Utility of Lower Limb Positive Pressure Test for Diagnosis of Diastolic Heart Failure : A Case Report

A 70-year-old woman with dyspnea on exertion was admitted to our hospital. She had a history of apical hypertrophic cardiomyopathy (HCM) and repeated hospitalization for heart failure. Results of physical examination were normal except for leg edema. Echocardiography showed apical HCM with preserved LV systolic function (LVEF=70%). Although dyspnea on exertion and leg edema improved rapidly with the use of diuretics, her symptoms soon worsened when daily activity was started again. In order to examine the effect of preload on hemodynamics, we performed a lower limb positive pressure test by compressing both legs using a household air leg massager. Echocardiography showed increases in mitral E velocity, E/A ratio and pulmonary venous D flow as well as decrease in stroke volume during the lower limb positive pressure test. Simultaneously-recorded pressure study also showed elevated LVEDP and increased v wave of pulmonary capillary wedge pressure. These results suggested that even a small increase in preload led to elevation of LVEDP and symptomatic worsening due to severe diastolic heart failure in the present case. The lower limb positive pressure test may be useful for assessing the effect of preload on hemodynamics in patients with diastolic heart failure

HTVL‐1キャリアへの免疫抑制療法中に発症したATLL

A ６４-year-old woman presented with lower leg edema, fever, and bilateral joint pain, involving the wrists, fingers, and knees, in April ２０１X. Serological test results were negative for rheumatoid factor, antinuclear antibody, and anti-cyclic citrullinated peptide antibody. A diagnosis of remitting seronegative symmetrical synovitis with pitting edema syndrome, a type of seronegative rheumatoid arthritis, was made and prednisolone was administered. The joint pain was refractory to prednisolone therapy. In February, ２０１X＋２, the patient presented with right cervical lymphadenopathy. The CT scan revealed swelling of the cervical, axillary, and inguinal lymph nodes bilaterally and rapidly enlarged. In April, １８F-fluorodeoxyglucose PET/CT scan showed an abnormal collection in the enlarged lymph nodes. The patient subsequently developed hoarseness with dyspnea and attended our department. Blood test results showed high levels of lactate dehydrogenase （５４７U/L） and soluble interleukin‐２ receptor （３４２００ IU/L） and were positive for anti-human T-cell leukemia virus type１ （HTLV‐１） antibody. Biopsy of the right cervical lymph node showed proliferation of abnormal lymphoid cells positive for CD３, CD４, and CD２５ and negative for CD７. Monoclonal integration of HTLV‐１ proviral DNA was detected in the lymph node. A diagnosis of adult T-cell leukemia/lymphoma （ATLL）, lymphoma type was made. The pain involving multiple joints was attributed to HTLV‐１associated arthropathy. Immunosuppressive therapy for HTLV‐１ carrier status may have played a role in the development of ATLL

Development of a novel automatic ascites filtration and concentration equipment with multi‐ring‐type roller pump units for cell‐free and concentrated ascites reinfusion therapy

