Structural basis for the activation of peroxisome proliferator-activated receptor-gamma by telmisartan

Telmisartan, a selective angiotensin receptor blocker, has been recently shown to act as a partial agonist for peroxisome proliferator-activated receptor-gamma (PPARγ). To understand the activation mechanism of PPARγ by telmisartan, we determined the ternary complex structure of PPARγ, telmisartan and coactivator peptide from SRC1 at 2.25 Å resolution. The overall fold of PPARγ is almost identical to previously-determined complex structures with agonists. However, telmisartan exhibits an unexpected binding mode, devoid of some essential hydrogen bonds for full activation of PPARγ

外傷後の肝外胆管狭窄にExpandable Metallic Stents (EMS)留置が有効であった2例

外傷後肝外胆管狭窄の2例にexpandable metallic stents (EMS)を使用し良好な結果を得たので報告する.経乳頭的ステント留置術を1例,経皮経肝的ステント留置術を1例に施行したところ,2例とも胆管炎,閉塞性黄疸は治癒した.両方法とも低侵襲で安全に施行でき,外傷後胆管狭窄など良性の胆管狭窄に対する有効な治療手段と考えられた.We had good results from using expandable metallic stents (EMS) in two patients with posttraumatic extrahepatic biliary duct strictures. A transpapillary biliary stenting (TBS) was performed on one patient, and a percutaneous transhepatic biliary stenting (PTBS) was performed on the other patient. In both cases, cholangitis and obstructive jaundice were cured. Both methods of stenting were performed safely with low invasion. Therefore, EMS is an effective treatment means for benign biliary duct strictures including posttraumatic biliary duct strictures

外傷後の肝外胆管狭窄にExpandable Metallic Stents (EMS)留置が有効であった2例

外傷後肝外胆管狭窄の2例にexpandable metallic stents (EMS)を使用し良好な結果を得たので報告する.経乳頭的ステント留置術を1例,経皮経肝的ステント留置術を1例に施行したところ,2例とも胆管炎,閉塞性黄疸は治癒した.両方法とも低侵襲で安全に施行でき,外傷後胆管狭窄など良性の胆管狭窄に対する有効な治療手段と考えられた.We had good results from using expandable metallic stents (EMS) in two patients with posttraumatic extrahepatic biliary duct strictures. A transpapillary biliary stenting (TBS) was performed on one patient, and a percutaneous transhepatic biliary stenting (PTBS) was performed on the other patient. In both cases, cholangitis and obstructive jaundice were cured. Both methods of stenting were performed safely with low invasion. Therefore, EMS is an effective treatment means for benign biliary duct strictures including posttraumatic biliary duct strictures

lllb型膵損傷術後膵仮性嚢胞に内視鏡的十二指腸・嚢胞ドレナージ術が奏功した1例

外傷性膵損傷術後に発生した仮性嚢胞に対して内視鏡的に十二指腸・嚢胞ドレナージを行い良好な経過を得たので報告する.症例は27歳,男性.ハンマーで腹部を強打され受傷し,腹腔内出血・遊離ガス像を認めたため緊急手術となった.膵はSMV直上で完全断裂しておりIIIb型膵損傷を呈していたため膵空腸吻合術(Letton-Wilson法)を施行し,また右半結腸の広範な穿孔・挫滅があり右半結腸切除術を施行した.術後,膵液瘻みられたが保存的治療で軽快し第40病日に退院となった.受傷より約3カ月後に上腹部痛が出現し,諸検査で離断した尾側膵から発生した膵仮性嚢胞と診断した.内視鏡的に十二指腸球部後壁の隆起部を針状ナイフで穿刺し貯溜液のドレナージを図った.その後,症状は軽決し嚢胞も消失し,処置後約1年が経過した現在も再発はみられず,膵機能も正常である.内視鏡的十二指腸・嚢胞ドレナージ術は小さな嚢胞でも壁に圧排像として認められれば確実に穿刺できる.また,今回のように膵管と交通性のある症例に対しても内瘻化が容易であり,膵液瘻を作りにくいなどの利点を有しており,膵損傷後の仮性嚢胞の治療に簡便にまた安全に施行でき有効な治療手段と考えられた.A patient in whom pancreatic pseudocyst after the surgery for traumatic pancreatic injury was successfully treated with endoscopic cystoduodenostomy (ECD). A 27-year-old man beaten on the abdomen with a hammer underwent emergency surgery due to intraperitoneal hemorrhage and free gas development. Pancreatojejunostomy (Letton-Wilson technique) was performed because the pancreas completely ruptured just above the superior mesenteric vein was diagnosed as type IIIb pancreatic injury. Right hemicolectomy was performed because of the extensive perforations and crush of the right side of the colon. A pancreatic juice fistula observed postoperatively was resolved with conservative therapy, and he was discharged on the 40th disease day. Epigastric pain developed about three months after he was injured. Examinations resulted in the diagnosis as pancreatic pseudocyst occurring from the caudal side of the ruptured pancreas. The fluid pooled in the pseudocyst was drained by endoscopically puncturing the elevated site on the posterior wall of the duodenal bulb with a needle knife. Then, all associated symptoms were resolved and the pseudocyst disappeared. Since then, he has been followed for about one year without recurrence, with his pancreatic function being normal. Endoscopic cystoduodenostomy (ECD) can reliably puncture even a small cyst when it is expanded on the wall. It has other advantages that it can easily change a fistula to an internal fistula even in cases with the communication to the pancreatic duct, such as the present case, and that it is unlikely to produce a pancreatic juice fistula. Therefore, ECD is considered easy, safe, and effective for treating pseudocyst after pancreatic injury

