Analysis of Technological Portfolios for CO2 stabilizations and Effects of Technological Changes

In this study, cost-effective technological options to stabilize CO2 concentrations at 550, 500, and 450 ppmv are evaluated using a world energy systems model of linear programming with a high regional resolution. This model treats technological change endogenously for wind power, photovoltaics, and fuel-cell vehicles, which are technologies of mass production and are considered to follow the “learning by doing” process. Technological changes induced by climate policies are evaluated by maintaining the technological changes at the levels of the base case wherein there is no climate policy. The results achieved through model analyses include 1) cost-effective technological portfolios, including carbon capture and storage, marginal CO2 reduction costs, and increases in energy system cost for three levels of stabilization and 2) the effect of the induced technological change on the above mentioned factors. A sensitivity analysis is conducted with respect to the learning rate.Energy systems model, Global warming, Technological portfolios, Technological changes

A Proposal for an Early Response to Delirium in Terminal Cancer Patients with the Aim of Preventing Extreme Grief

　余命２週間のがん末期の患者が，終末期のせん妄による看護師への暴力をきっかけに，「医療者に暴力をふるうような患者です．」と悪評され，不名誉を拭えないまま，両親に見守られる中，亡くなった．対応するスタッフが，終末期がん患者のせん妄に対し早期に対応できていればこのような事態を招かなかったと考えられる．今回の症例を通して，せん妄への早期対応を提案したく報告する．症例は30歳代男性で，４年前，中枢神経がんに対して化学療法が施行され奏効し寛解に到達した．しかし，社会復帰は困難な状況であったため，両親は共に仕事を辞め，付き添い本人を支えた．外来での経過観察中，１年前の３月に別のがんを発症した．後遺症による精神状態と PS不良を理由に化学療法は不可能と判断された．20XX 年２月になり，呼吸状態が悪化したため入院となった．入院後，状態悪化に伴うせん妄症状が出現し，せん妄のため看護師へ暴力行為を行ってしまった．暴力行為のため，転院せざるを得ない旨を両親に説明することとなったが，転院には間に合うことなく，転院の説明から１週間で永眠された．せん妄と，それに伴う暴力行為に対する早期予防・対策が立案できていないことが，この状況を招いた要因と考えられる．せん妄症状の発生に早い段階で気づき，暴力リスクを理解し対策していくことが，がん終末期患者とその家族の深い悲しみを回避する医療を行うために大切なことと考える．　A terminally ill patient with a life expectancy of two weeks was labeled as“a patient who is violent toward medical professionals.”The cause was his violent behavior toward the nurses, which was triggered by delirium that is prevalent in such end-of-life patients. Unable to overcome this unfortunate reputation, he passed away in the presence of his parents. It is thought that this would not have occurred if the support staff had taken some measures against delirium with the terminal cancer patient at an earlier stage. Through the example provided in this case, this paper proposes an early response to delirium. The patient, in this case, was an adult man in his 30s, who received chemotherapy for cancer of the central nervous system four years earlier and achieved remission. However, because of the difficulty he faced in returning to society, both of his parents quit their jobs to help support him. During an outpatient followup in March of the previous year, another cancer was detected. Due to his mental state caused by sequelae and his poor PS (performance status), chemotherapy was deemed impractical. In February 20XX, the patient was admitted to the hospital because of an aggravated respiratory condition. After his hospitalization, delirium symptoms associated with his aggravated condition developed. Because of his delirium, unfortunately, the nurses became victims of his violence. The patient\u27s parents were given the explanation that their son needed to be transferred to another hospital due to his violent behavior. However, before the transfer took place, just one week from the time the transfer was explained to the family, the patient passed away. It is believed the lack of early prevention and countermeasures against delirium and the associated violence had created this situation. It is thought that recognizing the appearance of delirium symptoms in their early stages, taking preventative measures with an understanding of the risk of violence, and providing medical care to end-stage cancer patients to prevent extreme grief for their families is important

