Postprandial Hypotension due to a Lack of Sympathetic Compensation in Patients with Diabetes Mellitus.

Postprandial hypotension is an important hemodynamic abnormality in diabetes mellitus, but few reports are available on the relationship between autonomic dysfunction and postprandial hypotension. Ten diabetic patients and 10 healthy volunteers were recruited for this study. Postural blood pressure and heart rate changes were measured before lunch, and then the hemodynamic responses to a standardized meal were investigated. Holter electrocardiogram (ECG) monitoring was conducted for assessing spectral powers and time-domain parameters of RR variations. Postural changes from the supine to the upright position decreased the systolic blood pressure of the diabetics from 133(+-)16 to 107(+-)20 mmHg (p<0.01), but did not decrease the systolic blood pressure of the controls. The heart rate remained constant in the diabetics but was increased in the controls. Food ingestion decreased systolic blood pressure in the diabetics, with a maximum reduction of 25(+-)5 mmHg. This decrease was not associated with any changes in the ratio of low frequency to high frequency, and yet the heart rate remained almost constant. Indexes involving parasympathetic tone were not affected. Food ingestion did not affect blood pressure in the control group. These findings suggest that lack of compensatory sympathetic activation is a factor contributing to postprandial hypotension in diabetics, and that parasympathetic drive does not make a significant contribution to this condition

Prognostic significance of right bundle branch block in patients with acute inferior myocardial infarction

There is little information available concerning the influence of right bundle branch block (RBBB) on the prognosis of patients with inferior myocardial infarction (MI). In this study we evaluated the influence of RBBB on the short-term prognosis of patients with inferior MI. Our study subjects were 1,265 hospitalized patients with Q wave MI. Patients were divided into 4 groups based on the presence or absence of RBBB and on the location of the infarction. RBBB was classified into 4 categories according to the timing of its appearance and its duration as new permanent, transient, old and age indeterminate. In-hospital death and pulmonary congestion were observed more frequently in patients with RBBB than in those without RBBB. Moreover, in inferior MI as in anterior MI, in-hospital death and pulmonary congestion occurred more frequently in new permanent RBBB patients than in patients with other types of RBBB. Multivariate regression analysis reveals that new permanent RBBB was a strong independent predictor for an adverse short-term prognosis in patients with inferior MI, as well as in patients with anterior MI. New permanent RBBB during inferior MI is a strong independent predictor for increased in-hospital mortality, regardless of the infarction location.</p

混合病棟におけるインシデントノートを使用したコミュニケーションエラー減少の取り組み

　2011年４月より合計12科の混合病棟となったことで，看護業務が煩雑化し，医療事故・過誤の高リスクとなっていた．その改善の目的で，当該病棟の看護師22名が，コミュニケーションエラーの回避・減少を目的としたインシデントノート（【ノート】と表記）を2011年7月10日から2011年12月31日まで使用し，記入されたデータから意図の共通性を分類した．さらに【ノート】使用の前後で実施した意識調査の結果を合わせて内容分析を行った．【ノート】の内容は，３つのコアカテゴリー（『コア』と表記），その下層に計9つのカテゴリー（≪カテゴリー≫と表記）に分類された．『意識付けによる安全行動への期待』では，≪発生したインシデントの状況の記述≫および≪確認不足による間違い≫から，具体的な事実を確認でき，病棟にある潜在的リスクが情報として表在化された．そして≪厳守規則≫として，情報発信，ルールづくり，遵守徹底が図られた．【ノート】の使用によって，それらの情報をタイムリーに，アサーティブな方法でエラーを指摘することができ，意識付け，チーム間で話し合うという安全風土の形成に有効であった．『潜在リスクの表在化』では，意識調査において，経験年数９年以下では10年以上のスタッフに比べ危険を察知する割合が低いという結果が得られた．≪不慣れ・知識不足からのインシデント情報≫から，知識・経験の豊富なスタッフやリスク感性の高いスタッフが情報を提供することが，相互サポートとして活用できたことが判明した．『医師からの知識情報』では，12科32名の医師の指示に対応する必要性があり，この項目もノートに記述されエラーの低減に有効であった．当該病棟では，混合病棟による環境に影響を受けた個人要因を一番高いリスク因子と捉えており，【ノート】の使用はリスク因子を表在化し，改善策に結びつけることができた．また，【ノート】をツールとした情報共有によるコミュニケーションが，患者安全を意識した風土作りに有効と考えられた．今後は必要に応じ【ノート】を使用することにより，更なる看護業務の改善を図りたい．　In April of 2011, Kawasaki Medical School General Medical Center created a mixed ward consisted of twelve different departments. This mixed-department ward initially resulted in more complex nursing duties and a higher risk of medical incidents. We analyzed descriptions written by 22 nurses in incident notebooks shared among the mixed-department ward nurses between July and December of 2011, and an awareness survey performed six months after the mixed ward was created. The contents of the notebooks were classified into three core categories with nine sub-categories. In the core category [safe behavior through awareness], incident data from the sub-categories “incident descriptions” and “errors due to a lack of communication” was presented to the ward nurses and “rules to be sure to follow”were decided and implemented. The notebooks were helpful for finding problems in a clear and timely fashion and helped create a culture of safety by raising awareness and communication among the various teams in the ward. The second core category [awareness of hidden risks] was especially noticed by nurses with over ten years of experience, according to the awareness survey. Nurses with vast knowledge and experience along with nurses with an above average risk sensitivity were able to mutually support less experienced nurses with information in the sub-category classified as“ incidents occurring from inexperience or a lack of knowledge.” The final core category [information from doctors] were notes written in response to information from one or more of the 32 doctors working in the ward. Knowledge from the physicians was recorded and shared among the nursing staff through the notebooks. In the mixed ward, the environmental factors considered to be the highest risk factors were recorded in the notebooks and led directly to improved measures. In addition, the communication fostered by sharing information in the notebooks contributed towards a conscious culture of medical safety management

