a clinically important condition with a high mortality rate and various known virulence factors. However, studies on the association of these virulence factors with the occurrence of K. pneumoniae bacteremia-induced sepsis are scarce. We aimed to investigate clinical variables and virulence factors in patients with K. pneumoniae bacteremia-induced sepsis. METHODS: We retrospectively reviewed the medical records of 76 patients with K. pneumoniae bacteremia between January 2012 and July 2017. Patients were divided into sepsis (n = 25) and non-sepsis (n = 51) groups. Patient background characteristics, antimicrobial regimens, and prognosis were evaluated. We assessed the distribution of virulence factors related to K. pneumoniae, such as mucoviscosity, capsular polysaccharide, and siderophores. Siderophore production levels were determined by measuring the orange halo zone on chrome azurol S agar plate assay. RESULTS: There were no intergroup differences in male-to-female ratio and age. Multivariable analysis revealed that siderophore production level (p < 0.01) was an independent predictor of K. pneumoniae bacteremia-induced sepsis. Furthermore, the optimal cut-off point of siderophore production to predict sepsis was 9.6 mm (sensitivity, 86%; specificity, 76%; AUC, 0.81). CONCLUSION: Siderophore production was an independent predictor of sepsis caused by K. pneumoniae bacteremia. The optimal cut-off point for siderophore production for sepsis occurrence prediction was 9.6 mm. To improve outcomes, patients with K. pneumoniae bacteremia-induced sepsis with high siderophore production levels should be managed prudently.

DOI： 10.1016/j.jfma.2021.06.027

PubMed

大阪市立大学医学部附属病院では、これまで腹部超音波検査(Ultrasonography;US)手技トレーニングを対面で実施してきた。今回、新型コロナウイルス感染症をきっかけに、受講者(初期臨床研修医)と指導者が、遠隔でリアルタイムにUS手技トレーニングを実施することとし、課題画像を対面時の10種類から13種類に増補して講習会を開催し、全受講者(5名)が課題画像の描出に成功した。US手技遠隔トレーニングは、感染症の流行下においても実施が可能であるだけでなく、1)遠隔地でのトレーニングを可能とし、2)1度に複数名の指導が実現できるため、医療手技教育の発展に有効な手段であることが示唆された。(著者抄録)

Publishing type：Research paper (scientific journal)   International / domestic magazine：International journal  

BACKGROUND: Healthcare workers (HCWs) who manage patients with the novel coronavirus disease 2019 (COVID-19) are at an increased risk and fear of contracting the infection themselves. Hospitals must reduce both the physical and mental burden of HCWs on the front lines and ensure their safety. No prospective study has focused on the physical health complaints among HCWs engaged in the care of critically ill COVID-19 patients. This study aimed to evaluate the prevalence of various physical symptoms experienced by HCWs following their exposure to COVID-19 patients and investigate the association between occupation and the manifestation of physical symptoms among HCWs at a tertiary hospital in Japan during the current ongoing COVID-19 pandemic. METHODS: A twice-weekly questionnaire targeting HCWs who care for COVID-19 patients was performed at Osaka City University Hospital from April 30 to May 31, 2020. The demographic characteristics of the participants, frequency of exposure to at-risk care, and physical complaints were evaluated. RESULTS: Seventy-six HCWs participated in this study, of whom 24 (31.6%) were doctors, 43 (56.6%) were nurses, and 9 (11.8%) were technicians. The frequency of experiencing any physical symptom was 25.0% among HCWs. Exposure to at-risk care was significantly higher among nurses than among doctors (p < 0.001). Notably, the frequency of physical symptoms among the nurses was very high at 39.5% and obviously higher than that of physical symptoms among the doctors (p < 0.01). CONCLUSIONS: Our results indicate that hospital occupational health care must be provided to HCWs who are engaged in the care of COVID-19 patients and are thus highly exposed to at-risk care.

DOI： 10.1016/j.jiph.2021.08.023

PubMed

Publishing type：Research paper (scientific journal)  

Publishing type：Research paper (scientific journal)  

DOI： 10.1016/j.jfma.2021.06.027

PubMed

Publishing type：Research paper (scientific journal)  

DOI： 10.11307/mededjapan.52.3_278

CiNii Article

Authorship：Last author   Publishing type：Research paper (scientific journal)  

54歳男性。1ヵ月にわたり持続する発熱の精査目的で入院となった。腹部超音波検査では肝右葉に最大40mm大の境界不明瞭な低エコー領域が認められた。また、腹部造影CTでは肝右葉に辺縁のみ造影される境界明瞭な低濃度域に加え、小腸内に20mm大の異物がみられた。一方、小腸内視鏡では異物は確認できなかったが、2度目のCTでも小腸内の異物は確認された。以上、これらの所見を踏まえて、本症例は小腸の異物穿孔による肝膿瘍が疑われた。腹腔鏡下手術を行ったところ、手術所見ではMeckel憩室に硬結が触知され、同部位を切除した結果、最終的にMeckel憩室への異物(魚骨)穿通による肝膿瘍と確定診断された。術後は発熱および炎症反応の再燃はなく、経過は良好であった。

Publishing type：Research paper (scientific journal)  

Publishing type：Research paper (scientific journal)   International / domestic magazine：International journal  

Smoking predisposes individuals to endothelial dysfunction. Flow-mediated dilation (FMD) and reactive hyperemia peripheral artery tonometry (RH-PAT) are used to assess endothelial function. However, whether smoking cessation demonstrates comparable effects on endothelial function evaluated by FMD and RH-PAT remains unclear. Thus, we aimed to evaluate the effects of smoking cessation on endothelial function evaluated simultaneously by FMD and RH-PAT and clarify the factors associated with these effects. Fifty-eight consecutive current smokers (mean ± standard deviation; age, 64 ± 11 years) who visited our smoking cessation outpatient department and succeeded with smoking cessation were enrolled. Twenty-one continued smokers were enrolled as age- and sex-matched controls. Clinical variables, FMD, and natural logarithmic transformation of the reactive hyperemia index (Ln-RHI) were examined before and 20 weeks after treatment initiation. In 58 smokers who succeeded with smoking cessation, FMD significantly improved (3.80 ± 2.24 to 4.60 ± 2.55%; p = 0.013), whereas Ln-RHI did not (0.59 ± 0.28 to 0.66 ± 0.22; p = 0.092). Spearman's rank correlation coefficient between changes in FMD and Ln-RHI was -0.004, and the intraclass correlation coefficient for a two-way mixed effects model was <0.001 (p = 0.499). In multivariate analysis, the presence of an increase in FMD was inversely correlated with the Brinkman index and changes in systolic blood pressure (SBP), whereas Ln-RHI was positively correlated with changes in SBP and inversely correlated with baseline body mass index. These factors may predict the varying effects of smoking cessation on the endothelial function of the conduit and digital vessels.

DOI： 10.1038/s41440-020-0516-z

PubMed

Publishing type：Research paper (scientific journal)  

血管内皮機能に対する禁煙の効果を血流依存性拡張反応(FMD)と反応性充血末梢動脈圧測定(RH-PAT)により評価し、その効果に関連する予測因子について検討した。禁煙成功者58名(平均64±11歳)と年齢、性を一致させた喫煙継続者21名を対象に、禁煙前および禁煙20週後の臨床検査値、FMD、および反応性充血指数の自然対数変換値(Ln-RHI)を解析した。禁煙成功者はFMDが有意に改善したが、Ln-RHIに著明な変化はなかった。両者の変化の関連性は、Spearmanの順位相関係数が-0.004で、級内相関係数が<0.001(p=0.499)であった。ロジスティック回帰分析でFMD増加と関連がみられた項目はBrinkman指数(オッズ比0.99,p=0.043)と禁煙前後の収縮期血圧変化(0.94,p=0.040)であり、Ln-RHI増加に関連する項目は収縮期血圧変化(1.06,p=0.047)と禁煙前BMI(0.83,p=0.032)であった。これらの項目が内皮機能に対する禁煙効果を予測し得る可能性が示唆された。

Publishing type：Research paper (scientific journal)  

DOI： 10.11307/mededjapan.52.3_278

CiNii Article

We held an abdominal ultrasonography(US)training seminar using by remoted WEB system. Trainees were instructed to acquire several target images and worked on their respective US simulators. Their ultrasound images were shared to the instructor simultaneously. All the trainees have successfully achieved the goals. Not only can this attempt be carried out under viral epidemic, but also it demonstrates possibilities of 1) distant area training, 2) parallel personalized teaching with multiple trainees. The study suggest that the method can be an effective means for the development of skills education in medicine.

DOI： 10.50950/jasehp.2021-09-06

CiNii Article

Publishing type：Research paper (scientific journal)  

当院では2012年より、医学部5年生を対象に、教授の病棟総回診の直前に呼吸音聴診シミュレータを用いた実習を開始している。本研究では、シミュレータを用いた呼吸音聴診実習の教育効果を調べた。医学部5年生をS群(9名)とN群(9名)に分けた。S群には教授回診の直前にシミュレータを用いた実習を1時間実施した。N群には四つの異常な呼吸音の録音を聞いてもらった。その後、両群の学生が患者の呼吸音を聴診し、その所見を教員が確認した。その結果、両側呼吸音聴取の正答率はS群がN群よりも有意に高かった。fine cracklesとcoarse cracklesについては、S群がN群よりも正答率が高い傾向にあった。標準予防策、コミュニケーション、受講者の態度ついては両群間で有意な差は認められなかった。聴診技術についてはS群がN群よりも有意に優れていた。

DOI： 10.1007/s10549-020-05835-8

Publishing type：Research paper (scientific journal)  

Publishing type：Research paper (scientific journal)   International / domestic magazine：International journal  

BACKGROUND AND AIMS: Eicosapentaenoic acid (EPA) has been reported to reduce cardiovascular risk in patients with hypertriglyceridemia. Although several mechanisms underlying the effects of EPA have been demonstrated, those responsible for its beneficial role in patients with hypertriglyceridemia without evidence of coronary artery disease (CAD) have not been fully elucidated. We sought to clarify the main factors associated with EPA administration that led to improved endothelial function. METHODS: Forty-seven consecutive patients with mild hypertriglyceridemia (mean age, 59 ± 13 years) without evidence of CAD were prospectively enrolled and administered purified EPA (1800 mg/day). Forty-four patients who were not administered EPA were enrolled as age- and sex-matched controls. Clinical variables and flow-mediated dilation (FMD) were examined before and after 6 months of treatment. Univariate and multivariate regression analyses were performed between FMD changes and clinical variables. RESULTS: EPA treatment decreased triglyceride levels (from 224.6 ± 58.8 to 151.8 ± 54.5 mg/dl, p < 0.001) and increased FMD (from 4.21% ± 1.91% to 6.21% ± 2.30%, p < 0.001). Multivariate analysis showed that the change in FMD was associated with the baseline high-density lipoprotein cholesterol (HDL-C) level (β = -0.331, p = 0.027) and the change in EPA/arachidonic acid (AA) ratio (β = 0.301, p = 0.048). CONCLUSIONS: EPA treatment improved triglyceride levels and FMD in patients with mild hypertriglyceridemia and without evidence of CAD. The baseline HDL-C level and the change in EPA/AA ratio predicted FMD improvement. The beneficial effects of EPA on triglyceride-rich lipoproteins and vascular endothelium may help improve endothelial function.

DOI： 10.1016/j.atherosclerosis.2020.07.013

PubMed

Publishing type：Research paper (scientific journal)  

DOI： 10.1038/s41440-020-0516-z

PubMed

Publishing type：Research paper (scientific journal)  

ノイラミニダーゼ阻害剤(NAI)であるラニナミビル、ペラミビル、オセルタミビル、ザナミビルの処方傾向を8年にわたって調べ、インフルエンザに関連する臨床データを評価した。インフルエンザと診断された患者に対しアンケート調査を依頼し、人口統計学的特徴、発熱などの症状、処方薬、インフルエンザの種類に関するデータを収集した。その結果、ラニナミビルは10歳以上の患者に最も処方され、オセルタミビルは10歳未満の患者に最も処方されていた。4種類のNAIはいずれもインフルエンザに対して同様の効果を示した。A型インフルエンザの患者はB型インフルエンザの患者よりも早く熱が下がった。高齢患者は発熱時の体温が低い傾向があった。ほとんどの季節で同様の結果となった。

Publishing type：Research paper (scientific journal)   International / domestic magazine：International journal  

Klebsiella pneumoniae bacteremia is a critical clinical presentation that is associated with high mortality. However, extremely few studies have investigated the virulence factors related to mortality of K. pneumoniae bacteremia in patients. The present study elucidated clinical and virulence factors associated with the 30-day mortality of K. pneumoniae bacteremia at a tertiary hospital. The medical records of 129 patients with K. pneumoniae bacteremia admitted to Osaka City University Hospital between January 2012 and December 2018 were retrospectively reviewed. Patient background characteristics, antimicrobial regimens, and prognosis were evaluated. Additionally, virulence factors were assessed using multiplex polymerase chain reaction to elucidate their association with K. pneumoniae. The 30-day mortality was 10.9% in patients with K. pneumoniae bacteremia. The male-to-female ratio, age, and underlying disease did not differ between the non-survivor and survivor groups. Multivariate analysis showed that sepsis (odds ratio (OR), 7.46; p = 0.005) and iutA (OR, 4.47; p = 0.046) were independent predictors associated with the 30-day mortality of K. pneumoniae bacteremia. Despite the relatively low 30-day mortality of patients with K. pneumoniae bacteremia, the treatment of those with sepsis and those infected with K. pneumoniae harboring iutA may require careful management for improving their outcomes.

DOI： 10.1007/s10096-019-03676-y

PubMed

Publishing type：Research paper (scientific journal)  

Publishing type：Research paper (scientific journal)   International / domestic magazine：International journal  

This study aimed to assess the predictive factors of bacteremia due to hypermucoviscous Klebsiella pneumoniae (hvKP), as well as the mortality. The medical records of 114 patients with K. pneumoniae bacteremia who were divided into the hvKP (n = 24) and non-hvKP (n = 90) groups and were retrospectively reviewed. The male-to-female ratio, age, and underlying disease did not differ between the 2 groups. Mortality was higher among patients in the hvKP bacteremia group than in the non-hvKP bacteremia group (29.2% vs 6.7%). Multivariate analysis showed that the independent predictors associated with hvKP bacteremia were abscess (P = 0.01) and no antibiotic exposure (P = 0.02); thus, early assessment of these conditions is important. For patients with a history of abscess and no antibiotic exposure, it is necessary to administer treatment while keeping the risk of hvKP in mind.