再生不良性貧血治療中にカルシニューリン阻害薬誘発性疼痛症候群を発症した２例

　CIPS（Calcineurin-inhibitor Induced Pain Syndrome）とはカルシニューリン阻害薬を使用中に下肢を中心とした部位に疼痛または掻痒感が生じる症候群である．今回，我々は再生不良性貧血の免疫抑制療法中に生じたCIPS の２例を経験したので報告する．１症例目は，60歳代の女性．近医にて汎血球減少を認め，当院紹介．再生不良性貧血（Stage4）と診断し，ATG（antithymocyteglobulin）/CyA（Cyclosporin A）併用療法を開始した．CyA 投与後，両側下肢の違和感・耐え難い疼痛を発症した．CIPS と診断し，CyA 中止にて症状改善した．その後，再生不良性貧血の増悪に対し低用量でCyA を再開．これによりCIPS が再発し，うつ症状の増強により治療継続が困難となり，原疾患悪化のため死亡した．２症例目は，60歳代の女性．貧血および血小板減少を認めたため，当院紹介．再生不良性貧血（Stage2）と診断し，CyA 療法を開始した．CyA 投与後，両側下肢の違和感・耐え難い疼痛を発症した．CIPS と診断し，CyA 中止にて症状改善した．CIPSは診断が遅れた場合，疼痛に伴うADL（activities of daily living）の低下や精神的苦痛によるうつ症状をきたすことがある．現在CIPS の報告は，臓器移植後にCyA を使用したものがほとんどであるが，それ以外でも発症する可能性があることを知っておくべきと考えられた．　Calcineurin inhibitor-induced pain syndrome (CIPS) involves pain and itchiness that occur at sites centered on the legs while using a calcineurin inhibitor. We report about two cases of CIPS that occurred during immunosuppressive therapy for aplastic anemia. The first case was a 60-year-old woman who was found to have pancytopenia in a blood test that was conducted by her local physician. After referral to our hospital, she was diagnosed with aplastic anemia (stage 4), and we initiated ATG (antithymocyte globulin) /CyA（Cyclosporin A） combination therapy. After administering CyA, she developed discomfort and almost intolerable pain in both legs. She was diagnosed with CIPS, and her symptoms improved upon cessation of CyA. Subsequently, aplastic anemia deteriorated; therefore, CyA was restarted at a low dose. This caused CIPS to recur, and the continuation of treatment became difficult because of worsening of depression. Deterioration of the underlying condition led to the patient’s death. The second case was a 60-year-old woman who was referred to our hospital after she was found to have anemia and thrombocytopenia in a blood test. She was diagnosed with aplastic anemia (stage 2), and CyA therapy was initiated. After administering CyA, she developed discomfort and almost intolerable pain in both legs. She was diagnosed with CIPS, and her symptoms improved with cessation of CyA. The late diagnosis of CIPS can cause depression owing to psychological distress and a decrease in ADL (activities of daily living) s owing to pain. Most current reports of CIPS result from the use of CyA after organ transplantation; however, the possibility of occurrences in other contexts should also be known

