bluuebunny/crossref_metadata_2025 huggingface dataset:
Amorphous Copper‐modified Gold Interface Promotes Selective CO2 Electroreduction to CO
Authors: Zhan Peng , Yang Shuai , Chu Mengen , Zhu Qian , Zhuang Yan , Ren Cong , Chen Ziyi , Lu Lu , Qin Peiyong
Published: April 2022

Electroreduction of CO2 into valuable chemicals exhibits promising application potentials. Herein, a kind of nano‐porous AuCu foam which possesses amorphous copper (Cu)‐modified gold (Au) interface was designed for highly selective electroreduction CO2 into CO. As‐obtained Au0.95Cu0.05 foam exhibits a Faradaic efficiency (FE) of 99.5 % for CO with a current density of 31.3 mA cm−2. Compared with other Au‐based electrocatalysts, Au0.95Cu0.05 foam shows a lower overpotential of 240 mV. The improvements in activity and selectivity of the AuCu foam might be attributed to the synergistic effect between the highly dispersed amorphous Cu and the matrix of Au. Detailed characterization indicates that the twisty nanowire morphology imparts multiple reactive sites on the electrode surface. The study demonstrates that amorphous Cu on the AuCu foam surface can boost CO2 activation by modifying the surface geometry and electronic structure. This finding provides a new strategy of modifying the metal interface to construct electrocatalyst.
Moleküle aus dem Weltraum
Authors: Groß Michael
Published: April 2022

Im Weltall finden sich überwiegend Wasserstoff‐ und Heliumatome, mit denen man nicht viel Chemie betreiben kann. Wo andere Elemente wie Kohlenstoff und Stickstoff auftreten, können aber auch unter Weltraumbedingungen interessante Moleküle entstehen. Diese lassen sich im Labor herstellen und in Proben von Meteoriten nachweisen.
A deep neural network using audio files for detection of aortic stenosis
Authors: Voigt Ingo , Boeckmann Marc , Bruder Oliver , Wolf Alexander , Schmitz Thomas , Wieneke Heinrich
Published: April 2022

Background

Although aortic stenosis (AS) is the most common valvular heart disease in the western world, many affected patients remain undiagnosed. Auscultation is a readily available screening tool for AS. However, it requires a high level of professional expertise.

Hypothesis

An AI algorithm can detect AS using audio files with the same accuracy as experienced cardiologists.

Methods

A deep neural network (DNN) was trained by preprocessed audio files of 100 patients with AS and 100 controls. The DNN's performance was evaluated with a test data set of 40 patients. The primary outcome measures were sensitivity, specificity, and F1‐score. Results of the DNN were compared with the performance of cardiologists, residents, and medical students.

Results

Eighteen percent of patients without AS and 22% of patients with AS showed an additional moderate or severe mitral regurgitation. The DNN showed a sensitivity of 0.90 (0.81–0.99), a specificity of 1, and an F1‐score of 0.95 (0.89–1.0) for the detection of AS. In comparison, we calculated an F1‐score of 0.94 (0.86–1.0) for cardiologists, 0.88 (0.78–0.98) for residents, and 0.88 (0.78–0.98) for students.

Conclusions

The present study shows that deep learning‐guided auscultation predicts significant AS with similar accuracy as cardiologists. The results of this pilot study suggest that AI‐assisted auscultation may help general practitioners without special cardiology training in daily practice.
Enzymatic Cascade for the Synthesis of 2,5‐Furandicarboxylic Acid in Biphasic and Microaqueous Conditions: ‘Media‐Agnostic’ Biocatalysts for Biorefineries
Authors: Milić Milica , Byström Emil , Domínguez de María Pablo , Kara Selin
Published: April 2022

5‐hydroxymethylfurfural (HMF) is produced upon dehydration of C6 sugars in biorefineries. As the product, it remains either in aqueous solutions, or is in situ extracted to an organic medium (biphasic system). For the subsequent oxidation of HMF to 2,5‐furandicarboxylic acid (FDCA), ‘media‐agnostic’ catalysts that can be efficiently used in different conditions, from aqueous to biphasic, and to organic (microaqueous) media, are of interest. Here, the concept of a one‐pot biocatalytic cascade for production of FDCA from HMF was reported, using galactose oxidase (GalOx) for the formation of 2,5‐diformylfuran (DFF), followed by the lipase‐mediated peracid oxidation of DFF to FDCA. GalOx maintained its catalytic activity upon exposure to a range of organic solvents with only 1 % (v/v) of water. The oxidation of HMF to 2,5‐diformylfuran (DFF) was successfully established in ethyl acetate‐based biphasic or microaqueous systems. To validate the concept, the reaction was conducted at 5 % (v/v) water, and integrated in a cascade where DFF was subsequently oxidized to FDCA in a reaction catalyzed by Candida antarctica lipase B.
Lignin‐First Depolymerization of Lignocellulose into Monophenols over Carbon Nanotube‐Supported Ruthenium: Impact of Lignin Sources
Authors: Su Shihao , Xiao Ling‐Ping , Chen Xue , Wang Shuizhong , Chen Xiao‐Hong , Guo Yanzhu , Zhai Shang‐Ru
Published: April 2022

Lignin‐first depolymerization of lignocellulosic biomass into aromatics is of great significance to sustainable biorefinery. However, it remains a challenge, owing to the variance between lignin sources and structures. In this study, ruthenium supported on carbon nanotubes (Ru/CNT) exhibits efficient catalytic activity toward lignin hydrogenolysis to exclusively afford monophenols in high yields. Catalytic tests indicate that the yields of aromatic monomers are related to lignin sources and decrease in the order: hardwoods > herbaceous plants > softwoods. Experimental results demonstrate that the scission of C−O bonds and the high selectivity to monomeric aromatic compounds over the Ru/CNT catalyst are enhanced by avoiding side condensation. Furthermore, the fabricated Ru/CNT shows good reusability and recyclability, applicability, and biomass feedstock compatibility, rendering it a promising candidate for lignin valorization. These findings pave the way for rational design of highly active and stable catalysts to potentially address challenges in lignin chemistry.
Challenges of Green Production of 2,5‐Furandicarboxylic Acid from Bio‐Derived 5‐Hydroxymethylfurfural: Overcoming Deactivation by Concomitant Amino Acids
Authors: Neukum Dominik , Baumgarten Lorena , Wüst Dominik , Sarma Bidyut Bikash , Saraçi Erisa , Kruse Andrea , Grunwaldt Jan‐Dierk
Published: April 2022

The oxidation of 5‐hydroxymethylfurfural (HMF) to 2,5‐furandicarboxylic acid (FDCA) is highly attractive as FDCA is considered as substitute for the petrochemically derived terephthalic acid. There are only few reports on the direct use of unrefined HMF solutions from biomass resources and the influence of remaining constituents on the catalytic processes. In this work, the oxidation of HMF in a solution as obtained from hydrolysis and dehydration of saccharides in chicory roots was investigated without intermediate purification steps. The amount of base added to the solution was critical to increase the FDCA yield. Catalyst deactivation occurred and was attributed to poisoning by amino acids from the bio‐source. A strong influence of amino acids on the catalytic activity was found for all supported Au, Pt, Pd, and Ru catalysts. A supported AuPd(2 : 1)/C alloy catalyst exhibited both superior catalytic activity and higher stability against deactivation by the critical amino acids.
Investigating the dynamics of Hilfer fractional operator associated with certain electric circuit models
Authors: Ibrahim Nuruddeen Rahmatullah , Gómez‐Aguilar J.F. , Garba Ahmad Abdulaziz , Ali Khalid K.
Published: April 2022

