Monivammapotilaan kivunhoito

Tämän opinnäytetyön tarkoituksena oli kartoittaa monivammapotilaan kivunhoitoa ennen sairaalaan tuloa, sairaalassa ja kotona systemaattista kirjallisuuskatsausta soveltaen. Tavoitteena on edistää monivammapotilaan kivunhoitoa. Opinnäytetyöhön valikoitui analysoitavaksi 38 (=n) julkaisua. Monivammapotilaan kivunhoito vaatii moniammatillista osaamista ja yhteistyötä. Kivunhoidon oleellisena osana on kivun arviointi. Kipua voidaan arvioida erilaisin mittarein, kuten sanallinen asteikko (VRS), numeroasteikko (NRS) ja visuaalianalogiasteikko (VAS). Potilaan ollessa tajuton, kivunarviointi muuttuu haasteellisemmaksi, sillä silloin mittareita ei voida käyttää. Monivammapotilaan kipua hoidetaan pääsääntöisesti lääkkeillä. Keskeisimpiä lääkkeitä ovat tulehduskipulääkkeet, parasetamoli ja opioidit. Lääkkeettömiä kivunhoitomuotoja kuten asentohoito, fysikaaliset hoitomuodot, hengitysharjoitukset, musiikin kuuntelu, rentoutumis- ja mielikuvaharjoitukset, käytetään myös, mutta ne ovat tehokkaampia yhdistettynä lääkkeelliseen kivunhoitoon. Lääkehoito koostuu monen lääkeryhmän yhdistelmistä eli multimodaalisesta kivunhoidosta. Puudutteet ovat keskeinen osa monivammapotilaan kivunhoitoa, sillä ne vähentävät huomattavasti opioidien käyttöä. Kivunhoito on tasapainoilua potilaan kivuttomuuden ja kivunhoidon haittavaikutuksien välillä. Potilaan kivunhoito jatkuu koko hoidon ajan, myös kotiutumisen jälkeen. Kivunhoito on potilaan oikeus eikä ole olemassa mitään pätevää syytä jättää kipua hoitamatta. Monivammapotilaat ovat todella kivuliaita, joten kivun hoidon tutkiminen ja kehittäminen on tärkeää. Tehokkaalla kivunhoidolla voidaan ehkäistä kivun kroonistumista.The purpose of this thesis is to improve multi-trauma patients pain management before coming to a hospital, in hospital and at home by using a systematic literature review. The aim is to improve multi-trauma patient’s pain management. There was 38(=n) publications chosen for this thesis. The pain management of a multi-trauma patient requires multi-professional expertise and cooperation. An essential part of pain management is assessment of pain. The pain can be assessed with different kind of rating scales for example verbal rating scale (VRS), numeric rating scale (NRS) and visual analog scale (VAS). When patient is being unconscious assessment of pain becomes challenging so the rating scales cannot be used. The pain of a multi-trauma patient is mainly managed with medicine. The most common medicines are inflammatory drugs, paracetamol and opioids. Drug-free pain management formats such as position management, physical therapies, breathing exercises, listening to music, relaxing and imagination exercises are used but they are more effective combined with medicinal pain management. Medication consist of the combination of different drug groups called multimodal pain management. Regional anesthetics are a key part of the pain management of a multi-trauma patient because regional anesthetics reduce remarkably the use of opioids. Pain management is balancing between painless and side effects pain management. The pain management of the patient goes through the whole care also after discharging from hospital. Pain management is the patients right and there is no competent reason to not treat the pain. Multi-trauma patients are in a high amount of pain so the study and development of pain management is really important. With efficient pain management you can anticipate chronical pain

STERNOCLAVICULAR JOINT MOVEMENT DURING BACKSWING IN BASEBALL PITCHING MAY BE A GOOD INDICATOR OF SHOULDER INJURY

The purpose of this study was to demonstrate the characteristics of joint movements performed by the pitchers who suffered from throwing shoulder injuries. Fourteen semiprofessional baseball pitchers participated in our longitudinal study. We captured their pitching using an optical motion capture system. We investigated their disease history once a year, for 5 years, in order to investigate the relationship between baseball-related throwing injuries and pitching mechanics. T w of the players suffered from shoulder pain and had to take a "no throw" rest for several weeks during the season. Both pitchers had a reduced range of motions for retraction at the sternoclavicular joint during backswing. However, they presented the same range of motions for shoulder horizontal abduction, as the other healthy pitchers