ロミプロスチムが奏効した肺胞出血併発移植後血栓性微小血管障害症

　造血幹細胞移植後に発症する血栓性微小血管障害症（thrombotic microangiopathy：TMA）は，治療法が確立されておらず，多臓器不全や重症出血をきたす予後不良な疾患である．今回，造血幹細胞移植後TMA と肺胞出血を発症し，ロミプロスチム投与が奏効した症例を経験したので報告する．症例は20歳代の男性．20XX 年６月節外性NK/T 細胞リンパ腫, 鼻型と診断し，化学療法後に母子間末梢血幹細胞移植を施行した．再発することなく経過し，移植１年後に，免疫抑制剤を中止した．治療による腎機能障害を呈していたが，高血圧に伴い腎機能障害が増悪した．高血圧緊急症と判断し，直ちに降圧剤を開始したが，腎機能障害はさらに進行し，血小板数は徐々に低下し，その後0.8万/μL まで急激に低下したため，精査治療目的に入院となった．貧血の進行，LD 高値，ハプトグロビン低値，破砕赤血球の出現を認め，ADAMTS13活性の低下やインヒビターは認めなかったため，TMA と診断した．血漿交換療法や新鮮凍結血漿（FFP）の定期輸注，rTM (recombinantthrombomodulin) 投与で治療したが，５週間経過しても血小板数や病態の改善を認めなかった。その後、入院38日目に肺胞出血を発症した．長期間のTMA 存在下での血小板輸血はリスクが高いと考え，ロミプロスチムの投与を開始した．その結果，血小板数増加により，肺胞出血は改善し，新たな臓器不全症状がでることなく治療し得た．移植後TMA における確立された治療法はないが，血小板減少に伴う出血症状に対してロミプロスチムが有害事象なく奏効する可能性が示唆された．ロミプロスチムの適応外使用については川崎医科大学附属病院医療倫理委員会にて承認されている．　The treatment for thrombotic microangiopathy (TMA), which develops after hematopoietic stem cell transplantation, has not been established. TMA has a poor prognosis in which multiple organ failure and serious bleeding occur. We hereby report a case in which TMA and alveolar hemorrhage developed following hematopoietic stem cell transplantation and romiplostim administration was effective for the treatment. The subject was a man in his twenties. He was diagnosed with extranodal NK/T-cell lymphoma, nasal type in June 20XX and underwent mother–child peripheral stem cell transplantation after chemotherapy. No relapse had occurred, and the administration of immunosuppressive drugs was terminated one year after transplantation. Due to treatment, he had renal dysfunction, which was exacerbated by hypertension. We determined it to be hypertensive crisis and immediately initiated the administration of antihypertensive drugs. However, since renal dysfunction further advanced, the platelet count gradually decreased and then, suddenly dropped to 8,000/μL; he was then admitted to the hospital for intensive examination and treatment. The examination showed severe anemia, high lactate dehydrogenase (LD) levels, low haptoglobin levels, and the emergence of schizocytes, and neither a decrease in ADAMTS13 activity nor its inhibitors were observed. Therefore, the patient was diagnosed with TMA. Although the patient was treated with plasma exchange, periodical transfusion of fresh frozen plasma (FFP), and recombinant thrombomodulin (rTM) administration, neither the platelet count nor pathological conditions improved in five weeks. On day 38 of admission, the patient developed alveolar hemorrhage. We considered platelet transfusion to be very risky under the condition of a long-term presence of TMA and initiated romiplostim administration. Consequently, due to an increase in the platelet count, alveolar hemorrhage improved and the patient could be treated without any new symptoms of organ failure. Although there is no established therapy for patients with transplantassociated TMA, the results suggest that romiplostim may be effective for bleeding due to a decrease in platelet counts without causing adverse events. The off-label use of romiplostim has been approved by the medical ethics committee of Kawasaki Medical School Hospital

同種造血幹細胞移植患者への緩和ケアチーム介入の試み

　血液がんの治療の一つである同種造血幹細胞移植治療（以下，移植）は，患者にとって唯一の治癒を目指した治療であるが，想像以上の副作用に苦しむ可能性の高い治療でもある．成功率20～30% 程度と説明された不安，前処置の副作用，生着前・後の感染症状，GVHD 症状，退院に向けての社会的負担などの苦痛が測り知れなく出現する．主治医は患者の生命維持に精一杯であり，看護師は大量の点滴や身体ケアに精一杯であり，移植患者の苦痛への対応が困難な状況に陥りやすい．そこで，2018年10月から緩和ケアチームが移植患者全例に介入することとした．移植治療のインフォームドコンセント時に緩和ケアチームの専従看護師が立ち会い，主治医から移植治療中の苦痛に対して緩和ケアチームが介入していくことを説明し開始した．これまでに，４症例の移植患者に介入できており，主に心理的対応と栄養士の早期対応が実現できた．しかし，主治医との連携は，良好なものから連携不良とさまざまであり，今後も検討していく必要性があると考えられた．移植患者の苦痛への早期対応が，患者，家族そして主治医と看護師を含めた医療者との三位一体の緩和ケアが可能となり，成果が期待される．　Allogeneic hematopoietic stem-cell transplantation (hereinafter referred to as transplantation) is one of the treatments for blood cancer. Although it is the only treatment that may cure cancer, it is highly likely to cause excruciating side effects. Patients undergoing transplantation face difficulties beyond their imagination such as anxiety upon learning that the success rate is approximately 20-30%, side effects from preliminary treatment, infection symptoms before and after engraftment, GVHD symptoms, and social burden while preparing for discharge. Such patients’ doctors and nurses find it difficult to deal with their and distress. While the doctors are fully engaged in maintaining patients’ lives, nurses are similarly engaged in performing a large amount of drip infusions and maintaining their personal hygiene. Owing to this situation, in October 2018, a palliative care team began interventions for all patients who undergo transplantation. At the beginning of the intervention, a dedicated nurse from the palliative care team attends an informed consent session for transplantation treatment. The doctor explains to the patient that the palliative care team will perform an intervention for him or her in order to alleviate pain and distress during the transplantation treatment. To date, the team has performed interventions for four patients who underwent transplantation. The main achievements were psychological support and early-stage interventions by a dietitian. However, collaborating with the doctors of patients is not always successful. Thus, this practice requires further research in the future. Dealing with the pain and distress of a patient who undergoes transplantation at an early stage makes it possible for the patient, his or her family, and healthcare providers-including doctors and nurses-to collaborate with each other in palliative care. It is believed that such collaborative practices will lead to favorable outcomes