The present manuscript investigates the action of the Hilfer fractional operator on the dynamics of resistor–capacitor (RC) and certain resistor–inductor‐capacitor (RLC) electric circuits using the Laplace transform method alongside utilizing the negative binomial formula. The choice of Hilfer's operator here was basically based on its interpolating nature between the well‐known Caputo and Riemann–Liouville fractional derivatives. Meanwhile, this operator has not been adequately scrutinized with regard to its effects on electric circuits in the literature. Thus, respective approximate exact solutions are determined convolutionally in the presence of certain periodic voltage source functions. Lastly, the significance of the operator on the dynamics of these models was demonstrated graphically for different values of the fractional‐order
and type
. More so, the present study will be beneficial in designing modern electric devices involving temporal delays and memory record.
Marginalized adult learners faced unique challenges during COVID‐19
Authors: Sutton Halley
Published: April 2022

SAN DIEGO, CALIFORNIA — “It's been my privilege to work with adult learners all the time,” Royce Ann Collins, Ph.D., Associate Professor of Adult Learning and Leadership at Kansas State University, said. Collins has worked with partner organizations, including working with the DeBruce Foundation, to conduct research on adult scholars at various programs, including the differences between adult learners and traditional students.
Can heat‐pumps provide routes to decarbonization of building thermal control in the US Midwest?
Authors: Doak Austin , Stanier Charles , Anthony Jerry , Udaykumar H. S.
Published: April 2022

Climate change mitigation demands rapid decarbonization; in cold regions such as the US Midwest, building thermal control (BTC) presents a potential for significant cuts in emissions by combining renewable energy with heat pumps. Trends in natural gas and electricity pricing over the period 2007–2020 have significantly upended economic feasibility of this decarbonization approach. Heat pump‐based BTC has moved from being cost advantageous in operations but higher GHG emitting (in 2007), to the exact opposite—higher cost but lower emitting (in 2020). Due to energy price fluctuations, the coefficient of performance required of a heat pump to breakeven on operational cost with high efficiency natural gas heating has doubled, changing from 2.25 to 4.5 over the period 2007–2019. The value of 4.5 is infeasible for all available cold‐climate heat pump systems. Thus, while electrification via both air‐source and ground‐source heat pumps is a commonly identified component of decarbonization plans in the region, actual implementation has declined. Improvements in heat pump performance, overcoming adoption barriers, and adopting policies that buffer long‐term climate solutions against short‐term price fluctuations are all needed. In part due to continuing decreases in carbon intensity of electricity, heat pump climate benefits can be substantial over project life cycles; however, there is no current policy mechanism to enable this benefit to be considered relative to short‐run economic considerations.
A comparison of using organic Rankine and Kalina cycles as bottom cycles in a solar‐powered steam Rankine cycle
Authors: Mirjavadi Koosha , Pourfayaz Fathollah , Pourmoghadam Peyman , Kasaeian Alibakhsh
Published: April 2022

This study has attempted to compare two thermodynamic cascade cycles, which in this paper are presented as Systems A and B. System A was consisted of a steam Rankine cycle (SRC) as a top cycle and an organic Rankine cycle (ORC) as a bottom cycle. System B was consisted of the same SRC as the top cycle and a Kalina cycle as the bottom cycle. The comparison of both systems has been made by changing a number of parameters. The chosen parameters for this comparison were bottom cycle mass flow rate, aperture area of the collector, top cycle condensing pressure, and bottom cycle turbine inlet and outlet pressures. Also, a short economic evaluation has been made between two proposed cascade cycles (Systems A and B). The result indicated that the Kalina cycle shows superiority over the ORC as the bottom cycle in a solar‐driven SRC. Furthermore, it was determined that the most effective parameters on the overall efficiency of the systems are the condensing pressure of the top cycle and the outlet pressure of the bottom cycle turbine. Also, among the chosen parameters, the outlet pressure of the bottom cycle turbine had the highest effect on the efficiency of the bottom cycles. Considering the economic aspect, the results showed that the levelized costs of energy for both systems are quite equal at 0.011 ($/kWh).
Rheological and functional characterization of gelatin and fat extracted from chicken skin for application in food technology
Authors: Mohammadnezhad Sedigheh , Farmani Jamshid
Published: April 2022

Chicken skin is a major byproduct of the poultry industry. This study was undertaken to extract and characterize fat and gelatin from chicken skin. To do this, the chicken skin was wet‐rendered at different temperature–time combinations and the yield and properties of the extracted gelatin and fat were determined. Gelatin and fat were recovered at yield ranges of 0.74%–2.03% and 24.01%–27.91%, respectively. The time and the interaction of time–temperature had a positive effect on gelatin yield (p < .05); however, the fat yield was not affected by the extraction condition. Protein, ash, and hydroxyproline content of gelatin and unsaponifiables and free fatty acids contents, peroxide value, and induction period of oxidation of the fat were affected by the extraction condition. Functional and rheological analyses showed chicken skin gelatin gel/solution had a higher bloom value, viscosity, foaming capacity, storage and loss moduli, and melting and gelling points than the commercial bovine gelatin. Oleic (42.13%), palmitic (24.6%), and linoleic (17.53%) acids were the main fatty acids of chicken skin fat. The storage modulus of chicken skin fat was higher than the loss modulus up to 31°C; however, because of a low slip melting point (22.74°C) and solid fat content, it was fluid at room temperature. The findings of this research can be useful in the development of processes for the extraction and application of chicken skin gelatin and fat.
Creative performance pressure as adouble‐edgedsword for creativity: The role of appraisals and resources
Authors: Liu Fangzhou , Li Peikai , Taris Toon W. , Peeters Maria C. W.
Published: April 2022

Creativity, or the generation of novel and useful ideas or products, is widely viewed as the cornerstone of organizational innovation and success. However, high pressure to be creative may have mixed implications for employee creativity. In this article, we first systematically conceptualize the nature of the concept of creative performance pressure. Next, building on transactional stress theory, we investigate (a) how creative performance pressure influences employee creativity through different appraisals (i.e., challenge and hindrance) and (b) the moderating role of a job and personal resource (i.e., servant leadership and promotion focus) in the stressor appraisal process. In Study 1, we developed a creative performance pressure scale and assessed its psychometric properties across two samples (N = 181 for Sample 1;N = 253 for Sample 2). In addition, using multi‐wave, multi‐source data (Study 2), we tested our hypotheses in a Chinese sample (N = 206). The results demonstrated that creative performance pressure can have both positive and negative effects on employee creativity through challenge and hindrance appraisals, respectively. Servant leadership moderated the effect of creative performance pressure on challenge and hindrance appraisals, by transmitting the beneficial and detrimental effects of creative performance pressure to creativity, respectively. Similarly, promotion focus moderated the relationship between creative performance pressure and hindrance appraisal. We discuss future research directions and offer several practical implications for both organizational leaders and human resource (HR) practitioners.
Environmental monitoring tools and strategies in salmon net-pen aquaculture
Authors: Bell Jennifer L. , Mandel Randy , Brainard Andrew S. , Altschuld Jon , Wenning Richard J.
Published: April 2022