Cell‐free and concentrated ascites reinfusion therapy (CART) is an effective therapy for refractory ascites. However, CART is difficult to perform as ascites filtration and concentration is a complicated procedure. Moreover, the procedure requires the constant assistance of a clinical engineer or/and the use of an expensive equipment for the multi‐purpose blood processing. Therefore, we developed a CART specialized equipment (mobility CART [M‐CART]) that could be used safely with various safety measures and automatic functions such as automatic washing of clogged filtration filter and self‐regulation of the concentration ratio. Downsizing, lightning of the weight, and automatic processing in M‐CART required the use of newly developed multi‐ring‐type roller pump units. This equipment was approved under Japanese regulations in 2018. In performing 41 sessions of CART (for malignant ascites, 22 sessions; and hepatic ascites, 19 sessions) using this equipment in 17 patients, no serious adverse event occurred. An average of 4494 g of ascites was collected and the total amount of ascites was processed in all the sessions without any trouble. The mean weight of the processed ascites was 560 g and the mean concentration ratio was 8.0. The ascites were processed at a flow rate of 50 mL/min. The mean ascites processing time was 112.5 minutes and a 106.5‐minutes (95.2%) ascites processing was performed automatically. The operator responded to alarms or support information 3.2 times on average (3.1 minutes, 2.1% of ascites processing time). Human errors related to ascites processing were detected by M‐CART at 0.4 times per session on average and were appropriately addressed by the operator. The frequencies of automatic washing of clogged filtration filter and self‐regulation of the concentration ratio were 31.7% and 53.7%, respectively. The mean recovery rates (recovery dose) of protein, albumin, and immunoglobulin G were 72.9%, 72.9%, and 71.2% (65.9 g, 34.9 g, and 13.2 g), respectively. Steroids were administered in 92.7% of the sessions to prevent fever and the mean increase in body temperature was 0.53°C. M‐CART is a compact and lightweight automatic CART specialized equipment that can safely and easily process a large quantity of ascites without the constant assistance of an operator

危険への感受性を育むディベート学習

医療事故防止には危険を察知し、認識するという個人の危険に対する感受性が大きく影響すると考えた。今回、学生が実際に体験したインシデント事例を提示し、危険性を判断させた。その結果、学年差はみられず、講義や臨床実習などの量的体験よりも個人の資質が大きく影響すると考えられた。調査から学生たちが危険ではないと判断した理由を分析し、判断を誤らせる5つの要因を明らかにした。再度の調査でも危険への感受性が変化しない学生には感受性の鋭い学生とのディベートが有効であった。ディベートでは自分の思考の根拠を示して、他の学生と意見を闘わせる能動的学習によって、学生自らが判断の誤りに気づくことができた。学習の早い段階から安全教育を取り入れることで、危険な状況を察知し、対処できる感受性や直感力を養う必要性が確認できた

看護基礎教育における「ヒヤリハット」防止の教育方法の検討 : トランスファー場面の分析を通して

基礎看護学実習における学生の「ヒヤリハット」体験を分析した結果、トランスファ一時の「ヒヤリハット」が53.3%を占めていた。そこでこれに焦点を絞って分析し、5つの具体的な危険因子を抽出した。その結果、「ヒヤリハット」はこれら5つの危険因子が複雑に絡み合って、複雑な状況で起きていることがわかった。それを解決するために看護基礎教育でできる医療事故防止のための、具体的な教育方法を工夫して試みたところ以下の事が明らかになった。(1)体験学習から、学生は人の身体の重さ、身体バランスの悪さを実感することができた。またトランスファー時、安定した姿勢で行うにはボディメカニクス活用の必要性が認識でき、知識と体験とが合致し、理解が深まった。(2)学生が実習で体験した「ヒヤリハット」を実例教材として提示し、グループ討議をすることで、「ヒヤリハット」は「自分にも起こり得ること」と捉え、思い込みや不注意などの危険性が認識できた。以上のことから体験学習や実例教材を使ったグループ討議を行うことが、学生の「ヒヤリハット」を防止する上で有効であるとわかった