Comparative histopathological studies in the early stages of acute pathogenic and nonpathogenic SHIV-infected lymphoid organs

AbstractTo clarify the early pathological events in simian and human immunodeficiency chimeric virus (SHIV)-infected lymphoid organs, we examined rhesus macaques infected with an acute pathogenic SHIV (SHIV89.6P) or a nonpathogenic SHIV (NM-3rN) by sequential biopsies and serial necropsies. In the SHIV89.6P-infected monkeys, acute thymic involution as shown by increased cortical tingible-body macrophages and by neutrophilic infiltrates without follicular aggregation in the medulla began within 14 days postinoculation (dpi). Cells that were strongly positive for the virus were identified in the thymic medulla. SHIV89.6P-infected lymph nodes showed severe paracortical lymphadenitis with scattered virus-positive cells at 14 dpi and they developed paracortical depletion without the obvious follicular involution. In contrast, NM-3rN-infected monkeys showed no signs of thymic dysinvolution and the lymph nodes exhibited only follicular hyperplasia. NM-3rN-infected monkeys showed much fewer virus-positive cells in these lymphoid tissues than did SHIV89.6P-infected monkeys during the same period. These differences clearly reflect the difference in the virulence of these SHIVs

ハムスター胆汁・膵液・十二指腸液胆道内逆流モデルにおける胆道上皮の組織学変化と発癌

膵胆管合流異常症は,胆道系癌が発生することで前癌状態として認識されている.その発癌機序の一つとしては,膵液の胆管への逆流が関与していると考えられている.そこで我々は,ハムスターに外科的に胆汁・膵液・十二指腸液が確実に胆道内に逆流する処置を加え,いわゆる膵胆管合流異常症モデル(cholecystoduodenostomy with dessection of the extrahepatic bile duct on the distal end of the common duct以下のCDDBモデル)を作成し,胆汁,膵液を含む十二指腸液の逆流が,胆道上皮へ及ぼす影響を検討した.術後,全てのハムスターに基本飼育を与え,水道水を自由摂取させた.そして発癌剤を投与することなく6ヶ月および12ヶ月以上観察した.病理組織学的には,6ヶ月観察の6例全例に胆嚢上皮の過形成を認め,1例では高度の腺管の異形成が認められた.そして胆嚢粘膜の増殖細胞の検出をPCNA LIを用い測定した結果,CDDBモデルは,手術非施行例に比べて高値であった.肝外胆管上皮は炎症細胞の浸潤はあるものの過形成は認められなかった.肝内胆管,膵管上皮には特別な病変を認めなかった.12ヶ月以上観察できた14例の胆嚢では,全例に胆嚢上皮の過形成がみられ,異形成はみられなかった.一方肝外胆管では,上皮の過形成が14例中半数の7例にみられ,1例に肝外胆肝癌の発生を認めた.しかしK-ras遺伝子変化はみられなかった.6ヶ月に比べ12ヶ月の長期観察では肝外胆管にも変化がみられた.この実験結果より,発癌剤を投与しなくとも,CDDBモデルは逆流した膵液と胆汁を含む十二指腸液が長期間にわたり直接粘膜に接触すると,胆嚢上皮と胆管上皮の細胞回転が亢進し,過形成,異形成が発症し,さらには発癌に至ることが示された.すなわち,この実験モデルは,発癌物質を投与することなく胆道の前癌状態から発癌にいたる過程を観察でき,発癌機構を解明できる有用なモデルとなる可能性がある.It is well known that pancreaticobiliary maljunction (PBM) in the pancreatobiliary system promotes development of biliary carcinoma in man. The reflux of pancreatic juice into the biliary tract is considered to be one factor promoting biliary carcinoma. Therefore, we carried out a cholecystoduodenostomy with dissection of the extrahepatic bile duct at the distal end of the common duct (CDDB) in hamsters in such a way that pancreatic juice and duodenal contents would enter the biliary tract. After with CDDB, all the animals were fed a basal diet and provided drinking water ad libitum without the use of a carcinogen until they were sacrificed at 6 months or 12 months. In the six-month group, hyperplasia of the epithelium in the gallbladder was observed in 100%. Severte dysplasia of the epithelium in the gallbladder was noted in one out of six hamsters. The cell kinetics of the gallbladder epithelium were examined using the PCNA-labeling index (PCNA LI). A high PCNA LI in the epithelium of the gallbladder was demonstrated in hamsters that had undergone CDDB but not in those who had not. Although inflammatory cells permeated the epithelium of the extrahepatic bile duct, no hyperplasia was observed. No pathological findings were made in the liver or pancreas. In the 12 month group, hyperplasia of the ipithelium of the gallbladder was observed in 100% and of the extrahepatic bile duct in 50%. Extrahepatic bile duct carcinoma was found in 1 out of 14 hamsters. K-ras gene mutation was not detected. In conclusion, the CDDB procedure itself greatly accelerated cell turn-over of the epithelium in the extrahepatic biliary system. We could observe extrahepatic biliary carcinogenesis in the model without a carcinogen. This model allows for observation of the process from hyperplasia to carcinoma without the use of a carcinogen, and is a useful model for investigating and clarifying the mechanism of carcinogenesis in the extrahepatic biliary sytem