As global salmon production accelerates in response to higher consumer demand for seafood, so does the need for sophisticated monitoring strategies to enable and maintain ethically sound, productive, and environmentally friendly production of fish. Innovative technologies are needed to ensure proper water quality, react to unfavorable hydrodynamic conditions, monitor for changes in fish health, and minimize ecological interactions with indigenous aquatic life, including fish escapes. Automated sensors connected wirelessly to data stations, visualization aids, and acoustic and physical tagging technologies are emerging tools capable of detecting environmental stress and its associated behavioral changes in farmed fish. Computer modeling of the monitoring data collected from a single salmon farm or collection of farms sharing a data network can be used to spot environmental trends vital for anticipating some of the consequences of climate change. Environmental regulations governing salmon farming in coastal areas are becoming more stringent in response to public pressures to protect coastal and ocean resources and to provide for multipurpose use of marine resources. As net-pen salmon aquaculture expands globally, new technologies will be essential to collect and interpret the anticipated larger volumes of data needed to meet these stringent regulatory requirements and to safeguard the high investment costs inherent in salmon farming. Integr Environ Assess Manag 2022;18:950–963. © SETAC

KEY POINTS

Innovative technologies are needed to ensure proper water quality, react to unfavorable hydrodynamic conditions, monitor for changes in fish health, and minimize ecological interactions with indigenous aquatic life. Automated sensors connected wirelessly to data stations, visualization aids, and acoustic and physical tagging technologies are emerging tools capable of detecting environmental stress and its associated behavioral changes in farmed fish. As net-pen salmon aquaculture expands globally, new technologies will be essential to collect and interpret the anticipated larger volumes of data needed.
Identification of B‐cell dominant epitopes in the recombinant protein P29 from Echinococcus granulosus
Authors: Lv Yongxue , Li Shasha , Zhang Tingrui , Zhu Yazhou , Tao Jia , Yang Jihui , Chang Liangliang , Wu Changyou , Zhao Wei
Published: April 2022

Introduction

Echinococcus granulosus (E. granulosus) causes a hazardous zoonotic parasitic disease. This parasite can occupy the liver and several areas of the body, causing incurable damage. Our previous studies have provided evidence that the recombinant protein P29 (rEg.P29) exhibit immune protection in sheep and mice against pathological damage induced by E. granulosus, showing its potential as candidate for vaccine development. However, information on the B‐cell epitopes of rEg.P29 has not yet been reported.

Methods

Immunological model was established in mice with rEg.P29. SDS‐PAGE and Western blot were used to identify protein. Screening for B‐cell dominant epitope peptides of rEg.P29 by enzyme‐linked immunosorbent assay (ELISA) and immune serum. Dominant epitopes were validated using ELISA and flow cytometry. Multiple sequence alignment analysis was performed using BLAST and UniProt.

Results

Immunization with rEg.P29 induced intense and persistent antibody responses, and the epitope of the dominant antigen of B cells are identified as rEg.P29166–185 (LKNAKTAEQKAKWEAEVRKD). Anti‐rEg.P29166–185‐specific antibodies lack epitopes against IgA, IgE, and IgG3, compared to anti‐rEg.P29‐specific antibodies. However, anti‐rEg.P29166–185 IgG showed comparatively higher titers, as determined among those peptides by endpoint titration. In addition, rEg.P29 and rEg.P29166–185 promote B‐cell activation and proliferation in vitro. The dominant epitopes are relatively conserved in different subtypes of the rEg.P29 sequence.

Conclusion

rEg.P29166–185 can act as a dominant B‐cell epitope for rEg.P29 and promote cell activation and proliferation in the same way as rEg.P29.
Risk of nonpulmonary infections requiring hospitalization in spondyloarthritis
Authors: Chung Ho Yin , Chan Shirley Chiu Wai , Sun Frances Sze Kei
Published: April 2022

Objectives

To compare the risk of five nonpulmonary infections leading to hospitalization between spondyloarthritis (SpA) and nonspecific back pain (NSBP), and to identify the risk factors.

Methods

A total of 3018 patients with SpA and 2527 patients with NSBP were identified. Data from December 1995 to June 2019 was retrieved from a centralized electronic medical record system. The date of onset of five types of nonpulmonary infections including: urinary tract infection (UTI), skin infection, gastroenteritis (GE), septic arthritis, and pancreato‐hepatobiliary tract infection were identified. Demographic data, comorbidities, and medications used were also retrieved. Comparative risk of each type of infection between SpA and NSBP was determined using propensity score adjustment method. Cox regression model was used to identified risk factors.

Results

Patients with SpA were younger in age, predominantly male, with fewer comorbid diabetes mellitus (DM), renal impairment, and depression. Compared with NSBP, patients with SpA had higher risk of UTI (hazard ratio [HR] 1.91; p < .001), skin infection (HR 1.79; p < .001), and septic arthritis (HR 4.57; p = .04). Risk of GE (HR 1.42; p = 1.00), and pancreato‐hepatobiliary tract infection (HR 1.67; p = .06) were not increased. Infliximab was an independent risk factor for UTI (HR 2.21; p = .04). Duration of steroid therapy >6 months (HR 2.22; p < .001), smoker (HR 1.81; p < .001), and psoriasis (HR 2.47; p < .001) were risk factors for skin infection.

Conclusion

SpA was associated with increased risk of UTI, skin infection, and septic arthritis. Infliximab, prolonged steroid therapy, smoking, and psoriasis were associated risk factors.
Elevated circulating myeloid‐derived suppressor cells associated with poor prognosis in B‐cell non‐Hodgkin's lymphoma patients
Authors: Wang Yangyang , Wang Jiyu , Zhu Fengfeng , Wang Huiping , Yi Liuying , Huang Keke , Zhai Zhimin
Published: April 2022

Introduction

Myeloid‐derived suppressor cells (MDSCs) are a heterogeneous cell population with the ability to suppress immune responses. MDSCs usually cluster in cancer, inflammation, and autoimmune diseases. Although there have been some studies on MDSCs in non‐Hodgkin lymphoma (NHL), the correlation between the peripheral levels of MDSCs in patients with various subtypes of B cell NHL and clinical features and prognosis remains inconclusive. This study aimed at the issue.

Methods

101 patients with B cell NHL and 15 age‐matched healthy controls were included in this study. Flow cytometric detection of monocytic‐MDSCs (M‐MDSCs) and granulocytic‐MDSCs (G‐MDSCs) was done.