ガン カガク リョウホウ ニオケル ショウカカン ドクセイ ト ケッセイ Diamine Oxidase DAO カッセイ ニ カンスル ケントウ

There are so many patients with advanced gastric cancer who undergo systemic chemotherapy worldwide. The quality of life（QOL）of patients with gastric cancer who receive chemotherapy is often lowed by various gastrointestinal toxicities during the chemotherapy. Nutrition is also impaired by gastrointestinal toxicities. However, it is difficult to predict their occurrence in advance and further there is no good serum marker for nutrition in the patients treated with chemotherapy. Thus, it is important to objectively evaluate and predict the toxicity of the digestive tract during cancer chemotherapy. Diamine Oxidase（DAO）is an enzyme that is expressed in intestinal epithelial cells. Recently it has been reported that DAO activity may reflect damage or atrophy of the intestinal villi, and therefore it may be a sensitive serum marker for nutritional state. In this study, we measured serum DAO activity of patients with gastric cancer treated with systemic chemotherapy, and investigated the correlation between DAO activity and gastrointestinal toxicities. Six patients with gastric cancer, who were treated by docetaxel+cisplatin+S‐１combination chemotherapy, were enrolled. DAO activity was measured by sensitive colorimetric assay. DAO activities diminished after treatment in４patients with moderate to severe gastrointestinal toxicities. In contrast, they did not change in２patients with no gastrointestinal toxicities. Our results may suggest that DAO activity is a good serum marker for the gastrointestinal toxicities as well as nutrition state in patients who receive systemic chemotherapy. More large scale study is needed to warrant

Prenatal exposure to perfluoroalkyl acids and allergic diseases in early childhood

Perfluoroalkyl acids (PFAAs) are persistent organic pollutants that are detected in humans worldwide. Laboratory animal studies have shown that PFAAs are associated with immunotoxic effects. However, epidemiological studies investigating the role of PFAAs, in particular PFAAs with longer chains than perfluorooctanoic acid, are scarce. We investigated associations between prenatal exposure to PFAAs, including long-chain compounds, and infant allergic diseases at 12 and 24 months in a large study population. The participants included mothers and their infants who enrolled in the Hokkaido Study on Environment and Children's Health 2003-2009. Eleven PFAAs were measured in maternal plasma taken at 28-32 weeks of gestation using ultra-performance liquid chromatography coupled to triple quadrupole tandem mass spectrometry. Characteristics of participants and information on infant allergic diseases were obtained from self-administered questionnaires and medical records. At 24 months, the adjusted odds ratio (OR) (first vs. fourth quartiles) for eczema in association with higher maternal perfluorotridecanoic acid (PFTrDA) levels was 0.62 (95% confidence interval (CI) 0.45, 0.86). After stratification by gender, the adjusted ORs in female infants from mothers with higher maternal perfluoroundecanoic acid (PFUnDA) and PFTrDA levels were also statistically significant (PFUnDA: OR = 0.50; 95% CI, 030, 0.81; PFTrDA: OR = 0.39; 95% CI, 0.23, 0.64). Our findings suggest that lower prenatal exposure to PFTrDA may decrease the risk of developing eczema in early childhood, only in female infants. 2014 Elsevier Ltd. All rights reserved

Prevalence of childhood wheeze and modified DNA methylation at 7 years of age according to maternal folate levels during pregnancy in the Hokkaido Study

Background A high dose of folic acid during pregnancy may increase the risk of asthma, wheezing, and respiratory disease in childhood. Folate acid can modify inflammation and immune susceptibility of offspring with some epigenetic differentiation, including DNA methylation. This study evaluated associations between maternal folate levels during pregnancy and childhood wheezing; furthermore, the study assessed whether maternal folate-modified DNA methylation is related to asthma. Methods Participants in the current study were 6651 mother-child pairs who had complete data on characteristics and who had completed at least one of the International Study of Asthma and Allergies in Childhood questionnaires when the child was 1, 2, 4, and 7 years of age. Moreover, a case-control study to assess DNA methylation at 7 years of age was conducted among 136 children who experienced wheezing and a control group of 139 children with no history of allergies. Results The median of maternal serum was 16.76 nmol/L, assayed by chemiluminescent immunoassay. We found significantly increased adjusted odds ratios of childhood wheezing at 2 years age according to maternal folate levels, compared with the lowest folate quartile (odds ratio [95% confidence interval] = highest; 1.27 [1.03, 1.56], and second, 1.27 [1.05, 1.55]); however, no changes were observed at 1, 4, and 7 years of age. In a case-control study, no association of maternal folate levels with DNA methylation was observed. Conclusion Our results suggest that maternal folate did not affect persistent wheezing in school-aged children, or DNA methylation of gasdermin B, orosomucoid-like 3, and Ikaros family zinc finger 3 at 7 years of age