lllb型膵損傷術後膵仮性嚢胞に内視鏡的十二指腸・嚢胞ドレナージ術が奏功した1例

外傷性膵損傷術後に発生した仮性嚢胞に対して内視鏡的に十二指腸・嚢胞ドレナージを行い良好な経過を得たので報告する.症例は27歳,男性.ハンマーで腹部を強打され受傷し,腹腔内出血・遊離ガス像を認めたため緊急手術となった.膵はSMV直上で完全断裂しておりIIIb型膵損傷を呈していたため膵空腸吻合術(Letton-Wilson法)を施行し,また右半結腸の広範な穿孔・挫滅があり右半結腸切除術を施行した.術後,膵液瘻みられたが保存的治療で軽快し第40病日に退院となった.受傷より約3カ月後に上腹部痛が出現し,諸検査で離断した尾側膵から発生した膵仮性嚢胞と診断した.内視鏡的に十二指腸球部後壁の隆起部を針状ナイフで穿刺し貯溜液のドレナージを図った.その後,症状は軽決し嚢胞も消失し,処置後約1年が経過した現在も再発はみられず,膵機能も正常である.内視鏡的十二指腸・嚢胞ドレナージ術は小さな嚢胞でも壁に圧排像として認められれば確実に穿刺できる.また,今回のように膵管と交通性のある症例に対しても内瘻化が容易であり,膵液瘻を作りにくいなどの利点を有しており,膵損傷後の仮性嚢胞の治療に簡便にまた安全に施行でき有効な治療手段と考えられた.A patient in whom pancreatic pseudocyst after the surgery for traumatic pancreatic injury was successfully treated with endoscopic cystoduodenostomy (ECD). A 27-year-old man beaten on the abdomen with a hammer underwent emergency surgery due to intraperitoneal hemorrhage and free gas development. Pancreatojejunostomy (Letton-Wilson technique) was performed because the pancreas completely ruptured just above the superior mesenteric vein was diagnosed as type IIIb pancreatic injury. Right hemicolectomy was performed because of the extensive perforations and crush of the right side of the colon. A pancreatic juice fistula observed postoperatively was resolved with conservative therapy, and he was discharged on the 40th disease day. Epigastric pain developed about three months after he was injured. Examinations resulted in the diagnosis as pancreatic pseudocyst occurring from the caudal side of the ruptured pancreas. The fluid pooled in the pseudocyst was drained by endoscopically puncturing the elevated site on the posterior wall of the duodenal bulb with a needle knife. Then, all associated symptoms were resolved and the pseudocyst disappeared. Since then, he has been followed for about one year without recurrence, with his pancreatic function being normal. Endoscopic cystoduodenostomy (ECD) can reliably puncture even a small cyst when it is expanded on the wall. It has other advantages that it can easily change a fistula to an internal fistula even in cases with the communication to the pancreatic duct, such as the present case, and that it is unlikely to produce a pancreatic juice fistula. Therefore, ECD is considered easy, safe, and effective for treating pseudocyst after pancreatic injury

重症例からみた気管支喘息治療の現状と危機管理に関する検討

1998年よりステロイド剤規則的吸入療法を主体としたガイドライン療法が導入され喘息死は徐々に減少してきたが,2000年度の本邦における喘息死は4,473名を数える.標準的治療が確立されたにもかかわらずなぜ死亡例が多いのかを,救命救急センターに3次救急搬送された重症気管支喘息患者54例を対象に検討した.救急搬送前の投薬内容をみると,ガイドラインにそった治療は行われず,喘息発作時だけβ受容体刺激剤(スプレー)を使用していた症例が平均92.9%でCPA(cardio pulmonary arrest)症例では100%であった.それに対してステロイド剤規則的吸入療法は2例3.7%にしか行われていなかった.気管支喘息を専門とする呼吸器専門医やアレルギー専門医はガイドラインにそった治療を行っているが,一般臨床医には未だ浸透していない可能性が示唆された.気管支喘息死を減少させるには,一般臨床医による患者教育の徹底,ステロイド剤規則的吸入療法をベースにした適切な定期的通院・治療の厳守,発作急変時に備えた病歴カードの常時携帯,救急医療機関側は救急隊のオーバートリアージを容認するなど危機管理の徹底を図ることが重要と考えられた.Asthmatic deaths have been gradually reduced since 1998 when regular steroid inhalation therapy was proved effective and widely introduced as guideline therapy. There were, however, still as many as 4,473 Japanese people who died of asthma in 2000. We examined the reasons for this large number of deaths, despite establishment of the guideline therapy, by investigating emergency patients who were carried to our emergency care center by ambulance as tertiary emergency cases for treatment of serious asthma. The investigation of medications used before emergency arrival showed that patients were not treated according to the guideline therapy: 92.9% of all patients and 100% of CPA (cardio pulmonary arrest) patients were treated with β-receptor stimulators (spray) only when they had asthmatic fits, and regular steroid inhalation therapy was performed on only 2 patients (3.7%). Although respiratory and allergy experts specializing in bronchial asthma follow the guideline therapy, it may not be widespread among general clinicians. To reduce the deaths from bronchial asthma, it is important to fully manage the possible risks of bronchial asthma by making general practitioners give patients full information on the disease; making patients strictly follow the appropriate hospital visit and treatment schedule based on regular steroid inhalation therapy; instructing patients to always carry their medical history cards for sudden attacks of bronchial asthma; and persuading emergency care centers to permit over-triaging by ambulance teams

