Less-invasive Treatment for Group A Streptococcal Fasciitis with Rapid Antigen Detection Test and Collagen/Gelatin Sponge

Patients with severe group A Streptococcus (GAS) induced necrotizing soft tissue infection sometimes develop Streptococcal toxic shock syndrome, which is a life-threatening condition with an extremely high fatality rate. Obtaining survival is the most important goal; however, an early diagnosis for debridement surgery and quick granulation formation for skin grafting surgery can better preserve the extremity functions. The patient was a 47-year-old man with a history of atopic dermatitis who presented with GAS-induced necrotizing soft tissue infection in his left lower extremity. His vital signs indicated shock, and he was diagnosed with streptococcal toxic shock syndrome. Emergency surgery was performed with his body pressure maintained with noradrenaline. Intraoperatively, rapid antigen detection tests (RADTs) were negative in the medial thigh and positive in the lower leg, which helped in decision-making regarding the area of aggressive debridement surgery. The wound culture results matched the intraoperative rapid antigen detection test results. A collagen/gelatin sponge with the sustained release of basic fibroblast growth factor was used as an artificial dermis before skin grafting. Excellent granulation was obtained, and skin grafting surgery was performed on the 11th day after collagen/gelatin sponge placement. He was discharged home on the 42nd day with normal lower extremity functions. First, an intraoperative diagnosis using GAS-rapid antigen detection tests with an appropriate sampling method from small incisions avoided excessive surgical debridement. Second, collagen/gelatin sponge with the sustained release of basic fibroblast growth factor promoted quick granulation tissue formation for wound bed preparation. These efforts resulted in the successful less-invasive treatment of a patient with streptococcal toxic shock syndrome caused by GAS-induced necrotizing soft tissue infection

Structured review of the literature of type 2 diabetes self-management: Toward the development of a patients' characteristics-based assessment tool

2型糖尿病患者の特性に応じた教育・支援を行うためのアセスメントツールの開発を目指して,自己管理に影響する要因を文献から抽出した.検索方法は,2型糖尿病の自己管理に関連したキーワードを設定し,MEDLINE,CINAHL,医学中央雑誌のデータベース過去10年間を検索した.ヒット件数は,各々1162,860,691件であった.次いで,ADA(American Diabetes Association)Evidence guideline(2002年)の水準を参考に研究デザインを吟味した.その結果,該当する文献は71件で,国内文献が20件あった.有意差を認めた因子を整理したところ86因子あり,「知識・教育」「心理面」「満足度」「個人的要因」「治療」「収入・保険」「関係」の7カテゴリーに分類できた.しかし,介入方法の分類に結びつく因子(特性)や因子間の関係性は不明であり,効果的な介入を導くためのアセスメントツールを開発するためには,これらを検討する必要性が示唆された.To develop an assessment tool for education and follow-up for type 2 diabetes patients related to their characteristics, a structured literature review was conducted. The method of the review was by key words related to self-management/self-care for type 2 diabetes taken from the database for the past 10 years of MEDLINE, CINAHL, and Japan Medical Abstract Society. One-thousand one- hundred and sixty-two articles were obtained from MEDLINE, 860 from CINAHL, and 691 from the Japan Medical Abstract Society. Research designs were then examined, based on the ADA (American Diabetes Association) Evidence guideline (2002) evidence level. As a result, 71 articles, of which 20 were domestic, were retained. Eighty-six factors were found statistically significant, and were categorized in groups under the headings “knowledge/education", “psychological aspects", “level of satisfaction", “personal factors",“therapy/treatment", “income/insurance", and “family/relationship". Factors/characteristics lead toselecting interventional strategies. However, their overall relations have not been examined yet, whichsuggests that these need to be tested to develop an assessment tool which leads to an effectiveintervention program

Hassall’s corpuscles induce thymic IFNα expression

Hassall’s corpuscles (HCs) are composed of cornifying, terminally differentiated medullary thymic epithelial cells (mTECs) that are developed under the control of Aire. Here, we demonstrated that HC-mTECs show features of cellular senescence and produce inflammatory cytokines and chemokines including CXCL5, thereby recruiting and activating neutrophils to produce IL-23 in the thymic medulla. We further indicated that thymic plasmacytoid dendritic cells (pDCs) expressing IL-23 receptors constitutively produced Ifna, which plays a role in single positive (SP) cell maturation, in an Il23a-dependent manner. Neutrophil depletion with anti-Ly6G antibody injection resulted in a significant decrease of Ifna expression in the thymic pDCs, suggesting that thymic neutrophil activation underlies the Ifna expression in thymic pDCs in steady state conditions. A New Zealand White mouse strain showing HC hyperplasia exhibited greater numbers and activation of thymic neutrophils and pDCs than B6 mice, whereas Aire-deficient B6 mice with defective HC development and SP thymocyte maturation showed significantly compromised numbers and activation of these cells. These results collectively suggested that HC-mTECs with cell-senescence features initiate a unique cell activation cascade including neutrophils and pDCs leading to the constitutive IFNα expression required for SP T-cell maturation in the thymic medulla

