海部病院の救急医療を支えるハードとソフト

In depopulated areas in Japan, it has been hard to maintain the high quality of emergency medical care system due to a lack of resident medical doctors. On the other hand, the few available clinicians work overtime to handle the medical burden, leading to social problems in Japan, especially in medical emergencies like stroke and acute myocardial infarction. To reduce the burden on healthcare personnel and promote a sustainable high-quality of emergency medical care system, we have introduced a telemedicine system known as “k-support” system at Kaifu hospital. The telemedicine system uses smartphones and Internet, and can provide medical radiological images such as CT（computerized tomography）and MRI（magnetic resonance imaging）to the smartphones of doctors employed full-time at the Tokushima Prefectural Kaifu hospital. Rapid dissemination of medical data ensures that the panel of doctors can discuss the diagnosis and treatment planning of emergency patients almost immediately. Using the telemedicine system, duty doctors can consult other doctors and can then manage the patients themselves without waiting for the arrival of on-call doctors. We have used the k-support system in ２３９ emergency patients from February ２０１８ to December２０１９. The majority of the cases（９８%）were during hours of reduced staff availability, i. e. during the night or during holidays. The k-support system was used in neurosurgical, orthopedic, and medical diseases with proportions５１%,３９% and ８% respectively. The years of experience of doctors using the k-support system varied from under１０years（４６%）, to１０-２０years（１３%）, and to over ２０ years（２９%）. After consultation using the k-support system, on-call doctors had to physically go to the hospital in only１８% of the cases―the duty doctor could treat the patients in８２ % of the cases, without requiring additional intervention. Equating the k-support telemedicine system to hardware, and cooperation and consultation between doctors using the system to software, we believe that a synergistic combination between the two is essential for setting up a sustainable emergency care system, which in turn would reduce the work burden of doctors in a depopulated area

Craniotomy for cerebellar hemangioblastoma excision in a patient with von Hippel–Lindau disease complicated by uncontrolled hypertension due to pheochromocytoma

INTRODUCTION: This report describes a patient with Von Hippel–Lindau (VHL) syndrome and uncontrolled hypertension due to pheochromocytoma who underwent craniotomy for the excision of a cerebellar hemangioblastoma combined with a laparoscopic adrenalectomy. CASE REPORT: A 31-year-old man presented with severe headache. MRI showed areas of abnormal enhancement in the left cerebellum that were determined to be hemangioblastoma with mass effect and obstructive hydrocephalus. His blood pressure rose abruptly and could not be controlled. CT of the abdomen revealed bilateral suprarenal tumors, and the patient was diagnosed as having VHL syndrome.On the third day, he presented with increasing headache, a decreased level of consciousness, and hemiparesis. We were not able to perform an craniotomy because abdominal compression in the prone or sitting position resulted in severe hypertension. We performed ventricular drainage to control his ICP. On the fifth day, we first performed a bilateral laparoscopic adrenalectomy to control ICP and then moved the patient to the prone position before performing a craniotomy to remove the left cerebellar hemangioblastoma. DISCUSSION & CONCLUSION: In patients with pheochromocytoma, the effects of catecholamine oversecretion can cause significant perioperative morbidity and mortality, but these can be prevented by appropriate preoperative medical management. When carrying out an excision of cerebellar hemangioblastomas in patients with intracranial hypertension complicated by abnormal hypertension due to pheochromocytoma whose blood pressure is not sufficiently controlled, tumor resection of the pheochromocytoma prior to cerebellar hemangioblastoma excision in the same surgery may prevent increased ICP and reduce perioperative risk

アクセイ シンケイ コウシュ ニ タイスル チュウセイシ ホソク リョウホウ : コンゴウ ビーム ネツチュウセイシ ト ネツガイチュウセイシ ビーム オ モチイタ アタラシイ チリョウ センリャク