Successful outcome of second allogeneic bone marrow transplantation for blastic plasmacytoid dendritic cell neoplasm with MYC locus rearrangement

A 62-year-old male was diagnosed with blastic plasmacytoid dendritic cell neoplasm (BPDCN) with a MYC rearrangement. Four months after the first unrelated bone marrow transplantation (BMT), he developed the relapsed BPDCN. After the achievement of partial remission following re-induction therapy, he underwent a second BMT from another unrelated donor, and experienced complete remission with grade II acute graft-versus-host disease and moderate chronic graft-versus-host disease. He remains alive in complete remission more than 71 months after the second BMT. These results suggested that donor change at the second transplantation may represent a considerable therapeutic option for patients with relapsed BPDCN

Early Stage of Establishment of Persistent Sendai Virus Infection: Unstable Dynamic Phase and Then Selection of Viruses Which Are Tightly Cell Associated, Temperature Sensitive, and Capable of Establishing Persistent Infection

We obtained 157 cloned cell lines persistently infected with Sendai virus; these cell lines were generated independently of each other. Infectious viruses could be isolated from 123 of these cloned cell lines by inoculation of culture fluids or infected cells into embryonated eggs. The majority of the viruses carried by cells persistently infected with viruses showed high cytotoxicity and did not have the ability to establish persistent infection. The association of carried virus with cells became stronger and virus isolation correspondingly became more difficult as cells persistently infected with virus were subcultured. Viruses derived from virus-infected cells eventually acquired the ability to establish persistent infection, although the ways in which the viruses acquired this ability varied. The viruses also acquired temperature sensitivity as persistently infected cells were subcultured. First, the hemagglutinin-neuraminidase and M proteins acquired temperature sensitivity, and then the polymerase(s) did so. The M proteins were localized in the nuclei of cells infected with cloned viruses that had the ability to establish persistent infection. Cells infected with viruses capable of establishing persistent infection showed no or slight staining by terminal deoxynucleotidyltransferase-mediated dUTP-biotin nick end labeling. Specific amino acid substitutions accumulated in the M protein and the L protein as virus-infected cells were subcultured. This study shows that there is an unstable dynamic phase at an early stage of the establishment of persistent Sendai virus infection (steady state), and then viruses capable of establishing persistent infection are selected

Prevalence, clinical course, and predictive factors of immune checkpoint inhibitor monotherapy-associated hepatitis in Japan

Background and Aim Immune checkpoint inhibitors (ICI) have revolutionized anti-malignancy therapy and thus have been increasingly used. Although ICI may cause immune-related adverse events (irAE) in various organs, including the liver, the prevalence and predictive factors of irAE have not been clarified. Methods In this retrospective study, consecutive patients who had malignancies and were treated with ICI without other chemotherapeutic agents at Hokkaido University Hospital between 2014 and 2019 were screened. Patients were excluded if they were Of the 233 patients screened, 202 patients met the inclusion criteria and were included in the analysis. The patients were aged 25-92 years, and 60.9% were male. The patients received nivolumab (n = 137), pembrolizumab (n = 45), ipilimumab (n = 17), atezolizumab (n = 2), and avelumab (n = 1). The prevalence of any grade and grade >= 3 irAE hepatitis was 8.4% (17/202) and 4.0% (8/202), respectively. irAE hepatitis occurred at a median duration of 42 days in any grade and 36 days in grade >= 3 after ICI initiation. The clinical course of grade >= 3 irAE hepatitis was generally favorable; however, 50% required corticosteroid treatment and two patients required additional mycophenolate mofetil. Female sex and history of ICI treatment were significantly associated with the incidence of grade >= 3 irAE hepatitis. Conclusions Grade >= 3 irAE hepatitis was observed in 4.0% of the patients who were treated with ICI. Female sex and history of ICI treatment were significantly associated with the incidence of grade >= 3 irAE hepatitis