DOI： 10.1016/j.diagmicrobio.2019.04.008

PubMed

Publishing type：Research paper (scientific journal)   International / domestic magazine：International journal  

A recent increase in the incidence of hypervirulent Klebsiella pneumoniae (hvKP) infections, especially those caused by a sublineage of clonal group CG23 (CG23-I), is raising serious health concerns worldwide. The high virulence of hvKP is, at least in part, attributed to the overproduction of capsular polysaccharide (CPS), which is triggered by a positive regulator of capsular polysaccharide synthesis (cps) genes, named rmpA (regulator of mucoid phenotype A). Although extensive research has been conducted on the mechanisms of hvKP virulence, no study has focused on the development of antivirulence therapeutics. This study attempted to identify and validate an antimicrobial agent able to suppress hvKP hypermucoviscosity. A total of 18 commercially available antimicrobial agents, including β-lactams, quinolones and aminoglycosides, were tested. Rifampicin (RFP) was found to have strong anti-mucoviscous activity against CG23-I hvKP even at subinhibitory concentrations. Polysaccharide extracts from hvKP showed substantially lowered viscosity when cells were grown with RFP. Moreover, microscopic observations demonstrated that RFP treatment results in a drastic reduction in the thickness of the CPS layer around hvKP cells. RFP treatment decreased transcript levels of rmpA and rmpA-regulated cps genes, indicating that RFP suppresses mucoviscosity of hvKP through inhibition of rmpA transcription. These data suggest that RFP may serve as a potential antivirulence agent for refractory hvKP infection.

DOI： 10.1016/j.ijantimicag.2019.05.018

PubMed

Publishing type：Research paper (scientific journal)   International / domestic magazine：International journal  

This study aimed to assess the prognostic factors of patients with bacteremia due to extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) as well as the antimicrobial susceptibility, particularly to piperacillin/tazobactam (PTZ), among ESBL-PE strains. The medical records of 65 patients with ESBL-PE bacteremia divided into the survivor group (n = 52) and nonsurvivor group (n = 13) were retrospectively reviewed. The male-to-female ratio, age, underlying disease, leukocyte count, C-reactive protein level, and treatment did not differ between the 2 groups. Multivariate analysis showed that the independent predictors associated with hospital mortality of ESBL-PE bacteremia were sepsis (P = 0.047) and febrile neutropenia (P = 0.008); thus, early assessment of these conditions is important. Further, the minimum inhibitory concentration values of ESBL-PE isolates in nonsurvivors tended to be higher than those in survivors. PTZ should be used with caution in cases of ESBL-PE strains with low susceptibility to the drug.

DOI： 10.1016/j.diagmicrobio.2019.01.018

PubMed

DOI： 10.3171/2019.1.JNS183085

PubMed

Publishing type：Research paper (scientific journal)  

<p>　We have conducted a nationwide survey on faculty development for simulation-based medical education in Japan. The response rate was 90%. Forty-seven (68%) schools have implemented faculty development programs for simulation-based education. The most commonly implemented contents were standardized patient development, task trainer, high fidelity manikin operation, and student evaluation, which were related to objective structured clinical examination objective clinical skill assessment. Only 15 percent of medical schools implemented topics on reflective practice, and scientific writing. A constraint on faculty time was the most commonly perceived barrier to simulation use (mentioned by 62 schools; 90%).</p>

DOI： 10.11307/mededjapan.50.3_245

CiNii Article

The 5th Medical Simulation Specialist Seminar was held to share and solve the problems of managing Simulation Centers. Many skills labs have financial problems for purchasing and repairing simulators, also have problems with unstable forms of employment of the stuff. Securing the necessary budget, and training simulation specialists would be challenges for the future to support career formation as a simulation specialist.

DOI： 10.50950/jasehp.2019-07-13

CiNii Article

Publishing type：Research paper (scientific journal)  

当大学で臨床実習後客観的臨床能力試験(Post-CC OSCE)を受けた医学部6年生(94名)の評価において、教員群内、標準模擬患者(SP)群内、および両群間での一致と相違について検討した。教員とSPが学生の結果を概略評価と6項目の項目別評価を用いて4段階で評価した。学生の概略評価と項目別評価の平均点は、教員群内、SP群内、両群間で有意差を認めなかった。教員とSPの間で概略評価の平均点に2段階以上の差を認めなかった学生88名の項目別評価の平均点は、1項目のみ両群間で有意差を認めた。残りの2段階以上の差を認めた6名のうち、SPより教員の方が2段階以上良い評価をした5名の項目別評価の平均点には5項目(「話しやすい目線」「聴こうとする姿勢・配慮」「自然な頷き・相槌」「着席や会話の自然な誘導」「清潔感のある身だしなみ」)で有意差を認めた。

Publishing type：Research paper (scientific journal)  

症例は47歳女性で、肛門からproglottidsが排出され、下腹部に不快感があった。患者は約10ヵ月前にフィリピンに1ヵ月間滞在し、生のブタ肝臓を食していた。触知腹部腫瘍や腹部圧痛は観察されず、身体検査は正常であった。血液検査、その他検査結果は正常範囲内であった。proglottidsの所見、臨床データ、食事歴からTaenia saginataまたはT.asiatica感染が疑われた。プラジカンテル600mg/日と下剤を投与し、多くのproglottidsと寄生虫の頭節が排出され、駆虫に成功した。多重PCRによってT.asiaticaと同定した。食事歴を調査したところ、日本では通常は肉を焼いて食べ、生では食べないことから、最終的に輸入T.asiatica感染症と診断した。

Publishing type：Research paper (scientific journal)  

DOI： 10.7883/yoken.JJID.2017.082

PubMed

CiNii Article

DOI： 10.1186/s12930-018-0043-0

PubMed

Publishing type：Research paper (scientific journal)  

目的:情報通信技術を活用した事前授業とシミュレータ演習を合体したブレンド型授業を導入した。方法:対象は看護学科1年生55名。授業前日までに録音付きスライドを視聴するよう指示した。結果:本授業は能動的な学びを促進した。実習時間を長く確保でき、学生の充足感があった。一方、準備、管理の問題点が指摘された。考察:今後、情報通信技術を活用した事前授業の配置についての議論、システムの構築、整備が必要である。(著者抄録)

Publishing type：Research paper (scientific journal)  

DOI： 10.1093/cid/cix579

Publishing type：Research paper (scientific journal)  

<p><i>Enterococcus faecium</i> has high levels of resistance to multiple antibiotics, and the mortality due to <i>E. faecium</i> bacteremia is high. Accordingly, <i>E. faecium</i> strains with low susceptibility to daptomycin are a concern in clinical practice. This study assessed the predictive factors and prognosis of patients with bacteremia due to<i> E. faecium</i> as well as the antimicrobial susceptibility, particularly to daptomycin, among <i>E. faecium</i> isolates. The medical records of patients admitted to Osaka City University Hospital with <i>E. faecalis</i> (n = 60) and <i>E. faecium</i> (n = 48) bacteremia between January 2011 and March 2016 were retrospectively reviewed. The <i>E. faecalis</i> group (mean age: 62.0 years) included 22 women, and the <i>E. faecium</i> group (mean age: 59.1 years) included 19 women. Predictive factors for infection, prognosis, and isolate antimicrobial susceptibilities were evaluated. The mean Sequential Organ Failure Assessment score and mortality rate did not differ between the two groups. The independent predictors of <i>E. faecium</i> bacteremia in multivariate analysis included quinolone use (p = 0.025), malignancy (p = 0.021), and prolonged hospitalization (p = 0.016). Cardiovascular disease was associated with a reduced risk of <i>E. faecium</i> bacteremia (p = 0.015). Notably, the percentage of <i>E. faecium</i> isolates with low daptomycin susceptibility was higher than that of <i>E. faecalis</i> (8.5% vs. 0%, p = 0.036). Thus, <i>E. faecium</i> should be considered when administering antibiotic therapy to patients with a history of these predictors. Furthermore, the use of daptomycin should be avoided in case of <i>E. faecium</i> with low susceptibility to daptomycin.</p>

DOI： 10.1620/tjem.243.211

PubMed

CiNii Article

3次医療機関におけるバンコマイシン感受性Enterococcus faecalis菌血症患者60名(男38名、女22名、平均62.0歳)及びE.faecium菌血症患者48名(男29名、女19名、平均59.1歳)の臨床的特徴を挙げ、感染、予後、分離株薬剤感受性の予測因子を調べた。その結果、E.faecalis菌血症患者のうち、血液悪性腫瘍9名を含む悪性腫瘍29名、心血管疾患19名、キノロン系抗菌薬投与12名、院内感染48名であった。E.faecium菌血症患者のうち、血液悪性腫瘍21名を含む悪性腫瘍患者40名、心血管疾患4名、キノロン系抗菌薬投与24名、院内感染46名であった。E.faecium菌血症での好中球減少症は35.4%で、E.faecalis菌血症での10.0%よりも有意に高かった。E.faecalis菌血症の治療は、ペニシリン抗菌薬投与が25名で、根治療法として18名に抗MRSA薬を投与した。E.faecium菌血症では、37名に抗MRSA薬を投与した。多変量解析にてE.faecium菌血症の独立予測因子はキノロン系抗菌薬使用、悪性腫瘍、長期入院で、心血管疾患は逆の予測因子であった。抗菌薬感受性に関しては、E.faecium分離株のダプトマイシン低感受性(MIC≧3μg/mL)菌の割合が8.5%とE.faecalisの0%よりも高かった。

Publishing type：Research paper (scientific journal)  

DOI： 10.1093/cid/cix579

Publishing type：Research paper (scientific journal)  

<p>　Recent changes in patient safety policy have led to the increasing significance of simulation-based medical education. However, among Japanese medical schools, we have confirmed considerable differences in simulation-based, clinical clerkship learning environments that may affect different learning opportunities for trainings with simulators or simulated patients. We conducted nationwide surveys on the prevalence and application of clinical skills laboratories for clerkships in 2012 and 2016. Registered questionnaires were sent to all medical schools (n=80). The response rate was 95%. Seventy-four schools (97%) have installed a skills laboratory. Floor space for the laboratory varied from 214 m² in 2012 to 339 m² in 2016. The mean number of annual uses by medical students increased from 1,402 to 1,978, Although there were favorable changes, such as more spacious learning areas and an increase in annual uses by medical students, there were significant disparities in the implementation of simulation-based learning among schools. For example, only 29 schools (38%) implemented training programs with simulated patients. Further effort to spread learning with simulated patients seems necessary.</p>

DOI： 10.11307/mededjapan.48.5_305

CiNii Article

Publishing type：Research paper (scientific journal)  

症例は42歳男性で、統合失調症であり、2週前より倦怠感の悪化が続いていた。ヘモグロビン値は2.8g/dLで、巨赤芽球性貧血に溶血と汎血球減少症を伴っていた。また葉酸値は正常下限未満であった。アルコール乱用とバランスの悪い食事に起因する葉酸欠乏性貧血と診断され、入院後、葉酸投与と飲酒の中止によりヘモグロビン値は改善した。葉酸欠乏性貧血に関連して動機づけ面接を行った後、患者自身が問題を把握し、行動変容が誘導された。連続飲酒を行っていなかったこと、飲酒を中止後も離脱症状はみられなかったことから、患者はプレアルコホリズムの状態と診断された。さらに患者の家族およびプライマリケア医と直接的な話し合いを行い、新たに社会的・公的支援を確立した。退院後2年間にわたり、バランスの取れた食事と飲酒の完全な中止を含む好ましい生活習慣を維持している。

Publishing type：Research paper (scientific journal)  

日本におけるシミュレーション医学教育の現状を2016年に全国アンケートにより調査し、先行調査と比較した。スキルスラボは新たに2大学に開設され、76校中74校(97%)に設置されていた。平均施設面積は、214m2から、339m2に拡大し、医学生の年間利用数は、1,402人から1,978人に増加していた。しかしながら、共用試験OSCE後の臨床実習でのスキルスラボの活用は4診療科、模擬患者参加型教育の実施は29校(38%)に留まった。臨床実習前教育としてタスクトレーニングの活用が増えているが、多様な状況への対応を学ぶシナリオ学習やチーム学習の拡充が必要と推察される。管理運営面では、専任スタッフの確保、安定的任用、施設維持の財務上の問題点が報告された。(著者抄録)

Publishing type：Research paper (scientific journal)  

DOI： 10.1002/jgf2.36

PubMed

Publishing type：Research paper (scientific journal)   International / domestic magazine：Domestic journal  

A 42-year-old man with schizophrenia was referred to our hospital after 2 weeks of worsening fatigue. His hemoglobin level was 2.8 g/dL owing to folic acid deficiency stemming from alcohol abuse and consumption of unbalanced meals. We induced behavioral changes in the patient by motivational interviewing. We had direct methodical conversations with medical staff involved with the patient as well as his family, and established new social support for him as well as public assistance. These have resulted in the patient maintaining a favorable lifestyle ever since.