The purpose of this study was to clarify the clinical interim results of boron neutron capture therapy (BNCT) using mixed epithermal-and thermal neutron beams in patients with malignant glioma. The mixed neutron beam for BNCT has been used clinically since 1998. Its great advantage consists of its greater ability than the pure thermal neutron beam to reach sites deep from the brain surface. Sixteen patients with malignant glioma (glioblastoma n=14, anaplastic ependymoma n=1, PNET n=1) underwent mixed epithermal-and thermal neutron beam treatment between 1998 and 2003. They included 2 children younger than 3 years. Sodium borocaptate (Na2B12H11SH, BSH ; 80-100 mg/kg) was administered intravenously at 12-15 hr before neutron irradiation. The radiation dose (i.e. physical dose of boron n-alpha reaction) in the he protocol used between 1997 and 2000 (Protocol A) prescribed a maximum tumor volume dose of 15 Gy. In 2001, a new dose-escalated protocol was introduced (Protocol B) ; it prescribes a minimum tumor volume dose of 18 Gy or, alternatively, a minimum target volume dose of 15 Gy. In both protocols, the maximum vascular radiation dose to the brain surface is not to exceed 15 Gy. Of the 12 patients, 8 were treated according to Protocols A and 4 according to Protocol B. Since 2002, the radiation dose was reduced to 80-90% dose of Protocol B because of acute radiation injury. A new Protocol was applied to four glioblastoma patients (Protocol C). Of the 8 patients treated under Protocol A, 7 died (dissemination n=4, local recurrence, infection, unknown causes, n=1 each). Of the 4 patients treated under Protocol B, 2 died. Concerning the adverse effects of BNCT, Protocol B resulted in higher complication rates with respect to both acute and delayed radiation injury. The estimated median survival time after diagnosis and after BNCT in all patients were 16.7 and 14.6 months, respectively. In 8 patients of Protocol A, the estimated median survival time after diagnosis was 16.0 months ; 1-year and 2-year survival rate were 75.0% and 12.5%, respectively. On the other hand, in 8 patients in Protocol B and C, the estimated median survival time after diagnosis was 15.5 months ; 1-year and 2-year survival rate were 80.0% and 53.3%, respectively. Our limited clinical evaluation suggests that BNCT could achieve local control of glioblastomas at the primary site and that possible dose escalation is limited. While the dose escalation can contribute to the improvement of survival rate, it results in the radiation injury. We conclude that not only the radiation dose at the target point, but also the distribution of neutron flux in the radiation field may contribute to the cure of glioblastoma by BNCT. Computation-assisted dose planning can contribute to improved clinical results following BNCT and to the prevention of cerebrospinal fluid dissemination. We will introduce pure epithermal neutron beam instead of mixed neutron beam in the near future. It has greater advantage than mixed neutron beam to deep-seated glioma because it has a peak in neutron flux at 2-3 cm depth from the brain surface. The dose-planning system and pure epithermal neutron beam can lead to further improvements in the clinical outcomes and the avoidance of adverse effects in brain tumor patients subjected to BNCT

中性子捕捉療法における硼素化合物の薬物動態と腫瘍内移行

BNCT (boron neutron capture therapy) is based on the intracellular nuclear reaction that occurs between the boron-10 nucleus and a thermal neutron. Upon capture, the boron nucleus disintegrates into highly energetic alpha (4He) and lithium (7Li) particles. Because of the short pathways of these heavy particles and 10B accumulation in target tissues, the great potential advantage of BNCT is a selective tumor destruction without significant damage to normal brain tissue. Since 1968, we have treated 146 patients with malignant brain tumors by BNCT. The 5-year survival rate of malignant glioma was 29%. Important factors which improve the results of BNCT are boron concentration in the tumor and neutron sauces. We have used BSH (mercaptoundecahydrododecaborate, Na2B12H11SH) as a boron compound in all patients. BSH is characterized by the absence of toxic side effects and represents the only promising boron carrier applied for the therapy of malignant glioma. However, data on the biodistribution and pharmacokinetics of BSH are few and lack in stadardization. We retrospectively analyzed the biodistribution and pharmacokinetics of BSH in 146 patients treated by BNCT from 1968 to 1994. 1) Pharmacokinetic parameters and standard expression of blood boron content of BSH were calculated by the two-compartment model theory in intra-arterial and intra-venous infusion groups. The parameters revealed that BSH could move easily from blood to the peripheral organs with sustained retention and that elimination was very slow. (CL=3.43L/hr, Vss=181.8 L, MRT=53.0 hrs) 2) Pharmacokinetic parameters were calculated in each case. The patients were divided into two groups : the intra-arterial (56 patients) and the intra-venous (31 patients) groups. BSH was administered into cervical brain arteries in the intra-arterial group, and peripheral veins in the intra-venous group. BSH in the intra-arterial infusion group was found to move from blood into the peripheral organs more easily than that of the intravenous infusion group. 3) In patients with malignant glioma, the average values of boron concentration in the tumor and the tumor to blood ratio (T /B ratio) after intra-arterial infusion (44 patients with 53 samples) were 26.8 μg/g and 1. 77 respectively. On the other hand, after intravenous infusion (13 patients with 13 samples) the values were 20. 9 μg/ g and 1. 33 respectively. There were no statistical significant differences in the average values of boron concentration in the tumor and the T /B ratio between the intra-arterial and the intravenous groups. 4) Both the average values of boron concentration in the tumor and the T /B ratio in patients with malignant glioma showed about 2. 7 and 3. 0 times higher that those of low grade glioma. However, there were no statistical significant differences in the tumoral boron concentration and the T /B ratio between cases of anaplastic astrocytoma and glioblastoma