Application of modified shrinking field radiation in RT-DeVIC chemoradiotherapy for treating localized extranodal natural killer/T-cell lymphoma

　Concurrent chemoradiotherapy (CRT) is the recommended treatment for localized extranodal natural killer/T-cell lymphoma, nasal type (ENKL). In 2009, the Japan Clinical Oncology Group first documented the safety and efficacy of a regimen involving radiotherapy (RT) plus dexamethasone, etoposide, ifosfamide, and carboplatin (DeVIC) in their phase I/II trials (JCOG0211 study). The application of this regimen has drastically improved outcomes of patients with localized ENKL. In 2013, the current guidelines were made to the cost in JCOG0211 study.　We retrospectively investigated the outcomes of three patients who received CRT for stage localized ENKL at the Kawasaki Medical School Hospital between August 2007 and March 2011. Our CRT protocol differed from that used in the JCOG0211 study as we used a different shrinking field RT method. A recent report on shrinking or extended-field RT raised questions regarding which fields are appropriate. Thus, we compared our clinical results with those of the JCOG0211 study and analyzed the effect of the differences in field size on clinical results. The median follow-up of the three patients in the present study was 9 months (range, 5-106 months), two and one of whom achieved complete and partial responses, respectively. Regarding adverse events, no severe acute side effects (e.g., mucositis) higher than Grade 4 were observed.　We reviewed cases and the JCOG0211 study which we experienced in the past about fields of the RT. The present study described our experiences with three patients receiving shrinking field RT