重症例からみた気管支喘息治療の現状と危機管理に関する検討

1998年よりステロイド剤規則的吸入療法を主体としたガイドライン療法が導入され喘息死は徐々に減少してきたが,2000年度の本邦における喘息死は4,473名を数える.標準的治療が確立されたにもかかわらずなぜ死亡例が多いのかを,救命救急センターに3次救急搬送された重症気管支喘息患者54例を対象に検討した.救急搬送前の投薬内容をみると,ガイドラインにそった治療は行われず,喘息発作時だけβ受容体刺激剤(スプレー)を使用していた症例が平均92.9%でCPA(cardio pulmonary arrest)症例では100%であった.それに対してステロイド剤規則的吸入療法は2例3.7%にしか行われていなかった.気管支喘息を専門とする呼吸器専門医やアレルギー専門医はガイドラインにそった治療を行っているが,一般臨床医には未だ浸透していない可能性が示唆された.気管支喘息死を減少させるには,一般臨床医による患者教育の徹底,ステロイド剤規則的吸入療法をベースにした適切な定期的通院・治療の厳守,発作急変時に備えた病歴カードの常時携帯,救急医療機関側は救急隊のオーバートリアージを容認するなど危機管理の徹底を図ることが重要と考えられた.Asthmatic deaths have been gradually reduced since 1998 when regular steroid inhalation therapy was proved effective and widely introduced as guideline therapy. There were, however, still as many as 4,473 Japanese people who died of asthma in 2000. We examined the reasons for this large number of deaths, despite establishment of the guideline therapy, by investigating emergency patients who were carried to our emergency care center by ambulance as tertiary emergency cases for treatment of serious asthma. The investigation of medications used before emergency arrival showed that patients were not treated according to the guideline therapy: 92.9% of all patients and 100% of CPA (cardio pulmonary arrest) patients were treated with β-receptor stimulators (spray) only when they had asthmatic fits, and regular steroid inhalation therapy was performed on only 2 patients (3.7%). Although respiratory and allergy experts specializing in bronchial asthma follow the guideline therapy, it may not be widespread among general clinicians. To reduce the deaths from bronchial asthma, it is important to fully manage the possible risks of bronchial asthma by making general practitioners give patients full information on the disease; making patients strictly follow the appropriate hospital visit and treatment schedule based on regular steroid inhalation therapy; instructing patients to always carry their medical history cards for sudden attacks of bronchial asthma; and persuading emergency care centers to permit over-triaging by ambulance teams

Noninvasive regional cerebral oxygen saturation for neurological prognostication of patients with out-of-hospital cardiac arrest: a prospective multicenter observational study.

[Aim]To investigate the association between regional brain oxygen saturation (rSO2) at hospital arrival and neurological outcomes at 90 days in patients with out-of-hospital cardiac arrest (OHCA). [Methods]The Japan-Prediction of neurological Outcomes in patients post cardiac arrest (J-POP) registry is a prospective, multicenter, cohort study to test whether rSO2 predicts neurological outcomes after OHCA. We measured rSO2 in OHCA patients immediately after hospital arrival using a near-infrared spectrometer placed on the forehead with non-blinded fashion. The primary endpoint was “neurological outcomes” at 90 days after OHCA. [Results]EMS providers are not permitted to terminate CPR in the field in Japan, and so most patients with OHCA who are treated by EMS personnel are transported to emergency hospitals. Among 1017 OHCA patients, 672 patients including 52 comatose patients with pulses detectable (8%) and 620 cardiac arrest patients (92%) at hospital arrival were enrolled prospectively and consecutively. Twenty-nine patients with good neurological outcome had a significantly higher value of rSO2 at hospital arrival than 643 patients with poor neurological outcome (mean [±SD] 55.6 ± 20.8% vs. 19.7 ± 11.0%, p 42% for predicting good neurological outcome, with sensitivity 0.79 (95% confidence interval [CI], 0.60?0.92), specificity 0.95 (95% CI, 0.93?0.96), positive predictive value, 0.41 (95% CI, 0.28?0.55), negative predictive value, 0.99 (95% CI, 0.98?1.00), and area under the curve 0.90 (95% CI, 0.88?0.92). [ConclusionThe rSO2 at hospital arrival can predict good neurological outcome at 90 days after OHCA