Results

In this study, we found that counts of circulating M‐MDSCs and G‐MDSCs were significantly increased in different clinical statuses of B‐NHL patients compared to healthy controls. Similarly, a significant increase in the levels of M‐MDSCs and G‐MDSCs was found among the diverse types of B‐NHL compared with healthy donors. Stratification studies indicated MDSCs expansion was closely associated with disease progression (tumor stage, LDH levels and B syndromes). Moreover, the overall survival time of patients with G‐MDSCs (%) ≥ 98.70% was shorter than patients with G‐MDSCs (%) < 98.70% in newly diagnosed B‐NHL subgroup, meanwhile, there was a significant difference in survival of patients with M‐MDSCs (%) ≥ 7.19% compared to patients with M‐MDSCs (%) < 7.19% in relapsed B‐NHL subgroup.

Conclusion

Our results suggested that M‐MDSCs and G‐MDSCs may be a potential and efficient index to evaluate the prognosis of B‐NHL patients.
Cell‐free DNA as a biomarker after lung transplantation: A proof‐of‐concept study
Authors: Magnusson Jesper M. , Ricksten Anne , Dellgren Göran , Wasslavik Carina , Nordén Rickard , Westin Johan , Boehmer Jens
Published: April 2022

Background

Lung transplantation (LTx) is a lifesaving procedure burdened with limited long‐term survival. The most common cause of death after LTx is chronic lung allograft dysfunction (CLAD). Today, useful biomarkers for the detection of CLAD are lacking. Circulating cell‐free DNA (cfDNA) is released during cellular decay and can be detected using polymerase chain reaction (PCR). Thus, donor‐derived cfDNA in recipient serum indicates cellular decay in the transplanted organ. In the current study, we explore the possibility of using a novel PCR method to detect cfDNA as a biomarker for clinical events, especially CLAD.

Methods

Four patients were retrospectively tested for levels of both donor and recipient‐derived cfDNA using digital droplet PCR after targeted preamplification. The results were correlated to recorded clinical events.

Results

All available samples rendered results. Both patients that later developed CLAD showed a persistently elevated ratio between donor‐and recipient‐derived cfDNA. Also, the mean level of cfDNA was higher in the two patients who later developed CLAD than in patients who did not (p = .0015).

Conclusions

This proof‐of‐concept study suggests that cfDNA quantified with PCR may be used as a biomarker of significant clinical events such as CLAD.
Evaluating outcomes of a clinical pharmacist medication management program in a multidisciplinary practice for outpatient buprenorphine treatment of opioid use disorder
Authors: Mattle Anna G. , Aladeen Traci , Blondell Richard D. , Capote Horacio , Rainka Michelle
Published: April 2022

Introduction

Treatment with medications such as buprenorphine has been shown to improve outcomes of patients with opioid use disorder (OUD); however, there is still potential to optimize care. Clinical pharmacists may benefit OUD patient treatment by making individualized medication recommendations and enhancing care as part of a multidisciplinary team. This study evaluates a novel outpatient practice model that incorporates pharmacists to manage OUD patients.

Methods

A multi‐center retrospective study compared outcomes of a multidisciplinary practice with clinical pharmacists to a physician‐only practice. Primary outcomes were treatment retention and opioid relapse rate. Secondary outcomes included patient engagement with counseling, toxicology results, and buprenorphine nonadherence. Data were collected from 75 patient records from each practice for up to 1 year after starting treatment. In addition, a prospective, observational study was conducted to describe pharmacist interventions at the multidisciplinary practice. Twenty patients were followed for up to 1 year to characterize pharmacist recommendations and assess treatment retention and opioid relapse rates among other secondary measures.

Results

In the retrospective study, treatment retention did not differ between practices (P > .05) but multidisciplinary practice patients experienced fewer opioid relapse months (P < .05). Similar rates of engagement with counseling (P = 1) and follow‐up visits with illicit substance use (P > .05) were observed. More buprenorphine nonadherence was identified at the physician practice (P < .01). In the prospective study, pharmacist recommendations included buprenorphine regimen changes and the addition of new medications for un/undertreated conditions. Pharmacists provided care coordination, medication counseling, non‐pharmacologic recommendations, and counseling regarding future/alternative treatment options.

Conclusion

This study demonstrates the ability of a practice with clinical pharmacists to provide quality care to OUD patients in an outpatient setting. These results have implications for OUD treatment by expanding addiction services in this underserved patient population.
Continuous glucose monitoring shared medical appointments improve diabetes self‐efficacy and hemoglobin A1C
Authors: Simonyan Anahit R. , Isaacs Diana , Lekic Sanela , Blanchette Julia E. , Noe Dawn , Galloway Nicholas R.
Published: April 2022

Introduction

Diabetes self‐management education and support and professional continuous glucose monitoring (CGM) were combined into shared medical appointments (SMA) to provide care for people with diabetes. Although the individual components have evidence of efficacy, this combination has never been studied.

Objectives

The purpose of this study is to assess the impact of CGM SMA on diabetes self‐efficacy and hemoglobin A1C (A1C) in persons with diabetes.

Methods

Adults who attended a two‐part CGM SMA at a large academic medical center were included in this retrospective, pre‐post study. The CGM SMA incorporated diabetes education, peer support, and seven days of professional CGM. The primary outcome was change in diabetes self‐efficacy through a validated eight‐item Likert Scale instrument. Secondary objectives were changes in A1C, changes in diabetes medications, and type of planned lifestyle changes. Paired t tests were used to analyze change in A1C and diabetes self‐efficacy scores.

Results

A total of 171 participants were included in this analysis. Diabetes self‐efficacy scores increased by a mean of 1.63 ± 2.09 points (P < .001) out of 10 points maximum after participation in the two‐part CGM SMA. The A1C decreased by a mean of 0.80 ± 1.52% (P < .001), with a mean follow‐up A1C of 7.8 ± 1.60%. Those with an A1C > 8% (n = 101) experienced a decrease of 1.20%. Participants utilizing the unblinded device (n = 133) experienced a decrease in A1C by 0.75% compared with 1.0% in those that utilized a blinded device (n = 38). Most medication changes made in the CGM SMA were dosage adjustments and changes in administration time.

Conclusions

The CGM SMA is a novel practice model incorporating diabetes education, peer support, professional CGM, and interprofessional care that demonstrated improvements in diabetes self‐efficacy and A1C.
Educational program to improve hypertension knowledge by a community pharmacist in a rural district in Indonesia
Authors: Wulandari Ulinnuha A. , Kristina Susi A. , Chindavijak Busba , Chulavatnatol Suvatna , Nathisuwan Surakit
Published: April 2022

Introduction

Public health services in a rural area of Indonesia, which are often understaffed and overcrowded, may not be able to provide adequate patient education leading to poor control of hypertension.

Objectives

To assess whether a community‐based, structured patient education program provided by a community pharmacist can improve blood pressure in Indonesian hypertensive patients living in a rural area.

Method

A quasi‐experimental study was conducted during February‐April 2019 in Kranggan Sub‐district, Central Java Province, Indonesia. Hypertensive patients from the community health center were identified and recruited into intervention and control groups. The intervention group received a structured patient education program from a community pharmacist while the control group received regular follow‐ups from the health center. The main outcome measure was hypertension knowledge as assessed by the Hypertension Knowledge‐Level Scale (HK‐LS).