QOL after RT or OP for uterine cervix cancer

This study aimed to research the post-treatment quality of life (QOL) between radiotherapy (RT)- and operation (OP)-treated early cervical cancer survivors, using separate questionnaires for physicians and patients. We administered an observational questionnaire to patients aged 20–70 years old with Stages IB1–IIB cervical cancer who had undergone RT or OP and without recurrence as outpatients for ≥6 months after treatment. We divided 100 registered patients equally into two treatment groups (n = 50 each). The average age was 53 and 44 years in the RT and OP groups, respectively. The RT group included 34 and 66% Stage I and II patients, respectively, whereas the OP group included 66 and 34% Stage I and II patients, respectively. The OP group included 58% of patients with postoperative RT. Combination chemotherapy was performed in 84 and 48% of patients in the RT and OP groups, respectively. On the physicians’ questionnaire, we observed significant differences in bone marrow suppression (RT) and leg edema (OP). On the patients’ questionnaire, significantly more patients had dysuria and leg edema in the OP group than in the RT group, and severe (Score 4–5) leg edema was significantly higher in the post-operative RT group than in the OP only group. The frequency of sexual intercourse decreased after treatment in both groups. On the patients’ questionnaire, there were no significant differences between the two groups regarding sexual activity. These findings are useful to patients and physicians for shared decision-making in treatment choices. The guidance of everyday life and health information including sexual life after treatment is important

Arabidopsis RPT2a, 19S Proteasome Subunit, Regulates Gene Silencing via DNA Methylation

The ubiquitin/proteasome pathway plays a crucial role in many biological processes. Here we report a novel role for the Arabidopsis 19S proteasome subunit RPT2a in regulating gene activity at the transcriptional level via DNA methylation. Knockout mutation of the RPT2a gene did not alter global protein levels; however, the transcriptional activities of reporter transgenes were severely reduced compared to those in the wild type. This transcriptional gene silencing (TGS) was observed for transgenes under control of either the constitutive CaMV 35S promoter or the cold-inducible RD29A promoter. Bisulfite sequencing analysis revealed that both the transgene and endogenous RD29A promoter regions were hypermethylated at CG and non-CG contexts in the rpt2a mutant. Moreover, the TGS of transgenes driven by the CaMV 35S promoters was released by treatment with the DNA methylation inhibitor 5-aza-2′-deoxycytidine, but not by application of the inhibitor of histone deacetylase Trichostatin A. Genetic crosses with the DNA methyltransferase met1 single or drm1drm2cmt3 triple mutants also resulted in a release of CaMV 35S transgene TGS in the rpt2a mutant background. Increased methylation was also found at transposon sequences, suggesting that the 19S proteasome containing AtRPT2a negatively regulates TGS at transgenes and at specific endogenous genes through DNA methylation