非心臓手術における、術前の蛋白尿と術後急性腎障害の関連: 奈良AKIコホート研究

Background: Little is known about the association between pre-operative proteinuria and post-operative acute kidney injury (AKI) in noncardiac surgery. Methods: This is a retrospective cohort study. Adults who underwent noncardiac surgery under general anesthesia from 2007 to 2011 at Nara Medical University Hospital were included. Those with obstetric or urological surgery, missing data for analyses or pre-operative dialysis were excluded. Exposure of interest was pre-operative proteinuria, defined as (+) or more by dipstick test. The outcome variable was post-operative AKI, defined by Kidney Disease: Improving Global Outcomes criteria, within 1 week after surgery. Multivariable logistic regression analyses were performed. Results: Among 5168 subjects, 309 (6.0%) developed AKI. Pre-operative proteinuria was independently associated with post-operative AKI, with an odds ratio (OR) [95% confidence interval (CI)] of 1.80 (1.30-2.51). A sensitivity analysis restricted to elective surgery yielded a similar result. As proteinuria increased, the association with AKI became stronger [OR (95% CI) 1.14 (0.75-1.73), 1.24 (0.79-1.95), 2.75 (1.74-4.35) and 3.95 (1.62-9.62) for urinary protein (+/-), (+), (2+) and (3+), respectively]. Subgroup analyses showed proteinuria was especially associated with post-operative AKI among subjects with renin-angiotensin system inhibitors, other anti-hypertensives, hypoalbuminemia or impaired renal function (P for interaction = 0.05, 0.003, 0.09 or 0.02, respectively). Conclusions: In noncardiac surgery, pre-operative proteinuria was independently associated with post-operative AKI. Subjects with proteinuria should be managed with caution to avoid AKI peri-operatively.博士（医学）・甲第777号・令和3年3月15日© The Author(s) 2019. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.This is a pre-copyedited, author-produced version of an article accepted for publication in Nephrology dialysis transplantation following peer review. The version of record Nephrology Dialysis Transplantation, Volume 35, Issue 12, December 2020, Pages 2111–2116, is available online at: https://doi.org/10.1093/ndt/gfz269

トシブ ノ ショウボウ ダンイン ニオケル カゾク ニ タイスル ストレス カイジ ヨクセイ タイド ト ソーシャル サポート ガ セイシンテキ ケンコウ ニ オヨボス エイキョウ

都市部の消防団員における精神的健康及びソーシャルサポートの実態を明らかにし、精神的健康の規定因として、家族からのソーシャルサポートと家族に対するストレス開示抑制態度に焦点を当て検討を行った。その結果、以下の2点が明らかになった。第1 に、都市部の消防団員のIES-R ハイリスク率は3.8%、GHQ ハイリスク率は14.0%であり、ソーシャルサポート源として同僚団員より家族や知人が多く挙げられた。第2 に、家族に対するストレス開示抑制態度の中で「あきらめ」「弱みの隠蔽」が精神的健康を抑制し、「自己解消」のストレス開示抑制態度と家族と「他愛のない話ができる」ことが精神的健康を促進していた。したがって、消防団員の惨事ストレス対策において、ピアサポートを根幹としている現在の消防職員の惨事ストレス対策の消防団員に対する適用に加え、知人や家族などのソーシャルサポート源の活用及び家族に対するストレス開示抑制態度を考慮する必要性が示唆された。The goal of this investigation was to examine (1) the actual condition of mental health and social support (2) determinants of the mental health among Japanese volunteer firefighters in urban area, especially focused on the social support from family and the attitudes toward inhibiting disclosure of stress to family. The results showed that 3.8% were identified as a high-risk group for PTSD at six months after the earthquake, and 13.0% were the high-risk group for General Health. With regard to the sources of social support, the proportion of family or acquaintances was higher than the colleagues volunteer firefighters. The predictors of mental health included [the resignation], such as “it is useless to talk about my stress to my family”,[hiding weakness], and [consideration for one’s family], such as “listening to my problems would bother her(him), as risk factors of the mental health. Meanwhile, [feeling sure of controlling one’s stress] as well as [casual conversation(mindless chatter)] facilitates the mental health. To sum up, with respect to the Critical Incident Stress Management system for volunteer firefighters, it is needed to regard both social support from family or acquaintances and attitudes toward inhibiting disclosure about stress to family as significant variables when applying Critical incident stress management system for firefighters based on peer-support to volunteer firefighters directly

Fournier's Gangrene with Edwardsiella tarda: A Gas Production Case by Bacterial Synergism with Streptococcus anginosus

