bluuebunny/crossref_metadata_2025_split huggingface dataset:
Implementation and evaluation of clinical pharmacy services through quality improvement in a Tertiary Hospital in Malawi
Authors: Dascanio Sarah A. , Nowa Samuel , Nicholas Simon , Kumwenda Hanna , Urick Benjamin Y. , Steeb David R. 
Published: April 2022

AbstractBackgroundClinical pharmacy services have been shown to improve patient outcomes, cost savings, and rational use of medications, yet there has been a slow transition from product‐focused to patient‐focused pharmacy practice in many low‐income countries.ObjectiveThe purpose of this study was to describe the implementation of a ward‐based clinical pharmacy program using quality improvement methods in a 1000‐bed tertiary hospital in Malawi and measure its associated impact on prescribing practices.MethodsThis was a post‐test only design with a nonequivalent control group evaluating the impact of a ward‐based clinical pharmacy program. The program was implemented in the female adult medical ward using 1‐month Plan‐Do‐Study‐Act cycles. Data were collected on the number of clinical pharmacy recommendations and acceptance rate. Outcome measures were collected in the intervention ward and a corresponding control ward and evaluated changes in prescribing habits across rational prescribing and antimicrobial prescribing. Data were collected over time and plotted on run charts. Logistic regression was used to examine differences in the trend in probability of rational prescribing and antimicrobial prescribing.ResultsOver 5 months, 321 clinical pharmacy recommendations were made and 67% were adopted by the medical team for implementation. For the intervention ward compared with the control ward, there was a significantly greater increase in probability of rational prescribing (P = .04), but no significant differences in antimicrobial prescribing (P = .48).ConclusionsThis study demonstrated a positive impact on rational prescribing as a result of ward‐based clinical pharmacy services in a low‐income country. This study can be used to inform development or improvement of clinical pharmacy services in other low‐income settings.
Cannabis education in United States Pharmacy Colleges and Schools
Authors: Kruger Daniel J. , Kruger Jessica S. , Bednarczyk Edward M. , Prescott William Allan 
Published: April 2022

AbstractIntroductionGiven the rapid change in legal status and rise in cannabis use within the United States (U.S.), pharmacists will increasingly require competence in issues related to cannabis, especially for medical use. Pharmacy students and professionals in other health fields report low levels of cannabis knowledge, and medical cannabis users report that their knowledge is mostly from their own experiences and the internet. Several pharmacy organizations have advocated for pharmacists' education on therapeutic and legal issues related to medical cannabis.ObjectivesTo determine the extent to which cannabis and its medical use are covered in the educational curricula of U.S. schools and colleges of pharmacy, plans for future coverage of medical cannabis, and differences by the state‐level legal status of cannabis.MethodsPharmacy schools and colleges located within the U.S. were identified via the Accreditation Council for Pharmacy Education website. A 19‐item survey was developed by researchers with experience in curriculum development and pharmaceutical issues related to cannabis. One individual from each school provided detailed information on the inclusion of medical cannabis/marijuana topics in their Doctor of Pharmacy program.ResultsTwo‐thirds (67%) of programs responded to the survey. Most programs (85.4%) had content on medical cannabis available in their curriculum, 53.1% in their required curriculum, 65.6% in their elective curriculum, and 33.0% in both their required and elective curricula. A small proportion (16.7%) had a stand‐alone medical cannabis elective course. Stand‐alone electives had the most comprehensive coverage of cannabis topics. General required and elective courses had minor differences in comprehensiveness.ConclusionResults demonstrate a moderately rapid expansion in cannabis coverage in pharmacy curricula, although coverage of cannabis topics is rarely comprehensive. Additional efforts are needed to integrate cannabis into coursework and experiential learning experiences.
Current and future state of quality metrics and performance indicators in comprehensive medication management for ambulatory care pharmacy practice
Authors: Clements Jennifer N. , Emmons Roshni P. , Anderson Sarah L. , Chow Marissa , Coon Scott , Irwin Adriane N. , Mukherjee S. Mimi , Sease Julie M. , Thrasher Kim , Witek Stephanie R. 
Published: April 2022