Influence of Skeletal Muscle Mass and Spinal Alignment on Surgical Outcomes for Lumbar Spinal Stenosis

Study Design Retrospective observational study. Purpose We considered the relationship between spinal alignment and skeletal muscle mass on clinical outcomes following a surgery for lumbar spinal stenosis (LSS). Overview of Literature There are no reports of preoperative factors predicting residual low back pain following surgery for LSS. Methods Our target population included 34 women (mean age, 74.4 years) who underwent surgery for LSS. Prior to and 6 months after the surgery, systemic bone mineral density and lean soft tissue mass were measured using dual-energy X-ray absorptiometry. Skeletal muscle mass index (SMI) was calculated as the sum of the arm and leg lean mass in kilograms divided by height in meters squared. The spinal alignment was also measured. Clinical outcomes were evaluated using the Japanese Orthopedic Association scoring system, leg and low back pain Visual Analog Scale, and Roland–Morris Disability Questionnaire (RDQ). Additionally, we examined the bone mineral density, skeletal muscle mass, and spinal alignment before and after the surgery. We used the Spearman correlation coefficient to examine the associations among clinical outcomes, preoperative muscle mass, and spinal alignment. Results Sarcopenia (SMI 6.12), RDQ was significantly higher in subjects with sarcopenia (p =0.04). RDQ was significantly negatively correlated with SMI (r =−0.42, p <0.05). There was a significant positive correlation between postoperative RDQ and pelvic tilt (PT; r =0.41, p <0.05). SMI and PT were significantly negatively correlated (r =−0.39, r <0.05). Conclusions Good postoperative outcomes were negatively correlated with low preoperative appendicular muscle mass, suggesting that postoperative outcomes were inferior in cases of decreased appendicular muscle mass (sarcopenia). Posterior PT due to decreased limb muscle mass may contribute to postoperative back pain, showing that preoperatively reduced limb muscle mass and posterior PT are predictive factors in the persistence of postoperative low back pain

関節炎で発症した高安動脈炎の1例

高安動脈炎は全身の大血管に炎症がおこる疾患の1つであり,大動脈及びその主要分枝や肺動脈,冠動脈に閉塞性あるいは拡張病変を来すのが特徴である.初期症状としては,発熱や全身倦怠感などを呈し,その他の症状は障害を受けた血管の部位により異なる.稀には,消化器症状や皮膚症状,関節症状を呈する事もある.我々は関節炎を主訴に当院を受診し,後に高安動脈炎と診断された症例を経験した.患者は40歳代女性.左膝及び左足関節痛があり,関節超音波で滑膜炎の所見が認められた.血清学的検査ではリウマトイド因子陰性,抗CCP抗体陰性であり,未分類型関節炎として少量プレドニゾロンで治療が開始された.メトトレキサートの併用により,関節症状は改善した.しかし,治療開始6ヶ月後,胸背部痛を訴えて受診し,血液検査ではCRP上昇を認めた.造影CT検査で,腕頭動脈,左総頚動脈,下行大動脈に壁肥厚と周囲脂肪織濃度の上昇が認められ,高安動脈炎と診断された.関節リウマチとしては非典型的な関節炎の症例に遭遇した場合には,常に高安動脈炎を含めた,他疾患の可能性を念頭に入れて診療を行う必要がある.Takayasu arteritis is an idiopathic large vessel vasculitis affecting the aorta and its major branches. Although systemic symptoms, such as malaise, weight loss and fever, are common in the early stages of this disease, joint manifestations are rarely seen. We report the case of a woman in her 40s, who complained of arthritis of left knee and left ankle. Both rheumatoid factor and anti-cyclic citrullinated peptide antibody were negative. Treatment with low dose prednisolone and methotrexate resulted in improvement of polyarthritis. Six months later, however, she presented with chest and back pain, with an elevation of serum C-reactive protein levels. Enhanced computed tomography demonstrated significantly wall thickness in the brachiocephalic trunk, left common carotid artery and descending aorta. She was diagnosed with Takayasu arteritis. We should keep Takayasu arteritis in mind for patients with seronegative undifferentiated arthritis