DOI： 10.1002/jgf2.36

PubMed

Publishing type：Research paper (scientific journal)  

症例は42歳男性で、統合失調症であり、2週前より倦怠感の悪化が続いていた。ヘモグロビン値は2.8g/dLで、巨赤芽球性貧血に溶血と汎血球減少症を伴っていた。また葉酸値は正常下限未満であった。アルコール乱用とバランスの悪い食事に起因する葉酸欠乏性貧血と診断され、入院後、葉酸投与と飲酒の中止によりヘモグロビン値は改善した。葉酸欠乏性貧血に関連して動機づけ面接を行った後、患者自身が問題を把握し、行動変容が誘導された。連続飲酒を行っていなかったこと、飲酒を中止後も離脱症状はみられなかったことから、患者はプレアルコホリズムの状態と診断された。さらに患者の家族およびプライマリケア医と直接的な話し合いを行い、新たに社会的・公的支援を確立した。退院後2年間にわたり、バランスの取れた食事と飲酒の完全な中止を含む好ましい生活習慣を維持している。

日本におけるシミュレーション医学教育の現状を2016年に全国アンケートにより調査し、先行調査と比較した。スキルスラボは新たに2大学に開設され、76校中74校(97%)に設置されていた。平均施設面積は、214m2から、339m2に拡大し、医学生の年間利用数は、1,402人から1,978人に増加していた。しかしながら、共用試験OSCE後の臨床実習でのスキルスラボの活用は4診療科、模擬患者参加型教育の実施は29校(38%)に留まった。臨床実習前教育としてタスクトレーニングの活用が増えているが、多様な状況への対応を学ぶシナリオ学習やチーム学習の拡充が必要と推察される。管理運営面では、専任スタッフの確保、安定的任用、施設維持の財務上の問題点が報告された。(著者抄録)

Publishing type：Research paper (scientific journal)  

日本におけるシミュレーション医学教育の現状を2016年に全国アンケートにより調査し、先行調査と比較した。スキルスラボは新たに2大学に開設され、76校中74校(97%)に設置されていた。平均施設面積は、214m2から、339m2に拡大し、医学生の年間利用数は、1,402人から1,978人に増加していた。しかしながら、共用試験OSCE後の臨床実習でのスキルスラボの活用は4診療科、模擬患者参加型教育の実施は29校(38%)に留まった。臨床実習前教育としてタスクトレーニングの活用が増えているが、多様な状況への対応を学ぶシナリオ学習やチーム学習の拡充が必要と推察される。管理運営面では、専任スタッフの確保、安定的任用、施設維持の財務上の問題点が報告された。(著者抄録)

DOI： 10.1016/j.ijrobp.2017.04.037

PubMed

Publishing type：Research paper (scientific journal)  

症例は48歳男性で、4ヵ月前から持続する全身疲労と食欲不振を主訴に来院した。顔面と体幹に色素斑が生じており、体重は14kg減少していた。皮膚所見では主に顔面、口唇、体幹に茶色の色素斑を認め、この他の身体所見に異常はなかった。臨床検査の結果から副腎不全を疑い、腹部超音波検査とCTを行ったところ両側副腎の肥大を認めた。さらに、胸部X線検査と胸部CTで両肺野に多発結節影を伴う空洞形成が認められ、結核誘発性Addison病、活動性肺結核の疑いで入院となった。生食の投与と経口ヒドロコルチゾン20mg/日を開始したところ、全身疲労や食欲不振をはじめとする諸症状の緩和と低ナトリウム血症の改善が得られた。また、2回目までの喀痰検査は陰性であったが、3回目の検査でMycobacterium陽性所見が得られ、PCR解析によってMycobacterium tuberculosis complexが検出された。このため、4剤併用(イソニアジド、リファンピシン、ピラジナミド、エタンブトール)による治療を開始し、色素過剰の著明な緩和を得て、1ヵ月後に退院となった。

Publishing type：Research paper (scientific journal)  

ESBL産生大腸菌による菌血症患者31例(男性12例、女性19例、平均62.5±18.9歳)、非ESBL大腸菌による菌血症患者98例(男性46例、女性52例、平均67.6±13.9歳)を対象に、菌血症発症の危険因子と予後について検討した。白血球数、CRPのような臨床検査値の測定を行い、臨床分離菌の検出を実施した。抗菌薬は菌血症発症の5日以内に経験的治療を開始した後に根治治療を行った。その結果、抗菌薬感受性に関して、ESBL大腸菌はレボフロキサシン、ゲンタマイシン、スルファメトキサゾール/トリメトプリムへの感受性が有意に低かった。投与した抗菌薬ではカルバペネム系が多く、ESBL菌血症群では18例(58.1%)がカルバペネムまたはタゾバクタム/ピペラシリンを投与されていた。危険因子について検討した単変量解析では、男女比、平均年齢、基礎疾患、白血球数、CRP値、SOFAスコアに群間差は認められなかった。多変量解析では、菌分離前の免疫抑制剤またはコルチコステロイド、キノロン投与がESBL大腸菌菌血症の発症の独立予測因子であることが示された。ESBL大腸菌菌血症患者のうち、9例にカルバペネム、4例にタゾバクタム/ピペラシリン、2例にセフメタゾールが投与されており、患者背景と死亡率に群間差はみられなかった。免疫抑制剤、コルチコステロイド、キノロンの投与によって、ESBL産生大腸菌による菌血症のリスクが高まる可能性が示された。

ESBL産生大腸菌による菌血症患者31例(男性12例、女性19例、平均62.5±18.9歳)、非ESBL大腸菌による菌血症患者98例(男性46例、女性52例、平均67.6±13.9歳)を対象に、菌血症発症の危険因子と予後について検討した。白血球数、CRPのような臨床検査値の測定を行い、臨床分離菌の検出を実施した。抗菌薬は菌血症発症の5日以内に経験的治療を開始した後に根治治療を行った。その結果、抗菌薬感受性に関して、ESBL大腸菌はレボフロキサシン、ゲンタマイシン、スルファメトキサゾール/トリメトプリムへの感受性が有意に低かった。投与した抗菌薬ではカルバペネム系が多く、ESBL菌血症群では18例(58.1%)がカルバペネムまたはタゾバクタム/ピペラシリンを投与されていた。危険因子について検討した単変量解析では、男女比、平均年齢、基礎疾患、白血球数、CRP値、SOFAスコアに群間差は認められなかった。多変量解析では、菌分離前の免疫抑制剤またはコルチコステロイド、キノロン投与がESBL大腸菌菌血症の発症の独立予測因子であることが示された。ESBL大腸菌菌血症患者のうち、9例にカルバペネム、4例にタゾバクタム/ピペラシリン、2例にセフメタゾールが投与されており、患者背景と死亡率に群間差はみられなかった。免疫抑制剤、コルチコステロイド、キノロンの投与によって、ESBL産生大腸菌による菌血症のリスクが高まる可能性が示された。

Publishing type：Research paper (scientific journal)  

DOI： 10.1002/jgf2.2

PubMed

Publishing type：Research paper (scientific journal)  

DOI： 10.14442/generalist.40.192

CiNii Article

Publishing type：Research paper (scientific journal)  

<p>　Recent changes in patient safety policy have led to the increasing significance of simulation-based medical education. However, among Japanese medical schools, we have confirmed considerable differences in simulation-based, clinical clerkship learning environments that may affect different learning opportunities for trainings with simulators or simulated patients. We conducted nationwide surveys on the prevalence and application of clinical skills laboratories for clerkships in 2012 and 2016. Registered questionnaires were sent to all medical schools (n=80). The response rate was 95%. Seventy-four schools (97%) have installed a skills laboratory. Floor space for the laboratory varied from 214 m² in 2012 to 339 m² in 2016. The mean number of annual uses by medical students increased from 1,402 to 1,978, Although there were favorable changes, such as more spacious learning areas and an increase in annual uses by medical students, there were significant disparities in the implementation of simulation-based learning among schools. For example, only 29 schools (38%) implemented training programs with simulated patients. Further effort to spread learning with simulated patients seems necessary.</p>

DOI： 10.11307/mededjapan.48.5_305

CiNii Article

Publishing type：Research paper (scientific journal)  

<p><b>Objective </b>In recent years, infection caused by extended-spectrum beta-lactamase (ESBL)-producing organisms has become an important issue. However, comparative studies of the bacteremia caused by ESBL <i>Enterobacteriaceae</i> and non-ESBL <i>Enterobacteriaceae</i> are extremely rare in Japan. This study aimed to assess the risk factors and prognosis of patients with bacteremia due to ESBL <i>Escherichia coli</i> (<i>E. coli</i>). </p><p><b>Methods </b>The medical records of 31 patients with ESBL <i>E. coli</i> bacteremia and 98 patients with non-ESBL <i>E. coli</i> bacteremia who had been admitted to Osaka City University Hospital between January 2011 and June 2015 were retrospectively reviewed. The patient backgrounds, risk factors for infection, and prognosis were evaluated. </p><p><b>Results </b>The male-to-female ratio, mean age, underlying disease, leukocyte count, and C-reactive protein (CRP) level did not differ between the patients in the ESBL <i>E. coli</i> bacteremia and non-ESBL <i>E. coli</i> bacteremia groups. The mean Sequential Organ Failure Assessment (SOFA) score for patients with ESBL and non-ESBL <i>E. coli</i> bacteremia were 3.6 and 3.8, respectively. Further, the mortality did not differ between the two groups (9.7% vs 9.2%). However, the independent predictors associated with ESBL <i>E. coli</i> bacteremia according to a multivariate analysis were the use of immunosuppressive drugs or corticosteroids (p=0.048) and quinolones (p=0.005) prior to isolation. The mortality did not differ between the carbapenem and tazobactam/piperacillin (TAZ/PIPC) or cefmetazole (CMZ) groups for the patients with ESBL <i>E. coli</i> bacteremia. </p><p><b>Conclusion </b>Whenever we encountered patients with a history of immunosuppressive drug, corticosteroid, quinolone administration, it was necessary to perform antibiotic therapy while keeping the risk of ESBL <i>E. coli</i> in mind. </p>

DOI： 10.2169/internalmedicine.56.7702

PubMed

CiNii Article

Publishing type：Research paper (scientific journal)  

<p>We herein report a case of Addison's disease caused by tuberculosis characterized by atypical hyperpigmentation, noted as exacerbation of the pigmentation of freckles and the occurrence of new freckles, that was diagnosed in the presence of active pulmonary tuberculosis. The clinical condition of the patient was markedly ameliorated by the administration of hydrocortisone and anti-tuberculosis agents. When exacerbation of the pigmentation of the freckles and/or the occurrence of new freckles are noted, Addison's disease should be considered as part of the differential diagnosis. In addition, the presence of active tuberculosis needs to be assumed whenever we treat patients with Addison's disease caused by tuberculosis, despite its rarity. </p>

DOI： 10.2169/internalmedicine.56.7976

PubMed

CiNii Article

<p>We herein report a case of Addison's disease caused by tuberculosis characterized by atypical hyperpigmentation, noted as exacerbation of the pigmentation of freckles and the occurrence of new freckles, that was diagnosed in the presence of active pulmonary tuberculosis. The clinical condition of the patient was markedly ameliorated by the administration of hydrocortisone and anti-tuberculosis agents. When exacerbation of the pigmentation of the freckles and/or the occurrence of new freckles are noted, Addison's disease should be considered as part of the differential diagnosis. In addition, the presence of active tuberculosis needs to be assumed whenever we treat patients with Addison's disease caused by tuberculosis, despite its rarity. </p>

DOI： 10.2169/internalmedicine.56.7976

PubMed

CiNii Article

Publishing type：Research paper (scientific journal)  

目的:情報通信技術を活用した事前授業とシミュレータ演習を合体したブレンド型授業を導入した。方法:対象は看護学科1年生55名。授業前日までに録音付きスライドを視聴するよう指示した。結果:本授業は能動的な学びを促進した。実習時間を長く確保でき、学生の充足感があった。一方、準備、管理の問題点が指摘された。考察:今後、情報通信技術を活用した事前授業の配置についての議論、システムの構築、整備が必要である。(著者抄録)

DOI： 10.14442/generalist.40.192

CiNii Article

<p><b>Objective </b>In recent years, infection caused by extended-spectrum beta-lactamase (ESBL)-producing organisms has become an important issue. However, comparative studies of the bacteremia caused by ESBL <i>Enterobacteriaceae</i> and non-ESBL <i>Enterobacteriaceae</i> are extremely rare in Japan. This study aimed to assess the risk factors and prognosis of patients with bacteremia due to ESBL <i>Escherichia coli</i> (<i>E. coli</i>). </p><p><b>Methods </b>The medical records of 31 patients with ESBL <i>E. coli</i> bacteremia and 98 patients with non-ESBL <i>E. coli</i> bacteremia who had been admitted to Osaka City University Hospital between January 2011 and June 2015 were retrospectively reviewed. The patient backgrounds, risk factors for infection, and prognosis were evaluated. </p><p><b>Results </b>The male-to-female ratio, mean age, underlying disease, leukocyte count, and C-reactive protein (CRP) level did not differ between the patients in the ESBL <i>E. coli</i> bacteremia and non-ESBL <i>E. coli</i> bacteremia groups. The mean Sequential Organ Failure Assessment (SOFA) score for patients with ESBL and non-ESBL <i>E. coli</i> bacteremia were 3.6 and 3.8, respectively. Further, the mortality did not differ between the two groups (9.7% vs 9.2%). However, the independent predictors associated with ESBL <i>E. coli</i> bacteremia according to a multivariate analysis were the use of immunosuppressive drugs or corticosteroids (p=0.048) and quinolones (p=0.005) prior to isolation. The mortality did not differ between the carbapenem and tazobactam/piperacillin (TAZ/PIPC) or cefmetazole (CMZ) groups for the patients with ESBL <i>E. coli</i> bacteremia. </p><p><b>Conclusion </b>Whenever we encountered patients with a history of immunosuppressive drug, corticosteroid, quinolone administration, it was necessary to perform antibiotic therapy while keeping the risk of ESBL <i>E. coli</i> in mind. </p>

DOI： 10.2169/internalmedicine.56.7702

PubMed

CiNii Article

DOI： 10.2169/internalmedicine.56.7976

PubMed

Publishing type：Research paper (scientific journal)  

Background: A few Japanese cases of hypermucoviscous Klebsiella pneumoniae (K. pneumoniae) invasive syndrome have recently been reported. Although extrahepatic complications from bacteremic dissemination have been observed, infected aneurysms are rare. Furthermore, the primary source of infection is generally a liver abscess, and is rarely the prostate. Therefore, we report two atypical cases of hypermucoviscous K. pneumoniae invasive syndrome.
Case presentation: The first case was an 81-year-old Japanese man with no significant medical history, who was referred to our hospital for vision loss in his right eye. Contrast-enhanced whole-body computed tomography revealed abscesses in the liver and the prostate, and an infected left internal iliac artery aneurysm. Contrast-enhanced head magnetic resonance imaging revealed brain abscesses. Cultures of the liver abscess specimen and aqueous humor revealed K. pneumoniae with the hypermucoviscosity phenotype, which carried the magA gene (mucoviscosity-associated gene A) and the rmpA gene (regulator of mucoid phenotype A). We performed enucleation of the right eyeball, percutaneous transhepatic drainage, coil embolization of the aneurysm, and administered a 6-week course of antibiotic treatment. The second case was a 69-year-old Japanese man with diabetes mellitus, who was referred to our hospital with fever, pollakiuria, and pain on urination. Contrast-enhanced whole-body computed tomography revealed lung and prostate abscesses, but no liver abscesses. Contrast-enhanced head magnetic resonance imaging revealed brain abscesses. The sputum, urine, prostate abscess specimen, and aqueous humor cultures revealed K. pneumoniae with the hypermucoviscosity phenotype, which carried magA and rmpA. We performed enucleation of the left eyeball, percutaneous drainage of the prostate abscess, and administered a 5-week course of antibiotic treatment.
Conclusions: Hypermucoviscous K. pneumoniae can cause infected aneurysms, and the prostate can be the primary site of infection. We suggest that a diagnosis of hvKP invasive syndrome should be considered in all patients who present with K. pneumoniae infection and multiple organ abscesses.