Results

A total of 96 patients were included in the study with 49 and 47 patients in the intervention and control groups, respectively. At week 8, patients in the intervention group had a significantly higher mean HK‐LS than the control groups (18.9 ± SD 2.9 vs 16.8 ± SD 3.7, respectively; P < .001). Significantly more patients in the intervention group had an increase in the Morisky Green Levine Adherence Scale (MGL) compared with the control group (38.8% vs 14.9%; P = .024). Significant reduction in blood pressure from baseline was also observed in the intervention group.

Conclusion

Community pharmacist's interventions led to a significant improvement in hypertension knowledge among hypertensive patients living in a rural area of Indonesia.
Clinicians' experiences and reflections from a health system cyberattack
Authors: Haase Krystal K. , Whitworth Maegan M. , Yalamanchili Kishore
Published: April 2022

Universal Health Services experienced a cyberattack in September 2020 that impacted all hospitals in their system. Nearly all computer systems that store and communicate patient care information were shut down to prevent malware propagation. The impact of this attack was magnified by the ongoing coronavirus disease 2019 (COVID‐19) pandemic. The objective of this paper is to describe the response of our intensive care unit (ICU) rounding team to the loss of all electronic health record (EHR) systems within our institution and to share lessons learned through the experience. Guidance is available on prevention of cyberattacks but does not effectively address the need to establish and train providers for alternative care mechanisms at the local level. Many providers and trainees have limited or no experience with manual patient care systems and had difficulty in transitioning to paper records, notes, and order writing. The transition also highlighted a number of unintended consequences that have occurred secondary to implementation and adaptation of EHRs over time. Institutional memory played a major role in addressing the crisis as providers who had utilized paper charting systems were more adaptive. Critical care pharmacists practicing as members of an integrated ICU health care team were an essential resource during the crisis, maintaining patient safety, assisting with order writing, troubleshooting medication issues, and providing education. The cyberattack provided an opportunity to re‐evaluate processes and procedures that have developed over time through the use of EHRs. The crisis magnified the importance of team‐based care and the integral role of the acute care clinical pharmacist.
Impact of team‐based pharmaceutical care on the humanistic outcomes among patients with long‐standing diabetes: An interim analysis of a randomized, controlled, multicenter study
Authors: Xu Yingqi , Gallagher Paul J. , Tan Cheryl W. Y. , Tsou Keith Y. K. , Tan David H. Y. , Ramaya Henry , Lee Joyce Y.‐C.
Published: April 2022

Introduction

Epidemiological studies have reported that diabetes‐related complications increase after 5 years of uncontrolled/suboptimal metabolic control. The risk of experiencing diabetes‐related microvascular diseases usually spike after 10 years of uncontrolled diabetes.

Objectives

The objective of this study was to evaluate the impact of team‐based pharmaceutical care on glycemic control, self‐care, diabetes‐dependent quality of life, and productivity loss in patients with long‐standing diabetes (≥5 years).

Methods

This was a prospective, multicenter, randomized, controlled study. Patients with a glycosylated hemoglobin (HbA1c) > 7%, long‐standing diabetes defined as having a disease duration of at least 5 years, and polypharmacy defined as taking 5 or more chronic medications were included in the study. Patients in the intervention arm received team‐based pharmaceutical care regularly while patients in the control arm received physician‐centered care. Patients' humanistic outcomes were followed for 6 months.

Results

A total of 248 patients (126 intervention and 122 control) were included in the study. In addition to improved glycemic control observed in the intervention arm (mean difference: 0.44%, P = .003, 95% confidence interval: [0.15, 0.73]), the intervention arm showed significant improvements in overall self‐care level (+0.36, 95% confidence interval: [0.01, 0.72], P = .045) and self‐monitoring of blood glucose (+1.87, 95% confidence interval: [1.00, 2.99], P < .001) compared with the control arm. There were no significant differences in the changes in diabetes‐associated quality of life and overall work impairment between the two arms. A significant difference in activity impairment (affected productivity in regular unpaid activity) between the two arms was found, with 43.3% impairment having occurred in the control group vs 27.9% in the intervention group (P = .047).

Conclusion

Team‐based pharmaceutical care significantly improved overall self‐care and glycemia without deteriorating quality of life and incurring productivity loss. Our findings highlighted the value of team‐based pharmaceutical care in managing diabetes‐experienced patients.
Research and scholarly methods: Systematic reviews
Authors: Sobieraj Diana M. , Baker William L.
Published: April 2022

Systematic reviews provide synthesized evidence to answer explicit research questions, using a transparent and reproducible process to minimize bias. Several guides are available to explain the in‐depth methods involved in conducting a systematic review and subsequent statistical analyses (meta‐analysis) if appropriate. Users of systematic reviews should consider the quality of the review prior to applying its evidence to practice, using a critical appraisal tool. While an in‐depth explanation of these methods is beyond the scope of this article, we present the critical steps of a systematic review and refer readers to these resources for further guidance.
Flight capacity drives circadian patterns of metabolic rate and alters resource dynamics
Authors: Stahlschmidt Zachary R.
Published: April 2022

Animals must acquire, use, and allocate resources, and this balancing act may be influenced by the circadian clock and life‐history strategy. Field (Gryllus) crickets exhibit two distinct life‐history strategies during early adulthood—flight‐capable females invest in flight muscle at a cost to ovary mass, whereas flight‐incapable females instead invest solely into ovaries. In female Gryllus lineaticeps, I investigated the role of life‐history strategy in resource (food) acquisition and allocation, and in circadian patterns of energy use. Flight capacity increased the standard metabolic rate (SMR) due to greater late‐day SMR and flight‐capable crickets exhibited greater circadian rhythmicity in SMR. Flight‐capable crickets also ate less food and were less efficient at converting ingested food into body or ovary mass. Thus, investment into flight capacity reduced fecundity and the amount of resources available for allocation to other life‐history traits. Given the increasing uncertainty of food availability in many global regions, work in Gryllus may clarify the important roles of food and circadian patterns in life‐history evolution in a changing world.
遅発性呼吸停止を来したグルホシネート中毒の1例(Delayed respiratory arrest after glufosinate toxicity: a case report)
Authors: (Hiroyuki Koami) 小網 博之 , (Yuichiro Sakamoto) 阪本 雄一郎 , (Hisashi Imahase) 今長谷 尚史 , (Mayuko Yahata) 八幡 真由子 , (Toru Miike) 三池 徹 , (Takashi Iwamura) 岩村 高志 , (Satoshi Inoue) 井上 聡
Published: April 2022