Ixazomib が奏効している心アミロイドーシス合併多発性骨髄腫

　Ixazomib は，経口のプロテアソーム阻害薬であり，特に非注射薬の組み合わせが選択される多発性骨髄腫患者の再発難治例にとって有用な治療薬である．今回，我々はIxazomib が奏効している心アミロイドーシス合併多発性骨髄腫を経験したため報告する．症例は50歳代女性で，20XX 年10月心不全精査のため当院循環器内科入院となり，精査にて洞不全症候群（type3），心アミロイドーシスと診断された．洞不全症候群（type3）に対して心臓ペースメーカー移植術が施行され，血液検査にてM 蛋白を認めたため当科紹介となった．骨髄検査では形質細胞の増加を認め，AL アミロイドーシス（心臓，消化管）合併多発性骨髄腫（IgG‐λ with BJP）と診断した．20XX 年12月から治療を開始．VRD 療法を１コース施行中に，ペースメーカー波形ではない不整脈が多発し，うっ血性心不全の併発や，心源性脳梗塞による左完全片麻痺を発症した．VRD 療法は継続困難と判断し，elotuzumab 併用RD 療法に変更し治療を施行した．２コースでPD となったため，脳梗塞の発症によるADL の低下があることから，施設入所をふまえて外来通院頻度が少ない治療法として，Ixazomib 併用RD 療法を選択し治療を開始した．治療効果および忍容性は良好で，M 蛋白の順調な低下を認め，心不全の増悪なく経過している．心アミロイドーシス合併多発性骨髄腫は，治療に伴い致死性不整脈や心不全を併発することが多い．プロテアソーム阻害剤であるbortezomib 投与にて，不整脈や心不全の併発症状が出現していたが，経口プロテアソーム阻害剤であるixazomib の投与では，不整脈や心不全を併発させることなく，治療が継続し得た．　Ixazomib is an oral proteasome inhibitor that is useful for the treatment of recurrent refractory cases, particularly when a non-injection combination drug therapy is chosen for the patient. Here, we report a case of cardiac amyloidosis treated with ixazomib in a patient with multiple myeloma. The patient was a 50-year-old woman hospitalized in the cardiovascular medicine department of our hospital in October 20XX for close examination of cardiac failure. On the basis of the test findings, sick sinus syndrome (type 3) and cardiac amyloidosis were diagnosed. A heart pacemaker transplantation was performed for the sick sinus syndrome (type 3), and additional tests indicated M-protein expression; thus, the patient was referred to our department. A bone marrow test revealed increased plasma cells, which led to the diagnosis of immunoglobulin light chain amyloidosis (heart and digestive tract) secondary to multiple myeloma (IgG‐λ with BJP). Treatment was initiated in December 20XX. During the first course of VRD treatment, multiple non-pacemaker waveform arrhythmias and congestive heart failure occurred. Left total hemiplegia due to cardioembolic stroke occurred. We judged it difficult to continue the VRD treatment, so we switched the treatment to concomitant elotuzumab and RD therapy. After 2 courses, the patient became PD. With a decrease in ADL due to the onset of cerebral infarction and considering the possible need for institutionalization, ixazomib combined with RD therapy was initiated as treatment to reduce the frequency of outpatient visits. The treatment efficacy and tolerance were good, the M-protein expression level decreased gradually. Her progress was uneventful with no worsening of cardiac failure. Cardiac amyloidosis secondary to multiple myeloma is commonly associated with treatment-related lifethreatening arrhythmias and cardiac failure. Treatment with the proteasome inhibitor bortezomib is associated with the onset of arrhythmias and cardiac failure. However, treatment with the oral proteasome inhibitor ixazomib can be continued without onset of arrhythmia and cardiac failure

Taking some heat off the NDCs? The limited potential of additional short-lived climate forcers’ mitigation

Several studies have shown that the greenhouse gas reduction resulting from the current nationally determined contributions (NDCs) will not be enough to meet the overall targets of the Paris Climate Agreement. It has been suggested that more ambition mitigations of short-lived climate forcer (SLCF) emissions could potentially be a way to reduce the risk of overshooting the 1.5 or 2 °C target in a cost-effective way. In this study, we employ eight state-of-the-art integrated assessment models (IAMs) to examine the global temperature effects of ambitious reductions of methane, black and organic carbon, and hydrofluorocarbon emissions. The SLCFs measures considered are found to add significantly to the effect of the NDCs on short-term global mean temperature (GMT) (in the year 2040: − 0.03 to − 0.15 °C) and on reducing the short-term rate-of-change (by − 2 to 15%), but only a small effect on reducing the maximum temperature change before 2100. This, because later in the century under assumed ambitious climate policy, SLCF mitigation is maximized, either directly or indirectly due to changes in the energy system. All three SLCF groups can contribute to achieving GMT changes

Looking under the hood: A comparison of techno-economic assumptions across national and global integrated assessment models

Integrated assessment models are extensively used in the analysis of climate change mitigation and are informing national decision makers as well as contribute to international scientific assessments. This paper conducts a comprehensive review of techno-economic assumptions in the electricity sector among fifteen different global and national integrated assessment models. Particular focus is given to six major economies in the world: Brazil, China, the EU, India, Japan and the US. The comparison reveals that techno-economic characteristics are quite different across integrated assessment models, both for the base year and future years. It is, however, important to recognize that techno-economic assessments from the literature exhibit an equally large range of parameters as the integrated assessment models reviewed. Beyond numerical differences, the representation of technologies also differs among models, which needs to be taken into account when comparing numerical parameters. While desirable, it seems difficult to fully harmonize techno-economic parameters across a broader range of models due to structural differences in the representation of technology. Therefore, making techno-economic parameters available in the future, together with of the technology representation as well as the exact definitions of the parameters should become the standard approach as it allows an open discussion of appropriate assumptions. © 2019 The Author