DOI： 10.1186/s12879-016-2011-3

PubMed

Publishing type：Research paper (scientific journal)   International / domestic magazine：International journal  

BACKGROUND: Most cases of disseminated carcinomatosis of the bone marrow (DCBM) arise from gastric cancer. DCBM from pancreatic cancer is very rare. We herein present a case of DCBM from pancreatic cancer. CASE PRESENTATION: A 57-year-old man was referred to our hospital for severe lumbago. Laboratory data indicated that he suffered from disseminated intravascular coagulation (DIC). Non-contrast abdominal computed tomography (CT) revealed multiple bone masses but no other abnormal findings. Left iliac bone marrow biopsy revealed poorly differentiated adenocarcinoma cells. Positron emission tomography (PET)-CT showed diffuse abnormal uptake in the bones and tail of the pancreas. Contrast whole-body CT showed a tumor measuring approximately 28 mm in diameter with poor enhancement in the tail of the pancreas. The patient's final diagnosis was pancreatic cancer located in the tail of the pancreas with diffuse bone metastases and DIC. His DCBM was thus believed to originate from the pancreatic cancer. He succumbed to the disease approximately 2 months after admission to our hospital. CONCLUSION: We herein describe a case of pancreatic cancer located in the tail of the pancreas with diffuse bone metastases and DIC, which, in our case, was DCBM. Therefore, in cases of DCBM with an unknown primary tumor, pancreatic cancer should be considered during differential diagnosis.

DOI： 10.1186/s12885-016-2849-1

PubMed

Publishing type：Research paper (scientific journal)  

Background and aims: Low-flow-mediated constriction (L-FMC), the endothelial response to reduced blood flow by forearm compression, is present in some smokers. The differences between smokers with and without L-FMC are unclear. It is also unknown whether flow-mediated total dilation (FMTD) or modified flow-mediated dilation (mFMD), both of which incorporate information concerning L-FMC, could be used to estimate cardiovascular risk. We sought to clarify the clinical factors associated with the presence of L-FMC in smokers according to sex and examine whether L-FMC incorporated indices would be better than a conventional index to estimate cardiovascular risk in smokers.
Methods: In total, 140 consecutive smokers (58 +/- 13 years old) with no coronary heart disease and 48 non-smokers, who comprised the age- and sex-matched control group, were enrolled.
Results: L-FMC was demonstrated in 33.6% (47/140) and 25% (12/48) of the smokers and non-smokers, respectively. In male smokers, the predictors of the presence of L-FMC were age (p = 0.014), body mass index (BMI) (p = 0.045), and baseline brachial arterial diameter (D-base) (p = 0.048). In female smokers, there were no predictors of the presence of L-FMC. The correlations between the Framingham risk score (FRS) and % FMTD (r = -0.34) and between FRS and % mFMD (r = -0.33) were stronger than that between FRS and conventional flow-mediated dilation (%cFMD) (r = -0.20).
Conclusions: Independent predictors of the presence of L-FMC were age, BMI, and Dbase in male smokers. L-FMC incorporated indices may be good alternatives to cFMD to estimate cardiovascular risk. (C) 2016 Elsevier Ireland Ltd. All rights reserved.

DOI： 10.1016/j.atherosclerosis.2016.06.022

PubMed

臨床実習を終了した国内9医学部の6年生903名を対象として、臨床能力に関する自己評価と教育方略を調査した。医学教育モデル・コア・カリキュラムに準じた27項目のうち約4割が病院実習とシミュレーションの両方、もしくは、シミュレーションのみで学習されていた。また、いずれの方略でも、学習経験のない項目が少なくないことが判明した。シミュレーション教育の高利用大学4校が低利用大学5校よりも、多くの学習領域で有意に医学生の臨床能力自己評価が高かった。(著者抄録)

【背景】医学科4年生の採血系実習は、各科が独自で行うため、指導法と学生の手技修得に差が生じていた。【目的】共通の知識と技術の修得を目指し、採血系実習の標準化を試み、その効果を明らかにする。【方法】2012年度より実習形式を「テーマ毎に3名の指導医で分担」、「同一指導医が同テーマを担当」、「全実習をSSCで実施」に変更した。実習後のアンケートから標準化の効果を検討した。【結果】90%超の学生が「理解できた」、「臨床実習で『採血させてください』と言える」と回答した。インストラクターを務めた研修医は80%が標準化を肯定した。【結語】今回の採血系実習の標準化は学生と指導者の双方にとって有用であった。(著者抄録)

Publishing type：Research paper (scientific journal)  

DOI： 10.1371/journal.pone.0147860

PubMed

Publishing type：Research paper (scientific journal)  

DOI： 10.1371/journal.pone.0150554

PubMed

<p>Abstract:</p><p></p><p> This study examined the ability of medical students to self-assess basic clinical competence and learning strategies including simulation-based medical education for sixth-year medical students (n=903) at nine universities in Japan. About 40% of 27 procedures to achieve clinical skills in a model curriculum were taught using simulators with or without clinical training in hospitals. We noted that significant numbers of procedures were not practiced through any learning strategies. Higher self-assessment scores were observed among students in 4 schools who had more frequent learning opportunities through simulation-based education than among those with less frequent opportunities in 5 schools.</p>

DOI： 10.11307/mededjapan.47.4_271

CiNii Article

Authorship：Corresponding author   Publishing type：Research paper (scientific journal)  

66歳男。脱毛症、味覚異常および下痢のため受診した。全身性脱毛、爪異栄養症、皮膚色素沈着および両下肢浮腫がみられ、リウマチ因子、メタロプロテアーゼ3および抗CCP抗体の上昇から自己免疫疾患が疑われた。上部消化管内視鏡および大腸鏡検査にて胃、十二指腸および結腸にポリープが観察された。以上の所見はCronkhite-Canada症候群(CCS)に一致した。生検にて胃ポリープに過形成、結腸ポリープに過形成および腺腫がみられた。CCSの診断後速やかに経口プレドニゾロン療法を開始し、症状の著明な改善を得た。4ヵ月間のプレドニゾロン漸減投与により上部消化管ポリープは消失し、残存していた4個の結腸ポリープは切除された。結腸ポリープの1つに粘膜内腺癌が発見されたが、断端に悪性所見はなく、CCSの完全寛解が確認された。プレドニゾロン療法中止から9ヵ月現在、再発はみられなかった。

Publishing type：Research paper (scientific journal)  

66歳男。脱毛症、味覚異常および下痢のため受診した。全身性脱毛、爪異栄養症、皮膚色素沈着および両下肢浮腫がみられ、リウマチ因子、メタロプロテアーゼ3および抗CCP抗体の上昇から自己免疫疾患が疑われた。上部消化管内視鏡および大腸鏡検査にて胃、十二指腸および結腸にポリープが観察された。以上の所見はCronkhite-Canada症候群(CCS)に一致した。生検にて胃ポリープに過形成、結腸ポリープに過形成および腺腫がみられた。CCSの診断後速やかに経口プレドニゾロン療法を開始し、症状の著明な改善を得た。4ヵ月間のプレドニゾロン漸減投与により上部消化管ポリープは消失し、残存していた4個の結腸ポリープは切除された。結腸ポリープの1つに粘膜内腺癌が発見されたが、断端に悪性所見はなく、CCSの完全寛解が確認された。プレドニゾロン療法中止から9ヵ月現在、再発はみられなかった。

Authorship：Last author   Publishing type：Research paper (scientific journal)  

PubMed

1.研究目的:新人看護師を対象に留置針を用いた点滴静脈内注射技術の習得プロセスを明らかにすることを目的に、研修当日、研修1ヵ月後、3ヵ月後に点滴静脈内注射技術習得の確認チェックリストを用いて調査を行い、検討する。2.研究方法:対象者:A病院に入職した看護師81名に研究の同意書を得たもの。2)実施方法:新人看護師に留置針を用いた点滴静脈内注射技術習得のための研修後、取得状況を作成したチェックリストを用いて、計4回評価を依頼した。3.倫理的配慮:本研究は大阪市立大学大学院看護学研究科の倫理審査で承認を受け、実施。4.結果・考察 本研究結果では、1、2回目の調査で「できなかった」と評価した者が1割以上いたチェックリストの6項目は、「駆血時間は1分以内にする(1分以上かかる場合は一度外して、再度駆血する)」、「針先が血管内に入ると留置針の針基に逆流があるので確認する」、「逆流確認後、留置針の刺入角度をやや小さくし、この「Lie distance」分の2-3mm距離を血管内に進める」、「逆血確認後、針基を右母指、中指で固定したまま、外筒のみを左母指、左示指でゆっくり血管内に送る」「外筒を根本まで送ったら、患者の手を開かせ、駆血帯を外す」、「皮膚の上から針先と思われる部分を左示指、中指、薬指の3本でしっかり押さえ、右母指、右示指または右中指で内針を抜く」であった。しかし、3、4回目調査では、「できなかった」と評価する人が減少した。このことは、事前学習や研修当日のインストラクターの指導体制に基づいてシミュレータに点滴静脈内注射を実施する経験をすることで、「受け入れ素地」がつくられ、次に、研修当日に同僚の上腕に穿刺し、その後研修1ヵ月後、3ヵ月後と、患者を対象に点滴静脈内注射の実施回数を増すことで、成功回数も増し、知識を自分で作り上げることにつながっていくことが示唆された(著者抄録)

Authorship：Corresponding author   Publishing type：Research paper (scientific journal)  

The etiology of and optimal treatments for Cronkhite-Canada syndrome (CCS) are still undetermined. Fewer than 5% of CCS patients experience complete remission and 15% of CCS patients develop malignancies. Here, we present a case of CCS involving autoimmune disorders, in which rapid diagnosis, rapid commencement of therapy, and complete remission were achieved after 4 months of prednisolone therapy and polypectomy, although biopsy specimens from all residual colonic polyps revealed adenocarcinoma in one polyp 4 months after prednisolone therapy. It is important to identify gastrointestinal or colonic polyps harboring malignant changes and to examine the involvement of autoimmune mechanisms for better outcomes in CCS patients.

DOI： 10.14442/jgfm.16.4_297

CiNii Article

<p>　To encourage the broad use of simulation-based medical education and establish partnerships to promote objective structured clinical examinations after clinical clerkship among medical teachers, we hosted the first team-based clinical skills competition event for medical students in Japan, named ‘Medical Students' Simlympic Games 2014'. Thirty-six (12 teams of three) open-recruited 5th or 6th grade medical students participated in this event. Student teams performed clinical tasks at 6 stations, which actively utilized the strengths of simulators or simulated patients. Contents, composition, difficulty level, and validity were tested by trainee doctors and examined by committee members in advance. In this report, we describe our concept, executive committee formation, a variety of arrangements, the outline on the day of the event, and the results of a questionnaire targeting participants. (126 words)</p>

DOI： 10.11307/mededjapan.46.3_259

CiNii Article

The etiology of and optimal treatments for Cronkhite-Canada syndrome (CCS) are still undetermined. Fewer than 5% of CCS patients experience complete remission and 15% of CCS patients develop malignancies. Here, we present a case of CCS involving autoimmune disorders, in which rapid diagnosis, rapid commencement of therapy, and complete remission were achieved after 4 months of prednisolone therapy and polypectomy, although biopsy specimens from all residual colonic polyps revealed adenocarcinoma in one polyp 4 months after prednisolone therapy. It is important to identify gastrointestinal or colonic polyps harboring malignant changes and to examine the involvement of autoimmune mechanisms for better outcomes in CCS patients.

DOI： 10.14442/jgfm.16.4_297

CiNii Article

Publishing type：Research paper (scientific journal)  

Publishing type：Research paper (scientific journal)  

DOI： 10.1016/S1470-2045(14)70221-9

PubMed

1.研究目的:新人研修医が「留置針使用可能な点滴注射技術練習」シミュレータ(以下、シミュレータと略す)の使用の有無による点滴静脈注射技術習得の効果を検討する。2.研究方法:対象者:A病院に入職した研修医52名(以下、新研修医と略す)に研究の同意書を得たもの。実施方法:(1)京都科学と共同で開発したシミュレータを、新研修医52名をシミュレータ使用群(以下、シミュレータ群と略す)と、使用しない群(非シミュレータ群)と2群に分け、2人ペアで実施。実施後、「チェックリスト」を自己評価で記載、提出依頼。3.倫理的配慮:本研究は大阪市立大学大学院看護学研究科の倫理審査で承認を受け、実施。4.結果・考察 両群のチェックリストの結果では、手指消毒から穿刺部位選択、留置針の穿刺、内針を抜き、注射器接続など項目は、両群ともに「できる」と自己評価され、有意差はなかった。しかし、シミュレータ群は非シミュレータ群に比べて「適切な穿刺部位を選択できる」を難しいと感じる人が多く、有意差を示した(p<0.05)。このことは、シミュレータを使用した方が留置針の挿入技術をイメージ化しやすく、習得しやすい可能性が示唆された。(著者抄録)

Publishing type：Research paper (scientific journal)  

目的:留置針の挿入を可能とする「点滴静脈内注射シミュレータ」の試作品を試用評価し、その実用性を検討する。方法:被験者は、留置針を用いた点滴静脈内注射を臨床で実施している看護師11名で、研究目的、方法に同意を得たもの。「点滴静脈内注射シミュレータ」の試作品に、留置針を用いて点滴静脈内注射を実施し、実施後、VASスケールの質問紙で試用評価を依頼した。結果・考察:シミュレータの評価は、「穿刺、血管に挿入した感じのわかりやすさ」の項目は低い評価であったことから、末梢静脈血管の選択や留置針挿入感覚のトレーニングは難しい。「血管の選定のわかりやすさ」、「静脈留置針を穿刺した場合の角度のつけやすさ」、「留置内針と外筒の操作のしやすさ」、「輸液ラインと挿入した留置針の接続しやすさ」、「輸液ライン接続後の滴下」、「留置針の固定のしやすさ」の項目評価は、6割以上の肯定評価であったことから、留置針の穿刺操作から輸液ラインの接続、滴下、固定の一連の技術の反復練習を可能とし、点滴静脈注射の技術習得トレーニングのためのシミュレータとして実用性が示唆された。(著者抄録)

Publishing type：Research paper (scientific journal)  