ASL for distinguishing GBM from metastasis

Purpose : To determine whether differences in tumor volume between arterial spin labeling (ASL) and contrast-enhanced T1-weighted MR images (CE+T1WI) can help differentiate glioblastoma (GBM) from brain metastasis. Materials and methods : Patients with a diagnosis of GBM (n=25) or brain metastasis (n=13) were examined by both conventional and ASL MR imaging. Volumes of interest with high signal intensity on ASL and CE+T1WI were defined using three dimensional analysis software. Tumor volume difference (ASL-CE) and tumor volume ratio (ASL/CE) were obtained. Absolute maximal tumor blood flow (TBF) and TBF ratio (normalized to white matter) were also measured. The Mann-Whitney U test and receiver operating characteristic curve analysis were performed to compare measurements between the tumor groups. Results : Both tumor volume difference and tumor volume ratio were significantly higher in GBM than in metastasis. Both TBF and TBF ratio were higher for GBM than for metastasis, but the differences were not significant. Conclusion : The difference in tumor volume as measured by ASL high signal intensity and CE+T1WI might be useful for differentiating GBM from metastasis, whereas ASL-derived TBF is insufficient

Boron neutron capture therapy (BNCT) for newly-diagnosed glioblastoma : Comparison of clinical results obtained with BNCT and conventional treatment

The purpose of this study was to evaluate the clinical outcome of boron neutron capture therapy (BNCT) and conventional treatment in patients with newly diagnosed glioblastoma. Since 1998 we treated 23 newly-diagosed GBM patients with BNCT without any additional chemotherapy. Their median survival time was 19.5 months ; the 2-, 3-, and 5-year survival rates were 31.8%, 22.7%, and 9.1%, respectively. The clinical results of BNCT in patients with GBM are similar to those of recent conventional treatments based on radiotherapy with concomitant and adjuvant temozolomide

イリョウ カソ チイキ デノ エンカク シンリョウ シエン システム オ モチイタ ノウコウソク キュウセイキ イリョウ

Introduction : The validity of intravenous rt-PA therapy for acute ischemic stroke patients within ４．５ hours after onset is reported, but the rate of the delivery of rt-PA therapy is assumed lower due to its lack of stroke specialists and its geographic location in depopulated areas. In February ２０１３, we developed the telemedicine system in our medically under-served area as a potential solution of medical disparities. Objects and Methods : After the introduction for １６ months, ９５ acute ischemic stroke patients were transferred to our hospital, seven （７．３７％） of which were subjected to the “drip and ship” method of rt-PA infusion using a telemedicine system for emergency medicine （k-support）. We examined the time course after onset and the treatment outcome of these seven cases. Results : Seven cases had rt-PA infusion started in the depopulated area. In five cases, recanalization of occluded vessels were demonstrated resulting in improved clinical symptoms. Conclusion : It was able to give a standard therapy using rt-PA infusion for acute ischemic stroke and the quality of the cerebral infarction medical treatment was improved by building the telemedicine system in the depopulated area

トクシマケン ナンブ ノ キュウキュウ イリョウ ノ ゲンジョウ ト アラタナ トリクミ : ノウシンケイ ゲカ ノ タチバ カラ

A regular neurosurgeon was absent in the southern part II health demographic division of medical services where Kaifu-gun of South Tokushima was located after 2008 and was the present conditions that stroke treatment could not perform enough in comparison with prefecture central part. Furthermore, medical care collapse progressed with the obstetrics and gynecology department and pediatrics closedown at one sweep from the same period and, at the prefectural Kaifu Hospital which was this local nucleus hospital, became hard to maintain the emergency care, and increase of closedown of the emergency outpatient department on Saturday and the emergency transportation to the prefecture central part became remarkable, and it was with a big social problem for Tokushima. A medical difference might occur about stroke medical care in central part and the southern part in Tokushima. We performed the epidemiology survey by stroke patient in the southern II demographic division of medical services （popular name “Kaifu project”） as a President of University of Tokushima discretion project for this fact-finding individually in the University of Tokushima neurosurgery classroom. In addition, I worked on the enlightenment for inhabitants in Kaifu-gun. “Local neurosurgical medical treatment part” was established as a college course financially maintained by private donations of Tokushima University Hospital from November 1，2011． Kaifu Hospital neurosurgery medical treatment was enabled daylong, and emergency correspondence came to be in this way possible. The Kaifu Hospital devises the maintenance policy about Tokushima, local inhabitants, a medical association, a local government and the figure which there should be of “the new Kaifu Hospital” for a tsunami now in the plan of the full-scale reconstruction move to the hill in 2015

