Mycophenolate mofetil for immune checkpoint inhibitor‐related hepatotoxicity relapsing during dose reduction of corticosteroid: A report of two cases and literature review

[Background] Immune checkpoint inhibitors (ICIs) sometimes cause immune-related liver injury, which can lead to cessation of treatment, hospitalization, and even mortality. Although high-dose corticosteroids are usually effective in treatment of ICI-related liver injury, one fifth of affected patients require additional immunosuppressive therapy. It remains uncertain how best to treat ICI-related liver injury that relapses under corticosteroid therapy after temporary remission. [Case] Here we report two cases of ICI-related liver injury successfully treated with mycophenolate mofetil (MMF). In the first case, a 74-year-old man with stage IIIA lung cancer underwent curative chemoradiotherapy. After the second infusion of durvalumab, grade 3 ICI-related liver injury (mixed pattern) developed. In the second case, a 46-year-old man with stage IVB lung cancer received pembrolizumab-containing chemotherapy. After the first cycle, grade 2 ICI-related hepatitis developed. In the both cases, liver injury improved with high-dose prednisolone but relapsed during tapering of the drug. After liver biopsy was performed to confirm the diagnosis of ICI-related liver injury, MMF (2000 mg/day) was added. MMF was effective for both patients and permitted discontinuation or reduction of prednisolone. [Conclusion] MMF appears to be an appropriate treatment option for ICI-related liver injury that respond to high-dose corticosteroids but relapse during steroid tapering

Analysis of cases applying shiatsu massage for nursing care

東洋医学の１つの手法である指圧を看護ケアに取り入れた論文の検討を行ない，その効果と問題点を明らかにすることを目的に，『医学中央雑誌』（WEB版ver．３）を使用して１９９３年から２００３年まで１０年間に，看護師による指圧の影響が明らかにできた論文を抽出した．その結果１０論文が得られた．１０論文の内訳は排便障害（便秘）の軽減および排ガスの促進５件，癌化学療法実施時の副作用（嘔気・嘔吐等）の軽減３件，癌性疼痛の軽減１件，リンパ節郭清後に発生した浮腫の軽減１件であった．それぞれの論文に共通して言えることは，患者が指圧について肯定的に捉える場合は，その効果が非常に大きいことであった．さらに指圧の圧迫部位，圧迫の強さ，頻度など，まだ一定の手技と効果が得られていないため，追試験を重ねる必要性が示唆された．Shiatsu massage is one of the common therapeutic methods in oriental medicine, and is considered to be useful for supporting conventional medicine. However, there has been little evidence for its effects. In this report, papers dealing with the application of shiatsu massage to nursing care are extracted from literature, in order to clarify the effects and problems of this method as a nursing care. Papers containing studies of shiatsu massage by nurses as a nursing care were extracted from literature by using the Japan Centra Revuo Medicina (WEB issue, version 3), and those published during 10 years from 1993 to 2003 were analyzed. It was found that the relaxation effects by shiatsu massage were reported for various symptoms. Among these, 10 papers were analyzed in detail, which described the effects on relief of the following symptoms ; dysphasia (constipation) (5 papers), nausea and vomiting at cancer chemotherapy (3 papers), pain from cancer (1 paper), and edema generated after lymphadenectomy (1 paper). It was found from these papers that shiatsu massage is effective for patients who have positive thinking to this therapy. On the other hand, the necessity of further experiments was indicated because of the lack of common methods and effects in this therapy ; for example, position, force, frequency, etc., should be optimized