遅発性に呼吸停止を来したグルホシネート中毒を経験した。症例は62歳男性で，来院直前にグルホシネート含有除草剤（バスタ®）を数十mLに薄めて服毒後に頻回の下痢が出現したため当院に救急搬送された。来院時，血圧低下や低体温を呈し，腸蠕動が亢進していた以外に特記所見は認めなかった。服毒量は重症化の目安とされる液剤100mL以下と考えられたため，胃洗浄と活性炭の投与を行い救命センターに入院となった。第3病日（服毒後約47時間）に突然の呼吸停止を認め，人工呼吸管理を開始した。その後，徐々に自発呼吸が回復し，第7病日に抜管した。経過良好で第15病日に退院となった。なお，血中グルホシネート濃度は，来院時に122µg/mLと高値を認めたものの，6時間後には著明に低下し，第2病日と呼吸停止が出現した第3病日には検出限界以下となっていた。バスタ®を服用した場合，急性期には，界面活性剤による悪心・嘔吐，下剤といった消化器症状が出現し，グルホシネートによる意識障害や呼吸障害は服毒の4～60時間後に出現すると言われている。グルホシネート中毒の治療としては，重症例ならば予防的気管挿管も検討すべきだが，基本的には通常の薬物中毒に準じた対応が中心である。すなわち，この中毒では，重症例をいかに予測するかが重要であり，服毒量の確認とノモグラムを用いた血中濃度測定が推奨されている。しかし，服毒量の推定は誤差が大きいことや，血中濃度の測定ができる施設が限られていることなど，いまだ障壁が多い。本邦にて遅発性呼吸障害を来した15例の文献を考察したところ，高齢者に多く，服毒量や症状出現時期にはかなりばらつきが見られた。現時点では，たとえ服毒量が少なく全身状態が良好であっても，重症化する可能性を念頭におき，服毒後72時間は人工呼吸管理が可能な集中治療室で厳重に管理すべきである。
出血性ショックを伴う腹部刺創に対し，IABO併用下のDCS後に下腿コンパートメント症候群を呈した1例(A complicated case of lower leg compartment syndrome after damage control surgery (DCS) with intra–aortic balloon occlusion (IABO) for severe abdominal stab injury under severe hemorrhagic shock)
Authors: (Hiroshi Suginaka) 杉中 宏司 , (Yuichi Fukumoto) 福本 祐一 , (Nobuhiro Hayashi) 林 伸洋 , (Yuka Sumi) 角 由佳 , (Yoshiaki Inoue) 井上 貴昭 , (Ken Okamoto) 岡本 健 , (Hiroshi Tanaka) 田中 裕
Published: April 2022

腹部刺創による出血性ショック症例に対して，大動脈閉塞バルーンカテーテル（intra–aortic balloon occlusion; IABO），Damage Control Surgery（以下DCS）を施行後，下腿コンパートメント症候群（Lower Leg Compartment Syndrome; LLCS）を呈した1例を経験したので報告する。症例は43歳男性で，腹部を刺し倒れているところを発見され，当院に救急搬送された。来院時ショック状態を呈し，腹部超音波検査にてMorison窩に液体貯留を認め，外表上，腹部2ヶ所の刺創より腸管脱出を認めた。初期輸液に反応せず，気管挿管及び，右大腿動脈からIABOを挿入し，濃厚赤血球の急速輸血を開始した。来院から約35分で緊急開腹術を施行した。開腹すると，複数箇所の腸管損傷を認め，刺入創先端は後腹膜に達していた。可及的な腸管切除後，後腹膜部位からの出血のコントロールが困難となり，deadly triadを認めたため，ガーゼパッキングを実施して速やかに閉腹した。初回術後，Intra–abdominal pressure（以下IAP）は最高値40mmHgを示したため，abdominal compartment syndrome（以下ACS）と判断し，術後約24時間でsecond look operationを施行し，腸管吻合を実施した後，閉腹した。その後IAPは16mmHgまで速やかに改善した。しかし初回緊急手術から約48時間後，右下腿の色調変化と，下腿コンパートメント圧の上昇（最大80mmHg）を認めた。血清クレアチニンキナーゼ（CK）は62100IU/Lまで上昇した。右LLCSと診断し，減張切開を行い，速やかにコンパートメント圧は低下した。しかし一部筋壊死を認めたため，術後13日目に，壊死筋部のデブリードマンを要した。術後経過は良好で，第53病日に独歩退院した。本症例におけるLLCSの成因として，IABOやDCSに伴う下腿虚血・還流障害が一因と考えられた。
ドクターヘリにて対応したクマ外傷の10症例(Ten cases of bear–inflicted injuries attended by air ambulance (Doctor–Heli))
Authors: (Naoya Matsumoto) 松本 尚也 , (Koichi Hoshikawa) 星川 浩一 , (Shigenori Kan) 菅 重典 , (Yasuhiko Yamada) 山田 裕彦 , (Yoshihiro Inoue) 井上 義博 , (Shigeatsu Endo) 遠藤 重厚
Published: April 2022

【目的】岩手県では以前からクマ外傷が多発していた。クマ外傷は顔面外傷が多く，出血性ショックを合併することもある。そのため，初期治療開始までの時間が短縮され，さらに，治療可能な施設へ直接搬送が可能であるとされているドクターヘリの出動が効果的と考えられる。今回，岩手県ドクターヘリが過去2年間に対応したクマ外傷の10症例について報告する。【症例】ドクターヘリが対応した症例は10症例であった。発生場所は県内全域であり，10症例中6症例は山菜取りのために山に入った際の受傷であった。全例で顔面挫創を認め，合併症は上肢の外傷が最多であった。2症例で出血性ショックを合併していたが，死亡症例はなかった。全ての症例で現場から補液を行ったが，スキンステープラによる止血を行った症例もあった。搬送先は全て当センターであった。8症例が受傷当日に全身麻酔下に緊急手術となった。【考察】クマ外傷に対してドクターヘリが出動することにより，初期治療開始までの時間が短縮され，さらに治療可能な施設まで直接搬送することで，根治治療開始までの時間も短縮することができた。そのため，出血性ショック症例も救命し得たと考えられる。また，出血性ショックを未然に防いだ症例もあった可能性も考えられる。【結語】ドクターヘリにて対応したクマ外傷について報告した。クマ外傷に対してドクターヘリの出動は有用であると考えられた。
下顎骨関節突起骨折による活動性外耳道出血に合併した気道緊急の1例(A case of a respiratory tract emergency as a complication of active bleeding in the external auditory meatus due to fracture of the mandibular condyle)
Authors: (Masahiro Okashiro) 陵城 成浩 , (Takahisa Kawashima) 川嶋 隆久 , (Seishiro Marukawa) 丸川 征四郎 , (Atsushi Tanaka) 田中 敦 , (Souichiro Shibata) 柴田 宗一郎
Published: April 2022