ノウソッチュウ センモンイ フザイ チイキ ニオケル ノウソッチュウ チリョウ ト ヨゴ ノ ケントウ : トクシマケン ナンブ Ⅱ ホケン イリョウケン ト トクシマ ダイガク ノウソッチュウ センター トノ ヒカク ケントウ

INTRODUCTION: For cranial nerve diseases, particularly stroke, early-stage treatment by stroke specialists can significantly alter patient prognosis. With respect to the treatment of acute cerebral infarction, t‐PA was approved for health insurance coverage in Japan in November２００５, and has greatly influenced medical practice. However, the use of t‐PA necessitates an expertise in stroke treatment, and the drug cannot be used in areas where stroke specialists are absent. Consequently, disparities may be occurring in stroke treatment among different areas. We accordingly aimed to evaluate stroke patients in the south Tokushima Ⅱ medical areas（south Ⅱ medical areas）without stroke specialists and those transferred to the stroke care unit in the Stroke Center of Tokushima University Hospital（Tokushima University Hospital SCU）, and to clarify the presence or absence of disparities in area-based stroke treatment in Tokushima. METHODS: The subjects were１０３stroke patients in the south Tokushima II medical areas without stroke specialists and ３１７ stroke patients in Tokushima University Hospital SCU, who were assessed between October１，２００９and September３０，２０１０. RESULTS: In the areas without stroke specialists, the prognosis of４２％ of the cerebral infarction patients was related to the absence of stroke specialists, and to geographical disadvantages. In４８％ of the cerebral infarction patients in the areas without stroke specialists, the lapse time after the onset of cerebral infarction exceeded３h at their initial examinations. However, this is considered likely to be improved by the implementation of stroke awareness activities. DISCUSSION: Cerebral infarction, which is common in the elderly, is expected to increase in frequency and severity in the future. Therefore, rigorous prevention, awareness activities to spread super-acute stroke treatment using t‐PA, and medical environmental improvement are necessary

Brain Tumor CE on T1-Cube versus 3D SPGR

Purpose: T1-Cube (GE HealthCare) is a relatively new 3-dimensional (3D) fast spin-echo (FSE)-based magnetic resonance (MR) imaging sequence that uses a variable flip angle to acquire gap-free volume scans. We compared the gadolinium enhancement characteristics of a heterogeneous population of brain tumors imaged by T1-Cube and then 3D fast spoiled gradient recall acquisition in steady state (3D FSPGR) 3-tesla MR imaging to identify the superior modality for specific diagnostic purposes. Methods: We examined 61 lesions from 32 patients using the 2 sequences after administration of gadopentetic acid (Gd-DTPA; 0.1 mmol/kg). Two neuroradiologists independently measured each lesion twice using a region-of-interest (ROI) method. We measured the contrast-to-noise ratio (CNR), the difference in signal intensity (SI) between the tumor and normal white matter relative to the standard deviation (SD) of the SI within the lesion, for both post-contrast 3D FSPGR and post-contrast T1-Cube images of the same tumor and compared modality-specific CNRs for all tumors and in subgroups defined by tumor size, enhancement ratio, and histopathology. Results: The mean CNR was significantly higher on T1-Cube images than 3D FSPGR images for the total tumor population (1.85 ± 0.97 versus 1.12 ± 1.05, P < 0.01) and the histologic types, i.e., metastasis (P < 0.01) and lymphoma (P < 0.05). The difference in CNR was even larger for smaller tumors in the metastatic group (4.95 to 23.5 mm2) (P < 0.01). In contrast, mean CNRs did not differ between modalities for high grade glioma and meningioma. Conclusions: Gadolinium enhancement of brain tumors was generally higher when imaged by T1-Cube than 3D FSPGR, and T1-Cube with Gd enhancement may be superior to 3D FSPGR for detecting smaller metastatic tumors