臨地実習で糖尿病患者を受け持った学生の学び

学士課程３年次での成人看護学実習で，糖尿病患者を受け持った看護学生（以下，学生）３４名の学びの内容について検討することを目的に，学生の記述したレポート内容を質的帰納的に分析した．その結果，４カテゴリー（「療養行動が主体的に実践できるための具体的な支援方法」「学生が感じた困難感や達成感」「療養生活支援のために必要な看護技術」「療養生活を送る対象の理解」）と１７サブカテゴリーが抽出された．学生は糖尿病患者を理解し，療養生活行動が主体的に行えるための支援方法を考えていた．そして，患者の行動変容を目指した介入の難しさを実感しながら，患者が主体的に療養行動を実践できるように支援することの大切さについて考え，学生としての立場での看護実践の喜びを感じていた．今後は，学生の学びについて，個々の事例ごとの確認を丁寧に行いながら，学びの内容を卒業時の到達目標と照らし合わせて確認する方法を考案することの必要性が示唆された．Purpose : To clarify what nursing students（hereafter referred to as students）learned during their clinical practice experiences with individuals with diabetes mellitus. Methods : Subjects were 34 nursing students enrolled in a bachelor program. Following clinical practice in adult nursing, data were obtained from students’ written reports on what they learned during nursing interventions for individuals with diabetes mellitus. Data were analyzed inductively. Results : Four categories and 17 sub-categories were extracted. The 4 categories were : “concrete nursing interventions for helping individuals with diabetes mellitus carry out their daily regimen”, “students’ feelings of difficulty and satisfied after the clinical practices”, “the necessity of nursing arts for facilitating a daily regimen”, and “knowledge about individuals with diabetes mellitus.” Conclusions : Through nursing practices, the students learned about individuals with diabetes mellitus and nursing interventions for individuals with diabetes mellitus. These findings suggest that teachers should carefully confirm what students learned in terms of both quality and quantity. Such confirmation ensures that students learn nursing interventions that are suitable for individuals with diabetes mellitus, and how to practically apply such nursing interventions. These findings will contribute to the improvement of nursing practices and education

糖尿病患者に対する看護介入の効果と評価 : 文献検討

医学中央雑誌Web版（Ver．３）を用いて，１９９４年から２００４年の過去１０年間に，糖尿病を有する人を対象に，看護師が行った教育や指導などの看護介入行為のうち，その効果が患者の持つ問題の解決に有効であると報告されている研究論文の分析を行い，以下の結果が得られた． １．対象となった論文は１６編あった． ２．介入内容は食に関連するものが１１編あった．看護師は，患者の持つ問題の明確化，その具体的な対応，到達目標の設定に対して，患者が主体的に取り組むことができるように，患者の情緒面も含めて援助していた． ３．介入内容の評価を看護師が行っていたものは１３編あった．評価項目は糖尿病の血糖コントロール指標としてのHbA１cがすべての文献で用いられていた． 以上のことより，今後は，患者の自己管理を支援するために，患者が一貫して主体的に取り組めるような介入方法を開発することが必要である．また，介入結果の評価においては，血糖コントロール指標に加えて，患者の行動や心理の変化を適切に評価できる評価方法や評価指標を開発する必要があると考えられた．Objective : The purpose of this study was to review published studies focusing on nursing interventions, which were effective in solving problems for persons with diabetes mellitus（hereinafter persons） in Japan. Method : We used the Ichushi-Web（Ver．３）to search from １９９４ through to ２００４. Results : １．We finally selected １６ primary studies. ２．Eight nursing interventions were related to diet and eating. Nurses supported that persons independently decide their own clinical goals, persons understood what were their problems and what they should do. Nursing involved emotional supports in this situation. ３．Thirteen evaluations were conducted by nurses, and all of evaluations used HbA１c as their control indexes for diabetes mellitus. Conclusion : To be able to support self controlled persons we have to develop ways to intervene, so persons can decide their clinical goals. Allowing them to learn to face their problems independently. It is necessary to evaluate not only HbA１c as diabetes control but also the changes of persons' activities and emotions in order to assess the effects of interventions suitably

Ultrasonographic evaluation of leg muscle and fatty tissue thickness in postoperative patients with gastrointestinal disease