AbstractThe American College of Clinical Pharmacy (ACCP) 2011 publication “Tenets for Developing Quality Measures for Ambulatory Clinical Pharmacy Services” describes comprehensive, accountable, feasible, scientifically sound, and usable quality metrics for ambulatory care (AC) practice. ACCP endorsed the definition of comprehensive medication management (CMM) in 2014 and has since advocated consistent implementation of CMM in patient‐centered, team‐based care. Given the decade of changes and advances in AC practice since the 2011 publication, the 2020 ACCP Publications Committee has developed the present white paper to update quality metrics and provide performance indicators with proposed guidance for CMM in AC practice.
Perceptions regarding training across four domains of pharmacy practice: A survey of new pharmacist practitioners
Authors: Santibañez Melissa , Sedlacek Jordan , Parmar Jayesh 
Published: April 2022

AbstractIntroductionUpon completion of professional pharmacy studies, licensed pharmacists can pursue postgraduate pharmacy training (PGT), like residency and fellowship, further education, or enter the workforce. The perceived benefits and risks of PGT have been infrequently assessed for pharmacists several years removed from completion of all training and have generally focused on single domains of pharmacy practice.ObjectiveTo compare perceptions of new pharmacist practitioners on the quality, satisfaction, and mentorship received during their training across four domains: clinical skills, teaching, research, and leadership.MethodsThis was an observational, cross‐sectional study of new pharmacist practitioners, defined as U.S. pharmacy school graduates within the previous 10 years (2008‐2018). An Internet‐based survey instrument was developed, validated, and distributed using professional organization membership lists. Perceptions regarding quality, satisfaction, and mentorship during either PGT or pharmacy school rotations across the domains were assessed. Respondents were stratified based on the highest level of training, with a predefined ascending hierarchy of no PGT, then postgraduate year 1 (PGY1) residency, then PGY2 residency, and then fellowship. For the primary analysis in each domain, the Kruskal‐Wallis test was performed, and a post‐hoc Dunn's test was subsequently performed for any domain with an adjusted P‐value <.05.ResultsThe primary analysis included 193 respondents, 178 having completed PGT (92.2%) and 15 with no PGT (8.4%). Between‐group comparisons revealed significant differences in perceptions toward clinical skills and teaching training, driven by respondents who completed PGY2, and in research training, driven by respondents who completed fellowship. There was no significant difference in leadership training perceptions.ConclusionPerceptions regarding quality, satisfaction, and mentorship in clinical skills, teaching, and research training were significantly different among new pharmacist practitioners based on the highest level of PGT completed, but this was not observed for leadership training.
Climate care is health care: A call for collaborative pharmacy action
Authors: Gahbauer Alice , Gruenberg Katherine , Forrester Catherine , Saba Amir , Schauer Samuel , Fravel Michelle , Lam Ashley , Brock Tina 
Published: April 2022

AbstractClimate change and ecosystem degradation threaten human health and exacerbate pre‐existing social determinants of health. The prescription drug sector accounts for a significant portion of health care system contributions to greenhouse gas and waste production. Pharmacists are therefore well‐positioned to transform health care toward environmentally sustainable models; however, additional pharmacist education on climate mitigation and sustainable practice is needed. A team of practicing pharmacists and pharmacy students from the United States and Australia aimed to define pharmacists' roles in environmental stewardship by evaluating pre‐existing pharmacy‐led efforts in reducing waste, greenhouse gas emissions, and other health care‐associated environmental impacts. We also describe opportunities for education in pharmacist training as a means to enhance the profession's capacity for environmentally sustainable health care practice and leadership. Information on specific drugs' ecological footprints is increasingly available; pharmacists, as drug information experts, can incorporate sustainability considerations into their drug procurement and prescribing recommendations. Pharmacists also play a critical role in public education about environmentally responsible drug disposal. Finally, we suggest collaborative steps that U.S. organizations involved in pharmacy education could take to ensure that future “practice readiness” includes competence in sustainable health care practices.
Opioid use practices of kidney transplant centers in the United States: A national survey of institutional practices
Authors: Kim Hannah , Jarrett Jennie B. , Ingemi Amanda I. , Lichvar Alicia 
Published: April 2022