目的:留置針の挿入を可能とする「点滴静脈内注射シミュレータ」の試作品を試用評価し、その実用性を検討する。方法:被験者は、留置針を用いた点滴静脈内注射を臨床で実施している看護師11名で、研究目的、方法に同意を得たもの。「点滴静脈内注射シミュレータ」の試作品に、留置針を用いて点滴静脈内注射を実施し、実施後、VASスケールの質問紙で試用評価を依頼した。結果・考察:シミュレータの評価は、「穿刺、血管に挿入した感じのわかりやすさ」の項目は低い評価であったことから、末梢静脈血管の選択や留置針挿入感覚のトレーニングは難しい。「血管の選定のわかりやすさ」、「静脈留置針を穿刺した場合の角度のつけやすさ」、「留置内針と外筒の操作のしやすさ」、「輸液ラインと挿入した留置針の接続しやすさ」、「輸液ライン接続後の滴下」、「留置針の固定のしやすさ」の項目評価は、6割以上の肯定評価であったことから、留置針の穿刺操作から輸液ラインの接続、滴下、固定の一連の技術の反復練習を可能とし、点滴静脈注射の技術習得トレーニングのためのシミュレータとして実用性が示唆された。(著者抄録)

目的:留置針の挿入を可能とする「点滴静脈内注射シミュレータ」の試作品を試用評価し、その実用性を検討する。方法:被験者は、留置針を用いた点滴静脈内注射を臨床で実施している看護師11名で、研究目的、方法に同意を得たもの。「点滴静脈内注射シミュレータ」の試作品に、留置針を用いて点滴静脈内注射を実施し、実施後、VASスケールの質問紙で試用評価を依頼した。結果・考察:シミュレータの評価は、「穿刺、血管に挿入した感じのわかりやすさ」の項目は低い評価であったことから、末梢静脈血管の選択や留置針挿入感覚のトレーニングは難しい。「血管の選定のわかりやすさ」、「静脈留置針を穿刺した場合の角度のつけやすさ」、「留置内針と外筒の操作のしやすさ」、「輸液ラインと挿入した留置針の接続しやすさ」、「輸液ライン接続後の滴下」、「留置針の固定のしやすさ」の項目評価は、6割以上の肯定評価であったことから、留置針の穿刺操作から輸液ラインの接続、滴下、固定の一連の技術の反復練習を可能とし、点滴静脈注射の技術習得トレーニングのためのシミュレータとして実用性が示唆された。(著者抄録)

Publishing type：Research paper (scientific journal)  

目的:留置針の挿入を可能とする「点滴静脈内注射シミュレータ」の試作品を試用評価し、その実用性を検討する。方法:被験者は、留置針を用いた点滴静脈内注射を臨床で実施している看護師11名で、研究目的、方法に同意を得たもの。「点滴静脈内注射シミュレータ」の試作品に、留置針を用いて点滴静脈内注射を実施し、実施後、VASスケールの質問紙で試用評価を依頼した。結果・考察:シミュレータの評価は、「穿刺、血管に挿入した感じのわかりやすさ」の項目は低い評価であったことから、末梢静脈血管の選択や留置針挿入感覚のトレーニングは難しい。「血管の選定のわかりやすさ」、「静脈留置針を穿刺した場合の角度のつけやすさ」、「留置内針と外筒の操作のしやすさ」、「輸液ラインと挿入した留置針の接続しやすさ」、「輸液ライン接続後の滴下」、「留置針の固定のしやすさ」の項目評価は、6割以上の肯定評価であったことから、留置針の穿刺操作から輸液ラインの接続、滴下、固定の一連の技術の反復練習を可能とし、点滴静脈注射の技術習得トレーニングのためのシミュレータとして実用性が示唆された。(著者抄録)

DOI： 10.24544/ocu.20180403-059

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Publishing type：Research paper (scientific journal)  

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Publishing type：Research paper (scientific journal)  

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1)大阪市立大学医学部は、学生組織ライフサポートクラブの部員を主なインストラクター(インスト)とし、1次救命処置(Basic Life Support、BLS)講習会をスキルスシミュレーションセンターで開催してきた。2)74回のBLS講習会(2006年12月-2008年7月)を対象とし、受講者とインストの人数と意見を調査した。受講者総数は1071名、インスト総数は1223名であった。学生インストは活動に意義を感じていた。3)受講者の学生インストに対する評価は高く、到達度自己評価も良好であった。学生インストによるBSL講習会は受講者、学生インスト双方にとって有益であると考えられた。(著者抄録)

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1) Osaka City University Medical School provides basic life support courses in the Skills Simulation Center. Most instructors are members of the Life Support Club, a medical students' extracurricular activity.<br>2) We investigated the numbers and opinions of participants(December 2006 through July 2008). The numbers of trainee and instructors were 1071 and 1223, respectively. The student instructors considered their activities worthwhile.<br>3) The trainees highly appreciated the student instructors and showed that the effectiveness of training was excellent. Our results show that basic life support courses taught by medical students are beneficial for both trainees and student instructors.

DOI： 10.11307/mededjapan.41.111

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1) The central venous catheterization (CVC) training program for 2 trainees involves an instructor, a CVC insertion simulator (Kyoto Kagaku Co., Ltd), and a simulated patient.<br>2) The questionnaire filled out by trainees after the program showed favorable opinions, particularly the method of learning after the practice.<br>3) It is important that effective simulation programs for trainees are designed to develop practical procedures and professional attitudes as a physician using both a simulator and a simulated patient.

DOI： 10.11307/mededjapan.41.291

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A novel index, the serum aspartate aminotransferase activity/platelet count ratio index (APRI), has been identified as a biochemical surrogate for histological fibrogenesis and fibrosis in cirrhosis. We evaluated the ability of preoperative APRI to predict hepatic failure following liver resection for hepatocellular carcinoma.
Potential preoperative risk factors for postoperative hepatic failure (hepatic coma with hyperbilirubinemia, four patients; intractable pleural effusion or ascites, 30 patients; and variceal bleeding, one patient) as well as APRI were evaluated in 366 patients undergoing liver resection for hepatocellular carcinoma. Prognostic significance was determined by univariate and multivariate analyses.
Hepatic failure developed postoperatively in 30 patients, causing death in four. APRI correlated with histological intensity of hepatitis activity and degree of hepatic fibrosis, and was significantly higher in patients who developed postoperative hepatic failure than in others without failure. Risk of postoperative hepatic failure increased as the serum albumin concentration and platelet count decreased and as indocyanine green retention rate at 15 min, aspartate and alanine aminotransferase activities, and APRI increased. Only APRI was an independent preoperative factor on multivariate analysis. Of the four patients who died of postoperative hepatic failure, three had an APRI of at least 10.
Preoperative APRI independently predicted hepatic failure following liver resection for hepatocellular carcinoma. Patients with an APRI of 10 or more have a high risk of postoperative hepatic failure.

DOI： 10.1007/s00534-008-0003-4

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Background/Aims: The liver hanging maneuver is widely used in right lobectomy to resect huge tumors and harvest living donors'. The convenience of tape assistance in other types of hepatectomy is not well known.
Methodology: Tape-guiding technique (TGT) was applied in 30 hepatectomies of different type between April 2003 and April 2006. The indications were liver carcinoma in 22 and living-donor in 8. Hepatectomies included right lobectomy, 14; left lobectomy with caudate lobectomy, 8; left lobectomy without caudate lobectomy, 2; lateral segmentectomy, 3; central bisegmentectomy, posterior segmentectomy, and superior dorsal partial resection, 1 each. A tape was placed in front of the inferior vena cava for right hepatectomy and left hepatectomy with caudate lobectomy. In other hepatectomies, the tape was positioned to be the target of parenchymal dissection.
Results: TGT was successfully performed in all 30 cases. Tape facilitated dissection by helping the surgeon maintain orientation, and traction on the tape flattened the parenchyma, making it easier to identify and manage vessels and ducts. With an assistant holding the tape, the surgeon's left hand was free, and ligation and suturing was easier and more secure.
Conclusions: The TGT is a convenient technique that is applicable to different types of liver resection.

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記事種別: 特集 ; 会議・学会報告・シンポジウム

DOI： 10.11307/mededjapan1970.39.205

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DOI： 10.1007/s00595-006-3403-6

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A 23-year-old Japanese man was admitted with a chief complaint of abdominal pain. He was previously healthy, and his past medical history was unremarkable. Local tenderness and rebound tenderness at McBurney's point were elicited. Abdominal roentgenography was non-diagnostic. Ultrasonography and computed tomography showed a tumor with a central core. Based on a diagnosis of appendicitis with omental inflammation or an omental tumor, laparotomy performed. Intraoperatively, no site of gastrointestinal perforation was detected; however, a 5-cm omental granuloma was identified that proved to have a fishbone nucleus on pathological examination. The postoperative course was uneventful, and upper gastrointestinal endoscopy and barium enema were unremarkable. A large solitary omental pseudotumor is rare, and the clinical course in this case was atypical compared with the usual course of intestinal perforation by a foreign body and formation of an intra-abdominal granuloma.

DOI： 10.1111/j.1440-1746.2006.03353.x

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Background/Aims: Liver resection for hepatocellular carcinoma in patients with cirrhosis carries risk of major hemorrhage and sometimes requires blood transfusion. We investigated risk factors for massive blood loss during liver resection and indications for storing blood for autologous intraoperative transfusion.
Methodology: We analyzed clinical records of 100 patients with cirrhosis who underwent liver resection for hepatocellular carcinoma. Autologous blood was stored preoperatively for 19 patients.
Results: Intraoperative blood loss ranged from 5 to 3000mL (mean, 640). Liver resection was performed without transfusion in 67 patients and with autologous blood storage in 17 patients not receiving homologous blood. In the other 16 patients, homologous blood was transfused. Univariate analysis identified youth, large tumors (&gt;4cm), major hepatectomy, portal tumor involvement, hepatic vein involvement, and prolonged operation time as risk factors for massive blood loss; multivariate analysis identified portal involvement and hepatic vein involvement as independent risk factors. Blood loss exceeded 1000mL in the 4 transfused group B patients and 3 of the 4 patients had hepatic vein involvement.
Conclusions: Portal involvement and hepatic vein involvement were risk factors for massive blood loss during liver resection for hepatocellular carcinoma in patients with cirrhosis. Autologous blood storage is indicated in patients with such risk factors.

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Background/Aims: Liver resection for hepatocellular carcinoma in patients with cirrhosis carries risk of major hemorrhage and sometimes requires blood transfusion. We investigated risk factors for massive blood loss during liver resection and indications for storing blood for autologous intraoperative transfusion.
Methodology: We analyzed clinical records of 100 patients with cirrhosis who underwent liver resection for hepatocellular carcinoma. Autologous blood was stored preoperatively for 19 patients.
Results: Intraoperative blood loss ranged from 5 to 3000mL (mean, 640). Liver resection was performed without transfusion in 67 patients and with autologous blood storage in 17 patients not receiving homologous blood. In the other 16 patients, homologous blood was transfused. Univariate analysis identified youth, large tumors (&gt;4cm), major hepatectomy, portal tumor involvement, hepatic vein involvement, and prolonged operation time as risk factors for massive blood loss; multivariate analysis identified portal involvement and hepatic vein involvement as independent risk factors. Blood loss exceeded 1000mL in the 4 transfused group B patients and 3 of the 4 patients had hepatic vein involvement.
Conclusions: Portal involvement and hepatic vein involvement were risk factors for massive blood loss during liver resection for hepatocellular carcinoma in patients with cirrhosis. Autologous blood storage is indicated in patients with such risk factors.

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A 51-year-old woman, with the diagnosis of pseudomyxoma peritonei, was referred to us for further evaluation of intestinal obstruction. Barium swallow showed a stricture of the distal stomach with complete obstruction. Endscopically no tumor invaded the mucosa on the stricture. Computed tomography of abdomen revealed that stomach was compressed by tumor and there was no obstruction in the small intestine and cob-rectum. The Stent was inserted as palliation for obstruction. She was alive for 7 years after stent insertion. Stent insersion was effective for the certain period for pyloric stenosis caused by extra-compression of pseudomyx-oma peritonei.

DOI： 10.11280/gee1973b.49.1419

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DOI： 10.1016/j.hepres.2006.07.011

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Influence of interferon (IFN) therapy on postoperative outcomes in patients with hepatitis C virus (HCV)-related hepatocellular carcinoma (HCC) is still inconclusive. Of 518 patients who underwent hepatic resection for HCV-related HCC, 312 patients with Japan integrated staging score 0-2 were included in this study. Of 50 patients underwent IFN therapy, 29 patients who obtained a normalized alanine aminotransferase (ALT) activity irrespective of disappearance of serum HCV RNA were classified as the response group, while 21 patients were classified as the non-response group because their ALT activities were not normalized and serum HCV RNA persisted. The non-IFN group included 262 patients who had not received IFN therapy. The tumor-free and the overall survival rates for patients in the response group were significantly higher than those in other groups. Only one patient in the response group died of HCC recurrence, and the proportion of deaths associated with liver disease (HCC recurrence or cirrhosis) was significantly lower in the response group than other two groups. IFN therapy can improve postoperative outcomes in patients with HCV-related HCC because of suppression of recurrence and preventing progress of cirrhosis, especially when IFN therapy has controlled their active hepatitis. (C) 2006 Elsevier Ireland Ltd. All rights reserved.

DOI： 10.1016/j.hepres.2006.07.011

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DOI： 10.1016/j.hepres.2006.07.011

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DOI： 10.11477/mf.1407100991

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Background/Aims: Bowel injury associated liver surgery is rare but can be fatal if not adequately treated. The contribution of underlying liver disease and previous hepatectomy to bowel injury in hepatectomy for hepatocellular carcinoma is unknown.
Methodology: Clinical records of 531 patients who underwent hepatic resection without combined resection of the biliary tract or intestine for hepatocellular carcinoma during 13 years were reviewed. Differences in incidence of bowel injury according to presence or absence of liver cirrhosis, technique of hepatectomy, and history of hepatectomy were investigated. Outcome after treatment also was reviewed.
Results: Bowel injury occurred in 5 patients (0.9%). Previous hepatectomy history was associated with an increased incidence of bowel injury [repeat hepatectomy, 3/91 (3.3%), and first hepatectomy, 2/440 (0.5%), p = 0.038]. Injury was recognized intraoperatively in two patients and postoperatively in three. In the former two patients, the injured bowel was repaired immediately but a fistula still developed in one patient. One patient with a fistula eventually required temporary fecal diversion and eventually limited colectomy. The other three patients were treated by continuous external drainage, but two of them required debridement or colic sleeve resection.
Conclusions: Previous hepatectomy increases the risk for bowel injury during hepatectomy. Care must be taken to prevent adhesion to the hepatic cut surface. Careful use of electrocautery to prevent burn injury also should be taken.