Edwardsiella tarda is an anaerobe associated with freshwater and marine life. Necrotizing soft tissue infection caused by E. tarda is rare, but its mortality rate is extremely high (61.1%). We experienced a survival case of Fournier's gangrene with E. tarda. A key clinical feature for the diagnosis was gas production; however, there have been no previous reports of such a phenomenon in relation to E. tarda. A 64-year-old man was admitted with a 3-day history of a high fever. His medical history, which included paraplegia from the Th6 level down, made the focus of inflammation at the perineum difficult to notice. Whole-body CT revealed subcutaneous gas from the posterior scrotum around the entire circumference of the anus. During emergency surgery, an incision at the posterior scrotum revealed extensive fascia necrosis, and E. tarda and Streptococcus anginosus were identified. We speculated the gas production in this case to be the product of a mixed infection of aerobes and anaerobes, which acted synergistically to induce bacterial growth. Timely surgical debridement and antibiotic therapy led to the patient's survival

MexEF-OprN multidrug efflux pump transporter negatively controls N-acyl-homoserine lactone accumulation in pseudomonas syringae pv. Tabaci 6605

Our previous studies revealed that flagellar-motility-defective mutants such as ∆fliC of Pseudomonas syringae pv. tabaci 6605 (Pta6605) have remarkably reduced production of N-acyl-homoserine lactones (AHL), quorum-sensing molecules. To investigate the reason of loss of AHL production in ∆fliC mutant, we carried out transposon mutagenesis. Among approximately 14,000 transconjugants, we found 11 AHL production-recovered (APR) strains. In these APR strains, a transposon was inserted into either mexE or mexF, genes encoding for the multidrug efflux pump transporter MexEF-OprN, and mexT, a gene encoding a putative transcriptional activator for mexEF-oprN. These results suggest that MexEF-OprN is a negative regulator of AHL production. To confirm the negative effect of MexEF-OprN on AHL production, loss- and gain-of-function experiments for mexEF-oprN were carried out. The ∆fliC∆mexF and ∆fliC∆mexT double mutant strains recovered AHL production, whereas the mexT overexpressing strain abolished AHL production, although the psyI, a gene encoding AHL synthase, is transcribed as wild type. Introduction of a mexF or mexT mutation into another flagellar-motility- and AHL production-defective mutant strain, ∆motCD, also recovered the ability to produce AHL. Furthermore, introduction of the mexF mutation into other AHL production-defective mutant strains such as ∆gacA and ∆aefR also recovered AHL production but not to the ∆psyI mutant. These results indicate that MexEF-OprN is a decisive negative determinant of AHL production and accumulation

Factors affecting the choice of delivery place in a rural area in Laos: A qualitative analysis

Background: Home delivery (HD) without skilled birth attendants (SBAs) are considered crucial risk factors increasing maternal and child mortality rates in Loa PDR. While a few studies in the literature discuss the choice of delivery in remote areas of minority ethnic groups; our work aims to identify factors that indicated their delivery place, at home or in the health facilities.Methods: A community-based qualitative study was conducted between February and March 2020. Three types of interviews were implemented, In-depth interviews with 16 women of eight rural villages who delivered in the last 12 months in Xepon District, Savannakhet Province, Lao PDR. Also, three focus group discussions (FGDs) with nine HCPs and key-informant interviews of ten VHVs were managed. Factors affecting the choice of the delivery place were categorized according to the social-ecological model.Results: Our sample included five Tri women and two Mangkong women in the HD group, while the FD group included three Tri women, two Mangkong women, one Phoutai woman, two Laolung women and one Vietnamese. Our investigation inside the targeted minority showed that both positive perceptions of home delivery (HD) and low-risk perception minorities were the main reasons for the choice of HD, on the individual level. On the other hand, fear of complication, the experience of stillbirth, and prolonged labour pain during HD were reasons for facility-based delivery (FD). Notably, the women in our minority reported no link between their preference and their language, while the HCPs dated the low knowledge to the language barrier. On the interpersonal level, the FD women had better communication with their families, and better preparation for delivery compared to the HD group. The FD family prepared cash and transportation using their social network. At the community level, the trend of the delivery place had shifted from HD to FD. Improved accessibility and increased knowledge through community health education were the factors of the trend. At the societal (national policy) level, the free delivery policy and limitation of HCPs’ assisted childbirth only in health facilities were the factors of increasing FD, while the absence of other incentives like transportation and food allowance was the factor of remaining of HD.Conclusions: Based on the main findings of this study, we urge the enhancement of family communication on birth preparedness and birthplace. Furthermore, our findings support the need to educate mothers, especially those of younger ages, about their best options regarding the place of delivery. We propose implementing secondary services of HD to minimize the emergency risks of HD. We encourage local authorities to be aware of the medical needs of the community especially those of pregnant females and their right for a free delivery policy