術後の健康回復の促進に向けた看護ケアの基礎的資料を得るため,超音波診断装置(周波数は7.5MHz)を用いて,開腹による胃あるいは大腸手術を受けた患者を対象に,手術経過に伴う下肢の筋組織厚および皮下脂肪厚の変化を明らかにした.術前,術後離床日,術後10日目,術後20日目の合計4回,下肢の大腿直筋上,大腿二頭筋上,長指伸筋上,ヒラメ筋上にプローブを当て,組織厚を測定した.開腹による胃または大腸手術を行なった患者のうち,合計4回の測定結果が得られた16名を分析対象とした.4箇所の測定部位の筋組織厚および皮下脂肪厚をそれぞれ合計し,筋組織厚総和および皮下脂肪厚総和を算出し,術前値との比較を行なった.その結果,下肢の筋組織厚総和は,術後離床日,術後10日目,術後20日目に有意な減少を認めた.一方,下肢の皮下脂肪厚総和は,術後には有意な減少を認めず,ほとんど変化しないことが明らかになった.胃手術群と大腸手術群の比較においては,胃手術群は,術後10日目から術後20日目にさらに減少し,回復の傾向を示さなかったが,大腸手術群は,術後10日目から術後20日目に下肢の筋組織厚が回復の傾向を示した.よって,開腹術後患者,特に胃手術患者に対して,より細やかな看護観察と栄養評価,および食事摂取量を増やす看護介入の必要性が示唆された.In order to obtain basic data for use in postoperative nursing care intended to promote the recovery of patients after surgery, the authors examined postoperative changes in lower limb muscular tissue thickness and subcutaneous fat thickness by ultrasonography (7.5 MHz) in patients who underwent open surgery of the stomach or large intestine. The ultrasound probe was placed on the skin above the following muscles: quadriceps femoris, biceps femoris muscle, extensor digitorum longus, and soleus. Measurements were taken on 4 occasions: before surgery, and on the 1st, 10th and 20th day after postoperative mobilization. Of all patients who underwent open surgery of the stomach or large intestine, 16 patients were selected for analysis and ultrasonic measurements. Muscular tissue and subcutaneous fat thicknesses at each of the four sites of measurement were totaled to yield measures of total muscular tissue and total subcutaneous fat. Postoperative and preoperative parameters were then compared. The total lower limb muscular tissue thickness at each of the 4 postoperative measurement points was significantly less than the preoperative thickness, whereas the total lower limb subcutaneous fat thickness showed no significant decrease after surgery and remained almost unchanged from the preoperative value. Comparing patients undergoing different types of surgery, leg muscular tissue thickness showed a tendency to recover on the 10th and 20th day after surgery in the colorectal surgery group, while the gastric surgery group showed further decreases in this parameter on the 10th and 20th day, with no trend towards recovery evident over the timeframe investigated. These results suggest the necessity of active nursing intervention for patients after open gastric surgery.G

Self-evaluation study of nursing students’ recognition of their degree of achievement of educational goals in clinical practice

臨地実習指導における教育的な介入への示唆を得ることを目的に，３年課程短期大学３年次学生を対象に，臨地実習開始前・中期・終了後に，国立大学医療技術短期大学部看護学科協議会臨地実習委員会A グループが作成した「臨地実習固有の学習内容」を用いて，学生の臨地実習固有の学習内容に対する到達度の認識に対する調査を行った．その結果，以下の結果が得られた． ①自己評価得点は，実習開始前と比べて終了時に自己評価が有意に上昇したもの（以下上昇群）と，上昇しなかったもの（非上昇群）の２群に大きく分類できた． ②上昇群のうち，段階的に評価が上昇した項目は７項目であった． ③学生は，認知領域は高く自己評価し，学習内容に到達したと認識していた． ④学生は１４項目は終了時に至っても，到達レベルに達していないと自己評価しており，それらの項目は，コミュニケーションや看護過程，理論との照合など看護を深める取り組みに関する内容であった． 以上のことから，教育的な介入として，学生がコミュニケーション技術を有効に用いながら，看護過程を展開し，看護実践を深めることができるように，カンファレンスを有効に活用し，場面を捉えて，学生の学習状況にあわせて，丁寧に指導を行うことが必要であると考えられた．学年進行に伴う到達レベルの詳細な明示など，学生の成長を長期的な視点に立って支援することの必要性が示唆された．Objectives : The purpose of this study was to : assess the nursing students’ recognition of their achievement of their educational goals in clinical practice ; and discuss the clinical teaching interventions of nursing education by means of self-evaluation for the students at a 3-year nursing junior college. Methods : We used the self-evaluation questionnaire (62 questions). Self-evaluation was performed three times : the first was before clinical practice (hereinafter first evaluation), at the middle point of clinical practice (middle evaluation) and after the clinical practice (final evaluation). Results : １．There ware 2 patterns in self-evaluation scores. One was rise, and the other was not rise by comparison between first evaluation and final evaluation. ２．Only 7 scores were improved among 62 questions. They were classified cognitive domain, and they were recognized by the nursing students to be achieved of their educational goals. ３．In the final evaluation there were 14 items for which they had not achieved their educational goals. They were the following items : comparing their clinical practice experience with nursing theory, performing clinical practice while thinking about the nature of nursing and using communication skills, and the process of nursing diagnosis. Conclusions : Nursing students need educational intervention. That is, they need teachers to teach them, or to think with them, how to use the nursing process to overcome patients’ problems in each clinical situation by means of communication skills. It is also important to make effective use of conferences at school to so that student’s can shore experiences