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DOI： 10.1007/s00595-005-3167-4

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Sporadic cases of hepatocellular carcinoma (HCC) originating from nonalcoholic steatohepatitis (NASH) have recently been reported. Thus, we investigated the prevalence of NASH in patients with HCC. A review of the clinical records of 481 patients who underwent liver resection for HCC in our department between January 1991 and December 2003 revealed only two (0.4%) patients with HCC associated with NASH. Both of these patients had noninsulin-dependent diabetes mellitus, and neither had a history of alcohol consumption or blood transfusion. All serologic markers for hepatitis B and C viruses were negative. Histological examination of the noncancerous hepatic tissue revealed NASH with moderate hepatic fibrosis in one patient and cirrhosis in the other. Thus, clinical follow-up and screening for HCC should be done for patients with hepatic fibrosis caused by NASH, even though this form of hepatitis is an uncommon cause of HCC.

DOI： 10.1007/s00595-005-3167-4

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DOI： 10.1007/BF02744871

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Objective: Impacts of mediastinal lymph node dissection on a patient's course after pulmonary resection is unclear in octogenarians with non-small cell lung cancer. Methods: Retrospectively identified subjects included 39 octogenarians and 1 nonagenarian, with grades according to the Charlson Comorbidity Index ranging from only 0 to 2. We performed mediastinal lymph node dissection in 19 patients (D group), and just lymph node sampling biopsy in the other 21 (S group). We compared clinicopathologic features and outcome after surgery between both groups. Results: Deterioration of performance status at the time of discharge, evident in 17 patients overall, was significantly more frequent in the D group. Postoperative complications occurred in 27 patients overall and there was no significant difference between the two groups. Survival rates in younger patients at 1, 3, and 5 years were 86, 59, and 49%, respectively
in octogenarians these were 83, 58, and 42% (no significant difference). Nor did survival differ significantly by surgical management of mediastinal lymph nodes
1-, 3-, and 5-year survival rates were 94, 63, and 40%, respectively in the D group and 78, 66, and 43%, respectively in the S group. Conclusion: Octogenarians with non-small cell lung cancer should be treated by urgent pulmonary resection whenever possible. Since mediastinal lymph node dissection has little effect on long-term survival or the carried risk of worsening performance status at discharge, pulmonary resection without complete mediastinal lymph node dissection should be considered.

DOI： 10.1007/BF02744871

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DOI： 10.1007/BF02744871

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DOI： 10.1007/s00534-005-1074-0

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DOI： 10.1007/s00595-005-3167-4

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DOI： 10.1007/s00534-005-1074-0

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Background/Purpose. Although some gallbladder carcinomas are immunoreactive for c-Kit, the reasons for the c-Kit expression and its clinicopathologic implications are unknown.
Methods. We investigated the prevalence of c-Kit immunoreactivity, its clinicopathologic correlates (including microvessel density and postoperative outcome), and the possible mechanisms of c-Kit expression. We reviewed retrospectively, the clinicopathologic records of 47 patients who had undergone macroscopically complete gallbladder carcinoma resection. The numbers of patients at pathologic stages I to IV, according to current TNM-based staging, were 10, 5, 18, and 14, respectively. For immunohistochemical examination, we used monoclonal antibodies against c-Kit and CD 34 (progenitor cell markers), cytokeratin 7 and cytokeratin 19 (cholangiocyte markers), and OCH1E5 (a hepatocyte marker). Control tissue samples were from five gallbladder specimens each with chronic cholecystitis, polyp, and adenoma.
Results. Cytoplasmic immunostaining for c-Kit was detected in 21 of the 47 gallbladder carcinomas (45%), and in 1 of the 15 control specimens (diagnosis, chronic cholecystitis). Young age was significantly associated with c-Kit positivity; however, there were no significant differences in the incidence of c-Kit positivity among other variables, including tumor stage and outcome. However, microvessel density was significantly higher in c-Kit-positive gallbladder carcinoma compared with c-Kit-negative gallbladder carcinoma. None of the 47 cancer specimens or the 15 control specimens were stained for CD34 and OCH1E5, but all 47 cancer specimens were stained for cytokeratins 7 and 19.
Conclusions. Gallbladder carcinomas positive for c-Kit are unlikely to arise from immature cells, but may be associated with neovascularization. Angiogenesis inhibitors, such as tyrosine kinase inhibitors, therefore, may suppress the growth of some gallbladder cancers.

DOI： 10.1007/s00534-005-1074-0

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Recently, it has been suggested that hepatitis C virus infection plays a role in the pathogenesis of some intrahepatic cholangiocarcinomas (ICC). We describe two patients with small ICC detected after interferon therapy for chronic hepatitis C. Case 1 was diagnosed with ICC by preoperative biopsy and underwent anterior segmentectomy of the liver, while Case 2 was diagnosed with hepatocellular carcinoma preoperatively and the tumor was diagnosed as ICC after biopsy and microwave coagulonecrotic therapy. Both patients are in good health six months and five months, respectively, after operation.
It is important to monitor carefully for ICC as well as hepatocellular carcinoma in patients with chronic hepatitis C, even when interferon therapy has been carried out, since the outcome of treatment for small ICC is favorable.

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Recently, it has been suggested that hepatitis C virus infection plays a role in the pathogenesis of some intrahepatic cholangiocarcinomas (ICC). We describe two patients with small ICC detected after interferon therapy for chronic hepatitis C. Case 1 was diagnosed with ICC by preoperative biopsy and underwent anterior segmentectomy of the liver, while Case 2 was diagnosed with hepatocellular carcinoma preoperatively and the tumor was diagnosed as ICC after biopsy and microwave coagulonecrotic therapy. Both patients are in good health six months and five months, respectively, after operation.
It is important to monitor carefully for ICC as well as hepatocellular carcinoma in patients with chronic hepatitis C, even when interferon therapy has been carried out, since the outcome of treatment for small ICC is favorable.

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DOI： 10.1007/s00535-005-1681-1

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Background. The Japan integrated staging (JIS) score is recognized to be useful in managing hepatocellular carcinoma (HCC). We evaluated the effects of the causative virus in patients stratified by this system. Methods. We compared clinicopathologic features, cumulative and tumor-free survival rates, and causes of death between 301 hepatitis C virus-positive patients (HCV group) and 60 hepatitis B virus-positive patients (HBV group). Results. Among patients with low JIS scores (0 or 1), the proportions of patients with high aspartate and alanine aminotranferase activities, moderate-to-severe active hepatitis, and with cirrhosis were significantly higher in the HCV than in the HBV group. Among patients with high JIS scores (2 to 4), the proportion with moderate-to-severe active hepatitis was also significantly higher in the HCV group. In patients with low JIS scores, those in the HCV group had significantly lower tumor-free and cumulative survival rates than those in the HBV group. Although no patient in the HBV group died of causes other than liver disease (HCC or hepatic failure), some patients in the HCV group died of causes other than liver disease. The proportion of patients who died because of HCC recurrence tended to be higher among patients with high JIS scores than among patients with a low JIS score. Conclusions. The effects of viral status on survival outcomes are greatest in patients with JIS scores of 0 or 1.

DOI： 10.1007/s00535-005-1681-1

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DOI： 10.1016/j.hepres.2005.01.012

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Hypothesizing that combined hepatocellular and intrahepatic cholangiocellular carcinoma originates from hepatic stem cells, we conducted a series of imnumohistochemical studies using hepatic stem cell markers to better understand the origin of the tumor. Specially, we investigated 15 combined tumors confirmed to be immunoreactive to anti-hepatocyte paraffin 1, and anti-cytokeratin 7 and 19 antibodies. Macroscopic investigation revealed cancer cells morphologically intermediate between neoplastic hepatocytes and cholangiocytes (combined tumor with intermediate morphology) in 11 of 15 tumors. The remaining four tumors lacking these cells were considered ordinary combined tumors. We used 20 hepatocellular carcinomas and 10 cholangiocarcinomas as controls. Immunohistochemical analysis was performed using stem cell markers (c-kit and CD34). Of the 15 combined tumors, 8 stained for c-kit (2 of the 4 ordinary tumors and 6 of the 11 intermediate morphologic tumors). Both of the tumor cell types in both of the ordinary combined tumors stained for c-kit. The c-kit staining was present in cells of all three morphologic types, including the intermediate cells, in all six of the intermediate combined tumors. None of the cells in the combined tumors showed immunoreactivity for CD34. None of the 30 control tumors expressed CD 34 or c-kit. The present study suggests that combined hepatocellular and intrahepatic cholangiocellular carcinomas originate not from a hepatic stem cell, but from a hepatic precursor cell, such as the canal of Hering cell. Alternatively, these tumors might show up-regulation of c-kit in relation to angiogenesis. (c) 2005 Elsevier B.V. All rights reserved.

DOI： 10.1016/j.hepres.2005.01.012

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DOI： 10.1007/s00595-004-2937-8

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Pancreatoduodenectomy can be difficult in patients with obstruction of the celiac axis because of the development of collateral arteries around the head of the pancreas. Bleeding from a pseudoaneurysm is a rare and serious complication of pancreatoduodenectomy. We report a case of a pseudoaneurysm of an enlarged dorsal pancreatic artery, which formed as a result of obstruciton of the celiac axis after pancreatoduodenectomy. We assumed that a weakness in the wall of this dorsal pancreatic artery caused by the dissection led to the formation of the aneurysm. Although transcatheter arterial embolization (TAE) could not treat the aneurysm or stop bleeding from the aneurysm completely, it achieved transient hemostasis, whereby the patients condition improved, making laparotomy safe. This case demonstrates that the dissection of arteries that have developed around the head of the pancreas must be considered in patients with obstruction of the celiac axis.

DOI： 10.1007/s00595-004-2937-8

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DOI： 10.1007/s00595-004-2919-x

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DOI： 10.1016/j.transproceed.2004.11.044

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Purpose. We compared the clinicopathologic features affecting outcome after surgery for hepatocellular carcinoma (HCC) between patients with concurrent and previous chronic hepatitis B.
Methods. Group A consisted of 58 patients with concurrent chronic hepatitis B, defined by seropositivity for the hepatitis B surface antigen (HBsAg), and group B consisted of 18 patients whose HCC was detected after disappearance of the HBsAg. We assessed the influence of various characteristics on outcome.
Results. The mean age and percentage of patients suffering from alcohol abuse or diabetes mellitus were significantly greater in group B than in group A, whereas histologic hepatitis activity, hepatic fibrosis, and alanine aminotransferase activity were significantly lower in group B than in group A. The tumor-free survival rates were similar between the two groups, but the risk factors of recurrence differed. In group A, relative youth, high aspartate aminotransferase activity, low platelet count, multiple tumors, large tumor size, portal invasion, cirrhosis, nonanatomic resection, and positive surgical margin were risk factors. In group B, large tumor size and poor differentiation were risk factors.
Conclusion. Hepatitis B status, tumor factors, and the type of operation affected cancer recurrence after surgery for HCC in patients with concurrent chronic HBV, as opposed to only tumor factors in patients with previous chronic hepatitis B.

DOI： 10.1007/s00595-004-2919-x

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To understand the recurrence rate and transplantability after liver resection (LR), which are essential factors to predict the prognosis of initial resection and salvage transplantation for hepatocellular carcinoma (HCC), we reviewed the clinical records of 279 consecutive HCC patients who met the Milan criteria and underwent LR between 1990 and 2000. Recurrence-free survival rates after 1, 2, 3, 5, and 10 years following LR were 84%, 62%, 49%, 29%, and 17%, respectively. Multivariate analysis using clinical factors such as age, sex, histological differentiation, serum levels of alpha-fetoprotein and 7S domain of type IV collagen (7S collagen), platelet counts, indocyanin green retention test after 15 minutes, and type of LR (resection of one or more segments, or less than one segment) revealed 7S collagen to be a independent factor that significantly affects recurrence-free survival. Yearly recurrence rates up to 5 years after resection ranged from 14% to 27%, averaging 20%. Concerning 169 patients who underwent tests for 7S collagen, the average yearly recurrence rate (27%) in patients with 7S collagen levels 8.0 ng/mL or higher was remarkably greater than that in the patients with levels less than 8.0 ng/mL (16%). The transplantability rate at the time of recurrence meeting the Milan criteria was roughly 60%. There were no pre-LR factors that significantly predicted transplantability. This result indicates that patients with lower 7S collagen levels are more eligible for initial LR and then salvage LT rather than primary LT.

DOI： 10.1016/j.transproceed.2004.11.044

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Clinicolpathologic variables favoring recurrence, after hepatic resections for intrahepatic cholangiocarcinoma showing intraductal growth remain-unclear. We investigated various clinicopathologic features in three patients who underwent resection for this type of intrahepatic cholangiocarcinoma. All underwent extended left hepatectomy plus resection of the cau date lobe and lymph node dissection. Lymph nodes showed no pathologic involvement. Although no cancer cells were seen in the mucosal layer by intraoperative pathologic examination-at the bile duct stump in any patient, pathologic examination of resected specimens showed cancer cells invading beyond the mucosal layer in connective tissues surrounding the bile duct stump (interstitial invasion) of the Glisson's sheath in 2 patients. One of them,died of cancer recurrence near the bile duct stump, while the third patient, without interstitial invasion, has survived for 10.6 years. In the intraductal growth type of intrahepatic cholangiocarcinoma, absence of cancer cells should be confirmed by intraoperative pathologic examination of not only the mucosal layer of the bile duct but also the connective tissue surrounding the bile duct, since interstitial invasion may be a risk factor for cancer recurrence.

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DOI： 10.1016/j.hepres.2004.09.008

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The etiologic role of alcoholic liver disease for hepatocellular carcinoma is uncertain. To assess the role of alcoholic liver disease on the development of carcinoma, we examined history of alcohol abuse and viral markers in the sera and/or resected specimens in 454 patients who underwent liver resection for hepatocellular carcinoma. Sera from 20 of the 454 patients were negative for hepatitis B, C, and D viruses. Of the 20 patients, one patient had autoimmune hepatitis, one had primary biliary cirrhosis, two had non-alcoholic steatohepatitis. Of the remaining 16 patients, 8 patients were alcohol abusers and 5 of the 8 patients were heavy alcohol abusers. Hepatitis G virus was not detected in sera form the 16 patients. Although hepatitis B x gene was detected in the cancerous and/or non-cancerous tissues in all three alcohol abusers but not heavy abusers and in 5 of 6 non-alcohol abusers whose surgical specimens were available, the gene was detected in only one of the five heavy alcohol abusers. The five heavy alcohol abusers had advanced hepatic fibrosis and active hepatitis. Alcoholic liver disease with advanced hepatic fibrosis and active hepatitis is a possible cause for the development of hepatocellular carcinoma. (c) 2004 Elsevier B.V. All rights reserved.