82歳の男性。転倒で下顎を強打し，近院に救急搬送された。バイタルサインの異常や口腔内出血は認めなかったが，左外耳道からの活動性動脈性出血をコントロールできず，当院へ転院搬送となった。搬入時，バイタルサインは正常，口腔内出血など気道緊急となる所見はなかったが，左外耳道からの出血は継続していた。CT検査で両下顎骨関節突起骨折，下顎骨中央部の骨折および両外耳道骨折を認めた。血管造影を準備する間，左外耳道出血に対し外耳道内で直接圧迫することで，動脈性出血は止血し得たにもかかわらず，血管造影では後耳介動脈に血管外漏出像を認めた。血管造影直後に舌左側の腫大による気道緊急が出現し，緊急気管挿管を施行した。舌の腫大が消退した第5病日には抜管，第15病日に下顎骨の観血的整復術を施行し，第28病日に軽快退院となった。日常診療において，下顎強打による下顎骨関節突起骨折，外耳道骨折および外耳道出血はしばしば遭遇するが，自験例では，外耳道出血部の圧迫止血による二次的な舌腫大によって気道緊急に至った。顔面外傷においては，繰り返し気道の開通を確認することが肝要であると再認識した。
血栓溶解剤の胸腔内投与が奏功した外傷後の遺残血胸の1例(A case of successful treatment of post traumatic retained hemothorax with intrapleural fibrinolysis)
Authors: (Kantoku Nagakawa) 永川 寛徳 , (Akio Yanagi) 柳 明男 , (Masanori Kujo) 久城 正紀 , (Tsunehiro Matsubara) 松原 庸博 , (Go Yanase) 柳瀬 豪 , (Kazuhide Maetani) 前谷 和秀 , (Hirofumi Norio) 則尾 弘文
Published: April 2022

外傷後の遷延する遺残血胸に対し，血栓溶解剤の胸腔内投与が奏功した症例を経験した。症例は21歳の男性。バイク走行中に転倒し，左前胸部を打撲した。左内胸動脈損傷に対して経カテーテル的動脈塞栓術を行い，左血胸に対しては胸腔ドレーンを留置し，循環動態は安定した。しかしながら，ドレナージ不良の血胸が残存し，無気肺の改善も得られなかったため，胸腔内血栓溶解剤投与法を施行した。第25病日から3日間，ウロキナーゼ12万単位を生理食塩水100mLに溶解して胸腔内投与し，6時間後に胸腔内を生理食塩水1,000mLで洗浄した。洗浄で血性の排液を認め，投与終了後の胸部CTでは，遺残血胸・無気肺の著明な改善を認めた。合併症については，疼痛や凝固系異常も含め，特に認めなかった。難治性の遺残血胸に対する胸腔内血栓溶解療法は侵襲度が低く，かつ合併症も少ないと報告されており，手術治療に先行する治療法として検討する価値があると考える。
外傷後急性硬膜下血腫により明らかとなった急性リンパ性白血病の1例(A case of acute lymphocytic leukemia diagnosed during the treatment of acute subdural hematoma by traumatic head injury)
Authors: (Soichiro Takamiya) 高宮 宗一朗 , (Mineji Hayakawa) 早川 峰司 , (Asumi Mizugaki) 水柿 明日美 , (Kenichi Katabami) 方波見 謙一 , (Daisuke Miyamoto) 宮本 大輔 , (Kiyohiro Hokin) 寶金 清博 , (Satoshi Gando) 丸藤 哲
Published: April 2022

頭部外傷による急性硬膜下血腫の治療中に明らかになった急性リンパ性白血病の1例を報告する。患者は6歳の男児。頭部打撲後に嘔吐，意識障害を伴って当科に救急搬送された。搬入時，深昏睡，瞳孔不同などから頭蓋内出血を疑い，緊急気管挿管後に頭部CTを施行した。急性硬膜下血腫の診断で緊急穿頭血腫除去術および開頭血腫除去術を行った。術後経過は良好であったが，汎血球減少を認めたため骨髄生検を施行した。急性リンパ性白血病の診断となり，頭蓋形成術後に化学療法を開始し，寛解を得た．重症頭部外傷では，出血や輸血，炎症などにより採血データに修飾が加わり，受傷直後の白血病の鑑別は困難であるが，経時的な観察により感知可能である。また，頭蓋内出血を伴う白血病においては，その治療にあたり，中枢神経浸潤を考慮する必要がある。
外傷患者に対する病院前輸液の功罪(Merits and demerits of prehospital intravenous fluid administration for trauma patients)
Authors: (Shinsuke Onishi) 大西 新介 , (Akiko Oshiro) 大城 あき子 , (Takafumi Shimizu) 清水 隆文 , (Yuki Naito) 内藤 祐貴 , (Yuka Morishita) 森下 由香 , (Satoshi Nara) 奈良 理 , (Isao Takahashi) 高橋 功
Published: April 2022

【目的】外傷患者に対する病院前輸液が生命予後に与える影響は議論が分かれている。今回我々はショックを呈した外傷症例に対し，病院前輸液が来院時のfibrinogen値に与える影響と，ショックに対する改善効果を検討した。【対象】2010年4月から2014年10月までに当院へ搬送された18歳以上の外傷患者で現場にて出血性ショックであったものを対象とし後方視的に診療録調査を行い，病院前輸液施行群と非輸液群に分けて比較検討した。【結果】91例中，非輸液群が50例，輸液群が41例であった。fibrinogen値が200mg/dL未満となる予測因子を求めて多重ロジスティック回帰分析を施行したところ，病院前輸液の調整オッズ比が3.16（95%信頼区間:1.15–8.68）であった。一方，輸液群においては来院時収縮期血圧が有意に高く（非輸液群100.6±26.2mmHg vs 輸液群113.0±27.1mmHg），Base Deficitが有意に低かった（非輸液群4.4 [1.6–9.3] mmol/L vs 輸液群2.6 [0.6–4.7] mmol/L）。院内死亡率に有意差はなかったが，輸液群で低い傾向があった。【結語】病院前輸液はfibrinogen値を低下させる要因であったが，ショックとそれに伴う代謝性アシドーシスを抑制し，少なくとも生命予後を悪化させなかった。
脳浮腫の評価に定量的瞳孔計を用いた重症頭部外傷の1例(Pupillometry for the evaluation of brain edema following severe head trauma: a case report)
Authors: (Yohei Okada) 岡田 遥平 , (Sakiko Hiraki) 平木 咲子 , (Ryoji Iiduka) 飯塚 亮二 , (Wataru Ishii) 石井 亘 , (Hiromasa Narumiya) 成宮 博理 , (Makoto Kitamura) 北村 誠
Published: April 2022