Study on the difference in observation points between students before and after experiencing related nursing practice : on the observations of vital signs and oxygen inhalation by use of an acute stage dummy

本研究は術後急性期の状況を設定したモデル人形を用い，実習開始前と実習終了後の学生が行なった術後患者に対する観察のちがいを分析し，今後の実習指導に生かすことを目的に行った． 対象は成人看護実習（急性期患者の看護）の実習開始前の学生７２名と実習終了後の学生４５名であった． 方法は実習室でモデル人形を用いて，１０分間学生に自由に観察させた．この時の観察用紙に記入された記入項目を分析対象とした．分析方法は「ドレーン・チューブについて」「輸液について」「バイタルサインについて」を自由に記載してもらい，筆者らが『観察できた』『誤認』『記入なし』の３つに分類した． その結果，「モニター上に表示：心拍数」は実習終了後の学生の方が観察できていなかった．「酸素流量」は，『誤認』がどちらの学生も他の項目より多く，酸素流量計の見方を正確に把握していないことがわかった．「モニター上に表示：深部体温」，「酸素濃度」に関してはどちらの学生も『記入なし』であった．今後は学生の術後患者に対する観察能力が，より向上するように指導を行なっていく必要性が示唆された．そのためには急性期モデル人形を活用することで観察の機会を多くして練習を重ねるとともに，演習時および実習時において観察が的確になされているかを教員が確認する必要が示唆された．The difference in observation points for postoperative patients between two groups of nursing students was analyzed in terms of the students’ experience of related training for the purpose of improving the training tutorial. The object was 72 students before starting adult nursing training (nursing of the acute stage patient) and 45 students after the training termination. The students were allowed to observe an acute stage dummy for 10 minutes and to write down the observation results of the ‘drains and tubes’, ‘fluid therapy’, and ‘vital signs’. The descriptions about these three items were analyzed by classifying them into ‘correct’, ‘mistaken’, and ‘no description’. The main results are as follows. The percentage of nursing students who correctly reported the ‘heart rate on the monitor’ was lower in the group after training termination comparing to the other group. As for the ‘oxygen flow rate’, many mistakes were found in the both groups, indicating the technical problem on the monitoring of the oxygen flow meter. In the both groups, no student described ‘core temperature on the monitor’ and ‘oxygen concentration’. These results suggest the necessity of developing tutorial method to improve the students’ observation ability for postoperative patients. The use of an acute stage dummy would be helpful for the practice of observations. It is also necessary for the teachers to check the observation behaviors of students during the exercises and practices in order to make the observations correct