DOI： 10.1016/j.hepres.2004.09.008

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DOI： 10.1016/j.hepres.2004.09.008

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DOI： 10.1007/s00595-004-2882-6

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Purpose. We investigated the correlation between serum concentrations of type IV collagen 7s domain (7s collagen) and changes in the volume of the nonembolized liver lobe after subsequent portal vein embolization (PVE).
Methods. The relationship between the pre-embolization results of laboratory tests and the increase in the left lobe volume was evaluated in 32 patients who underwent preoperative PVE via the right portal vein.
Results. By 2 weeks after PVE, the mean volume of the left lobe had increased significantly (P&lt;0.001). The percent increase in the left lobe volume correlated negatively with the pre-embolization serum concentration of 7s collagen (r=-0.472, P=0.0063). In three of four patients with high serum concentrations (&gt;8 ng/ml), the percent increase was less than 100% and right lobectomy was not performed. The serum 7s collagen concentration correlated with the histologic activity score (r=0.469, P=0.0061) and the histologic fibrosis score (r=0.425, P=0.0145).
Conclusion. The serum concentration of 7s collagen may predict the efficacy of PVE. Performing PVE before right lobectomy may not be indicated in patients with high serum concentrations of 7s collagen because the increases in left lobe volume may be insufficient.

DOI： 10.1007/s00595-004-2882-6

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DOI： 10.1159/000091446

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Background. Although hepatitis C virus (HCV) infection is a possible pathogenetic factor for intrahepatic cholangiocarcinoma (ICC), clinicopathologic features of ICC patients with HCV infection remain unclear. Patients and Methods: Of 50 patients with ICC treated, 19 were infected with HCV (HCV-positive group) and 38 underwent surgical treatment. Clinicopathologic features and postoperative outcome were compared between patients with and without HCV infection. Results: In 15 patients in the HCV-positive group, ICC was detected during follow-up for chronic hepatitis C. The proportion of patients who underwent curative resection was significantly higher in the HCV-positive than in the HCV-negative group, and tumors were significantly smaller in the HCV-positive than in the HCV-negative group. In the HCV-positive group, tumors were significantly smaller in patients who were followed up for chronic hepatitis C than in patients who were not followed up. Although cumulative survival rates did not cliff er significantly between groups, prognoses of patients with small ICC were significantly better than those with large ICC. Conclusion: Follow-up for patients with chronic hepatitis C by imaging series at regular intervals is important and provides the possibility to detect a small ICC as well as a hepatocellular carcinoma. Resection should be guided by liver function and the tumor stage in patients with HCV-associated ICC. Copyright (c) 2005 S. Karger AG, Basel.

DOI： 10.1159/000091446

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DOI： 10.11405/nisshoshi.102.1299

CiNii Article

A 53-year-old woman with chronic hepatitis B was found to have a hepatic tumor. CT performed in December 2004 demonstrated that the tumor increased to 16mm in diameter and showed low density. She was asymptomatic. Laboratory data showed mild hepatic dysfunction, but serum concentrations of minerals and tumor markers were within the normal ranges. Dynamic CT scan demonstrated that the tumor displayed homogenous enhancement with rapid washout. CT scan under angiography through the right hepatic artery demonstrated that the most part of the tumor was enhanced. On the basis of these findings, preoperative diagnosis of hepatocellular carcinoma was made. As the right adrenal gland firmly adhered to the tumor and the surrounding hepatic tissue, limited resection with concomitant resection of the right adrenal gland was performed. Macroscopically, the tumor, 1.6cm in diameter, was yellow in color and well-bordered without capsule. Histological examination revealed that the tumor was adrenocortical adenoma that compressed the liver. Hepatic parenchyma was diagnosed as cirrhosis. It was difficult to distinguish the disease from hepatocellular carcinoma before surgery, because abdominal CT scan visualized that the tumor was seemingly present in the liver and it was fed by the right hepatic artery.

DOI： 10.3919/jjsa.66.2569

CiNii Article

DOI： 10.1007/s00595-004-2882-6

PubMed

DOI： 10.1007/s00595-004-2937-8

PubMed

DOI： 10.1007/s00595-004-2919-x

PubMed

Publishing type：Research paper (scientific journal)  

Publishing type：Research paper (scientific journal)  

Publishing type：Research paper (scientific journal)  

Publishing type：Research paper (scientific journal)  

Publishing type：Research paper (scientific journal)  

Publishing type：Research paper (scientific journal)  

Publishing type：Research paper (scientific journal)  

Publishing type：Research paper (scientific journal)  

Publishing type：Research paper (scientific journal)  

Publishing type：Article, review, commentary, editorial, etc. (scientific journal)  

シミュレーション医療教育(SME)成功のポイントは、"ハード面"の体裁を整えることよりも、それらを活用して"いかに質の高い医療教育を提供・展開するか"という"ソフト面"の立案や実践である。本学スキルスシミュレーションセンター(SSC)での取組みから、SMEにおけるTeachingのコツとスキルスラボ運営の工夫についても言及した。利用者数は年間12,000名で、医学生、研修医、看護師、他職種連携、ならびに入学前教育とさまざまなSMEを行っている。これには常在スタッフが必須である。SMEにおけるteachingのコツは"失敗できること"を活かした"教えないこと"である。失敗体験が他者の行為への繊細な観察へつながる。もうひとつ、"かぶること"をおそれない繰り返しが学習効果を高める。競争意識を活かした実・講習の質の担保、"Teaching is Learning"の理念による指導者確保、ならびに、院外講習会の有料化による維持費の確保も質の高いSMEを長期的に実践するスキルスラボ運営の工夫である。(著者抄録)

Publishing type：Article, review, commentary, editorial, etc. (scientific journal)  

プライマリ・ケアにおける女性の心身医療を考えるとき、女性のライフサイクルや女性ホルモンの関与を考えなければならない。女性に周期的に起こる原因不明の愁訴の中には、女性ホルモンによる機能的な疾患が隠れている可能性がある。また、その女性ホルモンの恩恵が無くなる更年期以降は、心身の変化に特に留意する必要がある。一方で、産婦人科医以外の医療者が確認しづらい性生活の問題が疾患の原因であることもまれではない。女性特有の悩みに対峙するときには、女性ホルモンの変化がもたらす身体的特徴を念頭に、女性の気持ちに配慮した診療が望まれる。(著者抄録)

Publishing type：Article, review, commentary, editorial, etc. (scientific journal)  

1)京都科学社製の中心静脈穿刺手技(CVC)シミュレータと模擬患者を活用し,受講者2名に対してインストラクター1名を配置した講習会を行った.2)受講者のアンケート結果は好評であり,特に実技後の振返りの方法が高い評価を得た.3)効果的なシミュレーション医療研修を行うためには,シミュレータと模擬患者を活用し,技術や手順の習得だけでなく,同時に医療従事者としての態度を養成することが重要である.(著者抄録)

Publishing type：Article, review, commentary, editorial, etc. (scientific journal)  

Presentation type：Poster presentation  

Venue：出島メッセ長崎  

Presentation type：Poster presentation  

Venue：出島メッセ長崎  

Venue：大阪府歯科医師会館  

Venue：東大阪市立義務教育学校 くすは縄手南校  

Venue：大阪府立北野高等学校  

Presentation type：Public lecture, seminar, tutorial, course, or other speech  

Venue：滋賀県立膳所高等学校  

Presentation type：Public lecture, seminar, tutorial, course, or other speech  

Venue：滋賀県立膳所高等学校  

Presentation type：Public lecture, seminar, tutorial, course, or other speech  

Presentation type：Poster presentation  

Venue：Gメッセ群馬  

Presentation type：Oral presentation (general)  

Venue：Gメッセ群馬  

Presentation type：Poster presentation  

Venue：Gメッセ群馬  

Presentation type：Oral presentation (general)  

Venue：Gメッセ群馬  

Presentation type：Public lecture, seminar, tutorial, course, or other speech  

Venue：駿台大阪南校  

Venue：高知県ふくし交流プラザ  

Venue：高知県ふくし交流プラザ  

Presentation type：Public lecture, seminar, tutorial, course, or other speech  

Venue：駿台大阪校  

Presentation type：Oral presentation (general)  

Venue：Web  

Presentation type：Public lecture, seminar, tutorial, course, or other speech  

Venue：大阪府立北野高等学校  

Presentation type：Oral presentation (general)  

Venue：Web  

Presentation type：Oral presentation (general)  

Venue：Web開催（栃木）  

【目的】国際水準確保に向けた医学教育改革が全国的に進む中で、学生評価の質と量の充実ならびにデータの蓄積と解析が求められるようになった。
学生評価の充実は重要な課題であるが、学内システム構築は容易ではない。大阪市立大学では、これまで、臨床実習中の評価は、知識、技能、態度に関する概略評価を診療科ごとに形成的に行うことが主流であったが、2018年度より臨床実習中に客観的臨床能力試験(OSCE)を年5回、2021年度より簡
易版臨床能力評価法（Mini CEX）を年10回行うこととした。本学独自の臨床実習中OSCEの結果を他の試験結果と比較し、その特性や意義について考察した。【方法】各診療科の教育担当を5つのチームに分け、チームごとに共用試験実施評価機構が “診療参加型臨床実習で学生が行う行為”として提示した14の臨床能力が評価可能な5分程度の課題を作成するように依頼した。評価方法は共用試験OSCEに倣い、細目/概略評価を作成し評価した。本試験の特性を評価するため、国家試験の成績が把握できた167名の学生のデータを使用し、本試験と、共用試験CBT、実習前OSCE、本学卒業総合試験、Post CC OSCE、国家試験との関連を解析した。【結果】教育担当者の協議の上、“適切な身体診察ができる、基本的臨床手技ができる”、“インフォームドコンセントを得ることができる“、”正しい診療記録を記載できる“、”患者の申し送りを行うことができる“、”緊急性を評価し適切な初期対応ができる“に対応した課題を作成した。本試験結果は、CBT、国家試験、Post CC OSCEの成績とほとんど相関せず、実習前OSCEに弱い相関を示した。【考察】医師として重要なアウトカムを設定した試験であったが他の試験結果との相関性が低いことから、多様な医学生の能力が評価できたのではないかと考える。本試験を導入することで、学生評価の充実のみならず、教員の学生評価に対する意識を高めることにも寄与できたと考える。

Presentation type：Oral presentation (general)  

Venue：Web開催（栃木）  

【目的】国際水準確保に向けた医学教育改革が全国的に進む中で、学生評価の質と量の充実ならびにデータの蓄積と解析が求められるようになった。
学生評価の充実は重要な課題であるが、学内システム構築は容易ではない。大阪市立大学では、これまで、臨床実習中の評価は、知識、技能、態度に関する概略評価を診療科ごとに形成的に行うことが主流であったが、2018年度より臨床実習中に客観的臨床能力試験(OSCE)を年5回、2021年度より簡
易版臨床能力評価法（Mini CEX）を年10回行うこととした。本学独自の臨床実習中OSCEの結果を他の試験結果と比較し、その特性や意義について考察した。【方法】各診療科の教育担当を5つのチームに分け、チームごとに共用試験実施評価機構が “診療参加型臨床実習で学生が行う行為”として提示した14の臨床能力が評価可能な5分程度の課題を作成するように依頼した。評価方法は共用試験OSCEに倣い、細目/概略評価を作成し評価した。本試験の特性を評価するため、国家試験の成績が把握できた167名の学生のデータを使用し、本試験と、共用試験CBT、実習前OSCE、本学卒業総合試験、Post CC OSCE、国家試験との関連を解析した。【結果】教育担当者の協議の上、“適切な身体診察ができる、基本的臨床手技ができる”、“インフォームドコンセントを得ることができる“、”正しい診療記録を記載できる“、”患者の申し送りを行うことができる“、”緊急性を評価し適切な初期対応ができる“に対応した課題を作成した。本試験結果は、CBT、国家試験、Post CC OSCEの成績とほとんど相関せず、実習前OSCEに弱い相関を示した。【考察】医師として重要なアウトカムを設定した試験であったが他の試験結果との相関性が低いことから、多様な医学生の能力が評価できたのではないかと考える。本試験を導入することで、学生評価の充実のみならず、教員の学生評価に対する意識を高めることにも寄与できたと考える。

Presentation type：Oral presentation (general)  

Venue：Web開催（鹿児島）  

【背景】本学では2013年に、SP養成組織として＜あべのSP本舗＞を設立し、模擬患者（Simulated Patients／Standardized Patients：以下SP）の養成を開始した。医学科2年生対象のコミュニケーション実習では、学生約100名、SP約15名、教員約5名の総勢120名が1つの講義室に集まり、アイスブレイク、ミニレクチャー、患者役シナリオ作成、ならびにSPとのロールプレイを行ってきた。学生たちは、身だしなみ・姿勢・話し方・本人の癖など、SPから有意義なフィードバックを得ていた。しかし、2020年度はコロナ禍で完全オンラインに変更して実践したため報告する。【実践方法】変更
点として、アイスブレイクは割愛、ミニレクチャーと患者役シナリオ作成は事前課題とした。実習当日はZoomのブレイクアウトルーム機能を活用してオンライン上でグループ（学生約6名、SP1-2名、ファシリテーター1名）に分け、SPとのロールプレイを学生全員が行った。準備として、SPには事前の講習会でZoomの操作に慣れて頂き、学生には繰り返し周知するなどの工夫を凝らした。【得られた成果と振り返り】SPから学生へのフィードバックでは「目を見て共感してくれて安心できた」「早口だった」など、例年通り非言語的なものを含むコミュニケーションに関するものが多数みられ、一定以上の学びを学生は得ていた。一方、SPからは画面に入らない全身の仕草などの評価は難しいという声があった。これらは過去の報告と同様であった。また、雑談できないオンラインだからこそ実習に集中できたという予想外の成果の反面、自宅から参加した学生の緊張感が乏しくなることが明らかになった。【結語】コロナ禍はオンライン活用型教育の利点と欠点を整理整頓するための十分な機会になった。全身の仕草の評価、対面型と同様の緊張感を保つという課題を踏まえて、今後もオンライン活用型教育に取り組みたい