瞳孔の異常所見は重症頭部外傷において予後予測因子となる重要な理学所見の一つである。瞳孔所見は，従来集中治療室ではペンライトを用いて肉眼で評価していた。しかし，近年近赤外線を用いた定量的瞳孔計が臨床で用いられるようになり，瞳孔収縮速度（以下CV）や，収縮率（以下%CH）といった指標で肉眼より正確かつ再現性を持って瞳孔径や光刺激に対する反応を評価できるといわれる。症例は20歳の女性。交通外傷で当院に救急搬送された。意識レベルはGCS（E1V2M5）8点で，左急性硬膜下血腫，左側頭部脳挫傷，外傷性くも膜下出血と診断され保存的治療の方針でICU入室にした。第7病日に瞳孔の左右差および%CH，CVの低値を認めた。頭部CTで脳浮腫の増悪による脳幹周囲の迂回槽の消失およびmidline shiftを認めたので，急性硬膜下血腫除去，減圧開頭術を行った。術中にICPセンサーを挿入し術後よりICPとCV，%CHのモニタリングを行った。術後時間経過とともにICPは徐々に低下しCV，%CHは上昇した。術後ICPモニタリングを開始したICU入室時からICPセンサーを抜去した第13病日までのICPと同時間帯の%CH，CVのデータを単回帰分析で検討すると負の相関関係にあることが示された［右%CH（r=0.612, p<0.01）, 左%CH（r=0.414, p<0.01）右CV（r=0.551, p<0.01）, 左CV（r=0.403, p<0.01）］。脳浮腫に伴う脳ヘルニア徴候として動眼神経の障害が起こると%CH，CVの低下が起こると考えられ，瞳孔計で測定した%CH，CVは脳浮腫との関連性が示された。しかし，%CH，CVは様々な因子に影響され本症例においてもばらつきが大きいため，臨床におけるモニタリングとしての有用性についてはさらなる検討が今後必要である。
S状結腸憩室穿通・後腹膜膿瘍が閉鎖管を経由して波及した大腿壊死性軟部組織感染症の1例(A case of necrotizing soft tissue infection of the thigh extended from a retropenitoneal abscess via the obturator canal originating in a penetrated sigmoid diverticulum)
Authors: (Yasuaki Ogino) 荻野 泰明 , (Motoki Fujita) 藤田 基 , (Masaki Todani) 戸谷 昌樹 , (Takashi Miyauchi) 宮内 崇 , (Kotaro Kaneda) 金田 浩太郎 , (Yasutaka Oda) 小田 泰崇 , (Ryosuke Tsuruta) 鶴田 良介
Published: April 2022

我々は，消化管穿通後の下肢の二次性壊死性軟部組織感染症（necrotizing soft tissue infection: NSTI）の1例を経験したので報告する。本症例では，後腹膜膿瘍から下肢への感染の波及に閉鎖管を経由していた。閉鎖管が感染波及経路となった下肢の二次性NSTI症例はこれまでほとんど報告されていない。74歳の女性が，2週間前から続く股関節痛の増悪により起立困難となり，当センターに転院した。CT検査で膀胱左側から左大腿にかけてガス像を伴う膿瘍を認めた。膿瘍形成の原因として消化管穿孔を疑ったが，恥骨近傍の膿瘍の穿刺ドレナージ排液に便の混入は認めず，確定診断は得られなかった。第2病日に左臀部から大腿にかけて腫脹・発赤・圧痛が出現したため，左大腿のNSTIと診断し，直ちに大腿の切開排膿，デブリードマンを行った。第3病日，恥骨近傍の膿瘍腔に挿入していたドレナージチューブより便の排出を認めたため，消化管穿通による骨盤内膿瘍と診断して緊急開腹術を施行した。S状結腸憩室が後腹膜へ穿通して後腹膜膿瘍を形成し，左閉鎖管へ波及していたため，穿通部結腸の切除と人工肛門の造設を行った。第17病日に再度，左大腿のデブリードマンを行い，その後全身状態が改善したため第128病日に前医へ転院した。消化管の後腹膜穿通は腹膜刺激症状が乏しいため，診断までに広範に感染が波及する可能性が高い。感染源の不明な下肢のNSTIにおいては，その原因として消化管穿孔を念頭に置く必要がある。
外傷学会分類Ia型骨盤骨折に直腸・膀胱損傷を合併した1例(The case of rectal and bladder injury associated with a Ia type pelvic fracture)
Authors: (Kosei Kunitatsu) 國立 晃成 , (Kentaro Ueda) 上田　 健太郎 , (Shinji Yamazoe) 山添 真志 , (Yu Kawazoe) 川副 友 , (Syuji Kawashima) 川嶋 秀治 , (Yasuhiro Iwasaki) 岩崎 安博 , (Seiya Kato) 加藤 正哉
Published: April 2022

安定型骨盤骨折（外傷分類Ia型）に直腸・膀胱損傷を合併した1例を経験した。症例は71歳の女性。バイク事故による骨盤骨折で血尿を認め，尿路損傷が疑われたため他院から転院搬送となった。当院到着時バイタルサインは安定し，右恥骨部に圧痛を認めたが会陰部に裂傷はなく，直腸指診では異常を認めなかった。腹部造影CTで右恥坐骨・仙骨骨折・骨盤部後腹膜腔に液体貯留を認めたが，造影剤の血管外漏出はなく保存的加療となった。第2病日，受傷32時間後に血圧低下を認めたが，CT再検で骨盤周囲の血腫増大はなく，直腸周囲の遊離ガス像も認めなかった。輸液療法，輸血療法を行ったがバイタルサインは不安定で，第3病日に直腸損傷による敗血症性ショックを疑い，大腸内視鏡検査を施行した。肛門縁から7cmの部位に約1cmの裂傷を認め，直腸損傷による後腹膜膿瘍と診断し緊急手術を施行した。損傷部直腸を切除し，Retzius腔，後腹膜腔を剥離したが，術前膀胱造影でリークを認めた膀胱損傷部は確認できず，全身状態も不安定であったため，人工肛門造設術・洗浄ドレナージを行い手術を終了した。術後は軽快傾向であったが尿溢流があり，第23病日に膀胱修復術，第48病日に尿管皮膚瘻を造設した。術後経過は良好で第78病日に軽快退院となった。本症例のように安定型骨盤骨折においても直腸損傷の合併を念頭に置き，後腹膜腔に液体貯留など異常所見を認めれば，大腸内視鏡などで損傷の有無を確認することが重要と考える。
Fibrocartilaginous embolismの病態が関与したと考えられる一過性の両下肢麻痺を来した1例(A case of transient paresis on the legs suspected due to the pathological state of fibrocartilaginous embolism)
Authors: (Go Makishi) 眞喜志 剛 , (Tohru Okanishi) 岡西 徹 , (Kenji Mineta) 峯田 健司 , (Hisashi Dote) 土手 尚 , (Daihachiro Suwa) 諏訪 大八郎 , (Takahiro Atsumi) 渥美 生弘 , (Shigeru Tanaka) 田中 茂
Published: April 2022

Fibrocartilaginous embolism（FCE）は稀な脊髄梗塞の原因の一つである。FCEは椎間板の成分が脊髄循環に侵入し，主に前脊髄動脈に塞栓を起こす。軽微な外傷によって発生しうるが，重大な神経障害を生ずる。FCEの病態は本邦ではあまり認知されていない。症例は10歳の女児で，倒立から転倒し，直後は無症状だったが，その1時間後から急速に進行する両下肢の筋力低下，異常感覚，膀胱直腸障害が出現したため来院した。magnetic resonance imaging（MRI）ではTh9から脊髄円錐に腫脹および髄内の異常信号が認められた。これらの所見はFCEの臨床診断基準に合致した。脊髄障害に対し，ステロイド投与およびリハビリテーションによって運動機能は回復し，18日目に自宅退院とした。退院時には軽度の膀胱直腸障害が残存していたが，10か月後にはすべての症状が消失した。本症例は軽微な外力を契機とした進行性の両下肢麻痺が認められ，MRIで典型的な脊髄腫脹および異常信号が認められたため，FCEによる脊髄梗塞と臨床診断した。急性発症で進行性の麻痺を呈する症例では，軽微な受傷機転であってもFCEを鑑別に挙げるべきである。