臨地実習での学生自己評価 : 興味ある課題導入の有無による比較

臨地実習での学びを効果的にするために，３年課程３年次学生を対象に臨地実習固有の学習内容を用いた学生自己評価を継続しているが，自己評価得点は，実習開始前から中期にかけて上昇しても，中期から終了時には上昇しない傾向が続いた．そのため，成人看護学臨地実習（急性期）では，２００３年度後期に学生の興味・関心のあるテーマを課題学習として導入することを試みた．課題学習を導入した２００３年度後期（３６人）と導入しなかった２００１年度後期（３４人）の自己評価得点の差を統計的に検定することにより，課題学習の効果を検討した．その結果，以下の結果が得られた． ① 課題学習のテーマを決定する過程において，学生は，自己の学習状況を振り返り，整理することができた． ② 終了時の自己評価では，課題学習を導入しなかった２００１年度では４．０点以上の高得点の項目が２０項目であったのに対し，課題学習を導入した２００３年度では４０項目もあり，学生は学習内容に到達したと高く評価していた． これらのことより，興味・関心のあるテーマを課題学習として導入することは，学生の自発性を高め，学習内容に対する学生の到達度の認識を高める可能性があると考えられた．Objective : The purpose of this study was to assess the nursing students' recognitions of their achievement degrees for their educational goals in the clinical practices and discuss the effect of setting students the assignments of themes in which they had interested in the clinical practices. Methods : We used the self-evaluation questionnaire（６２ questions）. Self-evaluation was performed three times ; the first was before the clinical practice, at the middle point of the clinical practice and after the clinical practice. And we set the students assignments in which they had interested in the clinical practices at the middle point in２００３．And we didn't set them in２００１．Then we compared２００３with２００１，and we tested for equality between two means（p＜０．０５）． Results : １．The students assessed their clinical practices when they decided their own themes of assignments. ２．In the final evaluation, the students recognized they achieved their educational goals in４０items in２００３， though there were only２０items in２００１． Conclusion : These results suggest that it may be effective to set the students assignments of themes in which they had interested and that their arrival degrees may be raised by these programs

Caspase inhibition in select olfactory neurons restores innate attraction behavior in aged Drosophila

Sensory and cognitive performance decline with age. Neural dysfunction caused by nerve death in senile dementia and neurodegenerative disease has been intensively studied; however, functional changes in neural circuits during the normal aging process are not well understood. Caspases are key regulators of cell death, a hallmark of age-related neurodegeneration. Using a genetic probe for caspase-3-like activity (DEVDase activity), we have mapped age-dependent neuronal changes in the adult brain throughout the lifespan of Drosophila. Spatio-temporally restricted caspase activation was observed in the antennal lobe and ellipsoid body, brain structures required for olfaction and visual place memory, respectively. We also found that caspase was activated in an age-dependent manner in specific subsets of Drosophila olfactory receptor neurons (ORNs), Or42b and Or92a neurons. These neurons are essential for mediating innate attraction to food-related odors. Furthermore, age-induced impairments of neural transmission and attraction behavior could be reversed by specific inhibition of caspase in these ORNs, indicating that caspase activation in Or42b and Or92a neurons is responsible for altering animal behavior during normal aging.This work was supported by grants from the Japan Society for the Promotion of Science and the Japan Ministry of Education, Culture, Sports, Science and Technology to TC and MMi, from the Uehara memorial foundation to TC, from NIH to JWW (DK092640), and from NIH to RLD (2R37 NS19904-30). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript

Accuracy of tissue thickness of the rectus femoris region as measured by ultrasound

In order to verify the accuracy of the thickness of the rectus femoris muscle and overlying subcutaneous fat as assessed by ultrasound, experiments were conducted on １０ healthy subjects aged over ３０ years to assess the following： １） concordance of measurements made by two different observers； ２） concordance of repeated measurements made by the same observer ; and ３） concordance of repeated measurements made by the same observer with and without an imaging aid（ultrasound gel block）. Between two observers with varying experience in ultrasound, no significant difference in measured muscle thickness was observed ; however, there was a significant difference in subcutaneous fat thickness. When measurements were made by the same observer on two separate days, a significant positive correlation was evident for muscle and subcutaneous fat thickness between the first and second tests. While use of the imaging aid was associated with higher concordance of measurements between the first and second tests, the measurements themselves were affected. Although ultrasonic measurement of tissue thickness requires further investigation to minimize intra-observer error and examine correlations with other imaging techniques, the accuracy of the measurements in the present study suggests that clinical application may be possible