業務流れ図を用いた事故分析法について ―バリウム検査中の転倒を事例に用いて―

医療事故分析には多くの時間と経験が必要である。分析未経験者は現状把握と分析手法が混乱して、対策案構築に多大な時間を要する。ゆえに事故事象を時系列に並べただけの現状把握は、難しいのである。そこで我々は、現状把握の目的で「業務流れ図」を作成した。「業務流れ図」には手順書の事象と、事故時の事象を患者時間系列に沿って表示する。そしてエラー時と発見時を直線（又は点線）で結び、患者被害程度を書き込むことで事故の全容の解明ができる。得られた「業務流れ図（Work Flow Chart）」を基にWhy-Why Diagram を用いて背後要因を特定し対策案を構築する。ここでは、バリウムを用いた胃の検査事故を事例に報告する

Recurrent CCND3 mutations in MLL-rearranged acute myeloid leukemia

急性骨髄性白血病の新規遺伝子変異を発見 --乳がんの既存薬が治療に有効である可能性--. 京都大学プレスリリース. 2018-11-01.In acute myeloid leukemia (AML), MLL (KMT2A) rearrangements are among the most frequent chromosomal abnormalities; however, knowledge of the genetic landscape of MLL-rearranged AML is limited. In this study, we performed whole-exome sequencing (n = 9) and targeted sequencing (n = 56) of samples from pediatric MLL-rearranged AML patients enrolled in the Japanese Pediatric Leukemia/Lymphoma Study Group AML-05 study. Additionally, we analyzed 105 pediatric t(8;21) AML samples and 30 adult MLL-rearranged AML samples. RNA-sequencing data from 31 patients published in a previous study were also reanalyzed. As a result, we identified 115 mutations in pediatric MLL-rearranged AML patients (2.1 mutations/patient), with mutations in signaling pathway genes being the most frequently detected (60.7%). Mutations in genes associated with epigenetic regulation (21.4%), transcription factors (16.1%), and the cohesin complex (8.9%) were also commonly detected. Novel CCND3 mutations were identified in 5 pediatric MLL-rearranged AML patients (8.9%) and 2 adult MLL-rearranged AML patients (3.3%). Recurrent mutations of CCND1 (n = 3, 2.9%) and CCND2 (n = 8, 7.6%) were found in pediatric t(8;21) AML patients, whereas no CCND3 mutations were found, suggesting that D-type cyclins exhibit a subtype-specific mutation pattern in AML. Treatment of MLL-rearranged AML cell lines with CDK4/6 inhibitors (abemaciclib and palbociclib) blocked G1 to S phase cell-cycle progression and impaired proliferation. Pediatric MLL-MLLT3–rearranged AML patients with coexisting mutations (n = 16) had significantly reduced relapse-free survival and overall survival compared with those without coexisting mutations (n = 9) (P = .048 and .046, respectively). These data provide insights into the genetics of MLL-rearranged AML and suggest therapeutic strategies