Presentation type：Oral presentation (general)  

Venue：Web開催（栃木）  

【はじめに】2020年初頭より、新型コロナウイルス感染症（COVID-19）は日本においても猛威を振るい、その流行下において、医学科の臨床実習の実施にも多くの支障が生じた。2020年6月の緊急事態宣言の解除後、密集、密接、密閉の「3密」を避けた行動が求められ本学では座学は遠隔授業の継続
となり、医学科5年生のクリニカルクラークシップ（以下M5CC）は病院への立ち入りが制限される方針となった。【経過と方法】6月よりM5CCが再開となったが、病院に立ち入ることが出来ない為　大学の講義室やスキルスシミュレーションセンター（以下SSC）などを用いて,臨床実習が行われた。
SSCで行うシミュレータを用いた実習においては感染防御部のアドバイスの元、8項目の感染対策を決定しSSCの入り口にて周知した。
1　入室前までに体温測定、マスクの着用、手指衛生を行うこと
2　マスクは鼻と口をおおうこと
3　入室前に手指消毒を行うこと
4　学生入室時のExcel表の記載は担当者が入力、保管すること
5　実習中顔周りを触れないこと
6　機材使用後に清掃を確実に行うこと
7　換気を確実に行うこと
8　退室後の手指衛生を行うことM5CCの実習に来ている医学生にSSCにおける担当者が1から8の感染対策が適切にできていたのかアンケートを実施した。アンケートは8月31日から9月25日にWEBで行い各項目とも3段階（できた　できなかった　どちらでもない）からの選択とした。【結果】医学科5年生の74名から回答を得た。1、2、3、4は74名全員ができたと回答した。5、6、7、8についても90％以上はできたと回答した（それぞれ96％、90％、95％、95％）が、
一部にできていない、どちらでもない　の回答が見られた。【まとめ】実習終了後の感染予防対策の周知が足りない所があったが概ね大きな問題点の指摘はなかったので、この対策を基本とした感染予防を行いながら、以後の講習や実習を開催している。SSCが基本の感染対策を確実に行うことで感
染拡大は起きておらず、基本の感染対策を繰り返し行うことにより参加者に安心して実習していただけると思われる

Presentation type：Oral presentation (general)  

Venue：Web開催（栃木）  

【背景・目的】外来での診療参加型臨床実習（clinical clerkship: CC）は学生用のブース確保や指導医が自身の診療を中断し学生対応を行わなければならない等の障壁が高く、病棟中心の実習が行われる傾向にある。しかしながら、基本的臨床能力の涵養に外来での実習が重要である。大阪市立大学では、臨床実習として「外来型CC」コースを導入し、その期間は全診療科、学生に外来での実習を行うことを義務付けている。また、外来実習後には、学生を講義室に集め症例検討会を行い、自らの考えを明確に伝え、他者の意見を聞く能力を養っている。本学の「外来型CC」コースの取り組みと効
果について報告する。【方法】CCのはじめの２週間に外来型CCとして、学生を各診療科に割り当てて外来での実習を行っている。本実習の到達目標は、1) 医療面接、2) 各症例の要約とカルテ記載、ならびに3) 症例提示と質疑応答とした。学生は初診患者に対して医療面接を行い、診療録を作成、担当医への患者申し送りを行い、フィードバックを受けるようにした。症例検討会で、電子カルテの記載内容を講義室に投影しながら症例提示を行わせ、学生同士で質疑応答するよう義務付けた。数名の教員も症例検討会に参加しファシリテーターを務め、フィードバックを行っている。実習後の自己評価、アンケート結果を分析した。【結果】2020年度、97名の医学生による自己評価では、知識、臨床技能、診療業務行動ならびに学習態度について、80％以上「よくできた」もしくは「できた」と回答した。自由記載では、「主訴から鑑別疾患を想定して問診できるよう頑張りたい」、「アセスメントとプランの難しさを実感した」、「今後の実習でも質問するつもりで参加しようと思った」などの記載がみられた。指導体制については、到達目標1) ～3)に対して、85％以上が経験する機会を十分に与えられたと評価した。【考察】外来型CC、症例検討会を行うことで、1) 医療面接、2) 各症例の要約とカルテ記載、ならびに3) 症例提示と質疑応答を確実に経験させることができた。また、それらの経験から、その後のCCにおいても、自身の課題や目標を見出す機会を与えることができた。

Presentation type：Oral presentation (general)  

Venue：Web開催（栃木）  

【背景】救命の連鎖をつなげるためには、傷病者発生の現場に居合わせたバイスタンダーによる一次救命処置（Basic Life Support、以下BLS）が必須である。2020年度、新型コロナウイルス感染症の感染防止対策（以下、感染対策）の下、本学医学部医学科1年生を対象にBLS講習会を開催したため
報告する。【目的】感染対策下でのBLS講習会の効果および改善点を検討すること。【方法】受講者は本学医学部医学科1年生、インストラクターは同4年生とした。講習会は、レサシアンを用いて行った。各ブースはインストラクター、受講者が例年は2名ずつ配置していたが、それぞれ1名ずつとした。スライドと動画による説明後、実践練習を繰り返す形式をとった。感染対策は、手指消毒、マスクの着用、レサシアンの消毒、ブース同士の距離の確保とした。また、受講者とインストラクターには、事前に動画の視聴とその確認テストを実施し、講習会終了後にはアンケートを実施した。【結果】動画視聴後の確認テストでは、受講者の83.2%（受験者95人中79人）が90点以上であった。アンケートにおいて、「傷病者発見時の対応手順について理解し、実行することができるか」の質問に対して、４段階評価のうち最も高い評価であった割合は77.2%（回答者92人中71人）で、昨年度の54.4%（回答者68人中37人）に比して高かった。インストラクターへのアンケートでは、「後輩に教えることで緊張感と責任感を持って学習し直すことができた」や「一人のほうが教えやすかった」という意見が多かった。受講者へのアンケートでは、「非常に親しみやすく、理解もしやすいようにわかりやすく教えていただけた」という主旨の回答が複数得られた。【まとめ】感染対策下においても前年度以上の学習効果が認められた。さらに、少人数制にすることでインストラクターは責任感を持って指導を行うことができ、受講者は、よりインストラクターと親近感を持って取り組みやすくなった可能性がある。感染対策下でも、高い学習効果の期待できるBLS講習会を開催することができた。来年度以降も本講習会を開催し、医学生のBLSスキルの向上に寄与していきたい

Presentation type：Oral presentation (general)  

Presentation type：Oral presentation (general)  

Presentation type：Oral presentation (general)  

Venue：Web開催（栃木）  

【目的】国際水準確保に向けた医学教育改革が全国的に進む中で、学生評価の質と量の充実ならびにデータの蓄積と解析が求められるようになった。
学生評価の充実は重要な課題であるが、学内システム構築は容易ではない。大阪市立大学では、これまで、臨床実習中の評価は、知識、技能、態度に関する概略評価を診療科ごとに形成的に行うことが主流であったが、2018年度より臨床実習中に客観的臨床能力試験(OSCE)を年5回、2021年度より簡
易版臨床能力評価法（Mini CEX）を年10回行うこととした。本学独自の臨床実習中OSCEの結果を他の試験結果と比較し、その特性や意義について考察した。【方法】各診療科の教育担当を5つのチームに分け、チームごとに共用試験実施評価機構が “診療参加型臨床実習で学生が行う行為”として提示した14の臨床能力が評価可能な5分程度の課題を作成するように依頼した。評価方法は共用試験OSCEに倣い、細目/概略評価を作成し評価した。本試験の特性を評価するため、国家試験の成績が把握できた167名の学生のデータを使用し、本試験と、共用試験CBT、実習前OSCE、本学卒業総合試験、Post CC OSCE、国家試験との関連を解析した。【結果】教育担当者の協議の上、“適切な身体診察ができる、基本的臨床手技ができる”、“インフォームドコンセントを得ることができる“、”正しい診療記録を記載できる“、”患者の申し送りを行うことができる“、”緊急性を評価し適切な初期対応ができる“に対応した課題を作成した。本試験結果は、CBT、国家試験、Post CC OSCEの成績とほとんど相関せず、実習前OSCEに弱い相関を示した。【考察】医師として重要なアウトカムを設定した試験であったが他の試験結果との相関性が低いことから、多様な医学生の能力が評価できたのではないかと考える。本試験を導入することで、学生評価の充実のみならず、教員の学生評価に対する意識を高めることにも寄与できたと考える。

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Venue：Web開催（栃木）  

【はじめに】2020年初頭より、新型コロナウイルス感染症（COVID-19）は日本においても猛威を振るい、その流行下において、医学科の臨床実習の実施にも多くの支障が生じた。2020年6月の緊急事態宣言の解除後、密集、密接、密閉の「3密」を避けた行動が求められ本学では座学は遠隔授業の継続
となり、医学科5年生のクリニカルクラークシップ（以下M5CC）は病院への立ち入りが制限される方針となった。【経過と方法】6月よりM5CCが再開となったが、病院に立ち入ることが出来ない為 大学の講義室やスキルスシミュレーションセンター（以下SSC）などを用いて,臨床実習が行われた。
SSCで行うシミュレータを用いた実習においては感染防御部のアドバイスの元、8項目の感染対策を決定しSSCの入り口にて周知した。
1 入室前までに体温測定、マスクの着用、手指衛生を行うこと
2 マスクは鼻と口をおおうこと
3 入室前に手指消毒を行うこと
4 学生入室時のExcel表の記載は担当者が入力、保管すること
5 実習中顔周りを触れないこと
6 機材使用後に清掃を確実に行うこと
7 換気を確実に行うこと
8 退室後の手指衛生を行うことM5CCの実習に来ている医学生にSSCにおける担当者が1から8の感染対策が適切にできていたのかアンケートを実施した。アンケートは8月31日から9月25日にWEBで行い各項目とも3段階（できた できなかった どちらでもない）からの選択とした。【結果】医学科5年生の74名から回答を得た。1、2、3、4は74名全員ができたと回答した。5、6、7、8についても90％以上はできたと回答した（それぞれ96％、90％、95％、95％）が、
一部にできていない、どちらでもない の回答が見られた。【まとめ】実習終了後の感染予防対策の周知が足りない所があったが概ね大きな問題点の指摘はなかったので、この対策を基本とした感染予防を行いながら、以後の講習や実習を開催している。SSCが基本の感染対策を確実に行うことで感
染拡大は起きておらず、基本の感染対策を繰り返し行うことにより参加者に安心して実習していただけると思われる

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Venue：久留米大学（福岡）  

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Venue：久留米大学（福岡）  

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Venue：久留米大学（福岡）  

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Venue：Web開催（群馬）  

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Venue：河合塾北キャンパス東大・京大・医進館  

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Venue：河合塾北キャンパス東大・京大・医進館  

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Venue：学校法人河合塾 大阪北キャンパス東大・京大・医進館  

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Venue：学校法人河合塾 大阪北キャンパス東大・京大・医進館  

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Venue：河合塾北キャンパス東大・京大・医進館  

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Venue：大阪医科大学医学教育センター（大阪）  

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Venue：大阪医科大学医学教育センター（大阪）  

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Venue：大阪医科大学医学教育センター（大阪）  

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Venue：大阪医科大学医学教育センター（大阪）  

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Venue：大阪医科大学医学教育センター（大阪）  

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Venue：Web開催（大阪）  

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Venue：Web開催（大阪）  

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Venue：Web開催（広島）  

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Venue：Web開催（広島）  

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Venue：Web開催（鹿児島）  

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Venue：Web開催（鹿児島）  

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Venue：Web開催（鹿児島）  

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Venue：Web開催（鹿児島）  

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Venue：Web開催（鹿児島）  

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Venue：Web開催（鹿児島）  

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Venue：Web開催（鹿児島）  

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Venue：Web開催（鹿児島）  

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Venue：Web開催（鹿児島）  

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Venue：Web開催（鹿児島）  

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Venue：Web開催（鹿児島）  

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Venue：Web開催（鹿児島）  

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Venue：Web開催（鹿児島）  

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Venue：Web開催（鹿児島）  

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Venue：Web開催（鹿児島）  

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Venue：Web開催（鹿児島）  

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Venue：Web開催（鹿児島）  

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Venue：Web開催（鹿児島）  

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Venue：Web開催（鹿児島）  

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Venue：大阪府府立大手前高等学校  

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Venue：大阪府府立大手前高等学校  

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Venue：石切生喜病院  

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Venue：石切生喜病院  

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Venue：石切生喜病院  

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Venue：石切生喜病院  

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Venue：Web開催  

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Venue：Web開催  

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Venue：大阪府立豊中高等学校  

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Venue：大阪府立豊中高等学校  

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Venue：駿台予備学校大阪南校  

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Venue：駿台予備学校大阪南校  

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Venue：学校法人河合塾　大阪校医進校  

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Venue：学校法人河合塾 大阪校医進校  

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Venue：学校法人河合塾 大阪校医進校  

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Venue：札幌医科大学  

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Venue：札幌医科大学  

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Venue：札幌医科大学  

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Venue：大阪国際交流センター  

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Venue：大阪国際交流センター  

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Venue：大阪国際交流センター  

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Venue：大阪府立北野高等学校  

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Venue：大阪府立北野高等学校  

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Venue：大阪府立北野高等学校  

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Venue：CE西本町ビル6階会議室（大阪）  

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Venue：CE西本町ビル6階会議室（大阪）  

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Venue：CE西本町ビル6階会議室（大阪）  

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Venue：Paris Expo Porte de Versailles（フランス）  

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Venue：Paris Expo Porte de Versailles（フランス）  

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Venue：Paris Expo Porte de Versailles（フランス）  

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Venue：帝塚山学院泉ヶ丘中学校高等学校  

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Venue：帝塚山学院泉ヶ丘中学校高等学校  

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Venue：学校法人河合塾 大阪校医進館  

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Venue：学校法人河合塾 大阪校医進館  

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Venue：京都府立京都学・歴彩館 / 稲盛記念会館（京都）  

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Venue：京都府立京都学・歴彩館 / 稲盛記念会館（京都）  

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Venue：京都府立京都学・歴彩館 / 稲盛記念会館（京都）  

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Venue：萱島生野病院  

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Venue：萱島生野病院  

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Venue：萱島生野病院  

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Venue：駿台予備学校大阪校  

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Venue：駿台予備学校大阪校  

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Venue：駿台予備学校大阪校  

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Venue：駿台予備学校名古屋校での講演  

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Venue：駿台予備学校名古屋校での講演  

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