AbstractBackgroundThe opioid epidemic in the United States and the known risks of opioid utilization highlight the need for a better understanding of pain management around kidney transplantation. Although studies have been recently published describing efforts to minimize opioid therapy, clinical practices across the U.S. remain unknown.ObjectiveThe primary outcome of this study was to describe the programmatic use of opioids in the perioperative timeframe and upon discharge after kidney transplantation in the U.S.MethodsThis study was a cross‐sectional survey of transplant pharmacists to evaluate the national landscape of opioid management with regard to pretransplant candidacy, perioperative pain management, and posttransplant pain management. A 25‐question survey was distributed to members of transplant pharmacy listservs within the U.S. in March 2020.ResultsSixty‐three of 208 (30.3%) adult kidney transplant centers responded to the survey. The majority of institutions would actively list patients on an opioid (84.1%, 53/63) or medication for opioid use disorder (MOUD) (58.2%, 32/55). The majority of institutions (84%) utilized opioids for first‐line postoperative pain management in opioid‐naïve patients. More than half of the centers (55%) did not differentiate the postoperative pain regimen between opioid‐naïve and opioid‐experienced patients. A total of 72.6% of institutions prescribed opioids upon discharge from transplant, and 10.8% of the institutions prescribed subsequent opioid analgesics in the outpatient setting. Most (82.7%) of responders reported that their institutions did not have a written protocol or policy for posttransplant pain management.ConclusionThis survey highlights the existence of significant practice heterogeneity regarding opioid and MOUD utilization across kidney transplant programs in the U.S. Thus, transplant pharmacists have the opportunity within the context of their multidisciplinary team to develop multimodal pain management strategies to minimize opioid use while maintaining adequate pain control in kidney transplant candidates and recipients to continue to optimize patient care.
Divide and conquer: Feasibility and Impact of antimicrobial stewardship in a safety‐net community hospital after a syndrome‐based education initiative for pharmacists
Authors: Mena Lora Alfredo J. , Li Ella , Ali Mirza , Krill Candice , Spencer Sherrie , Takhsh Eden , Bleasdale Susan C 
Published: April 2022

AbstractIntroductionAntimicrobial stewardship programs (ASP) have been shown to reduce antimicrobial utilization (AU) and cost. ASP has been required by the Joint Commission for hospital accreditation since 2017. Community hospitals with limited pharmacy staffing and infectious diseases (ID)‐trained pharmacists may have barriers for implementing and sustaining comprehensive ASP.ObjectivesOur objective was to assess the feasibility and impact of syndrome‐based ASP training on pharmacist knowledge, perceptions, and AU in a community hospital with limited pharmacy staff.MethodsA quasi‐experimental study at a 151‐bed hospital was conducted. Pharmacist training on syndrome‐based guidelines was developed by an ID physician. A qualitative cross‐sectional survey to assess pharmacist knowledge and perceptions of ASP was administered before and 3 months after ASP training. Prospective audit and feedback (PAF) were deployed with responsibilities divided between shifts. The Centers for Disease Control and Prevention (CDC) checklist of core elements was done quarterly for 12 months. AU, Clostridium difficile rates, and cost were compared for 12 months before and after implementation.ResultsMost pharmacists did not feel comfortable managing infections before ASP training. All pharmacists found the guidelines helpful and felt more comfortable managing infections at 3 months. ASP was successfully deployed by dividing tasks between shifts. Days of therapy per 1000 patient days increased from 355.5 to 376. The proportion of parenteral antimicrobials decreased from 71% to 65%.Total antimicrobial expenditures decreased by 23%. C. difficile rates decreased by 21% (3.27 vs 2.56) per 10 000 patient days.ConclusionASP was successfully implemented in a safety‐net community hospital without ID‐trained pharmacists using a syndrome‐based education initiative. This strategy improved pharmacist knowledge and perceptions of ID syndromes and ASP. Dividing tasks between shifts can leverage existing resources to fulfill all core elements. Clear guidelines and access to an ID physician are necessary to develop materials and provide support for pharmacists without ID‐specific training and can help curb costs and optimize AU.
Association between Active Mobility Index and sarcopenia among Japanese community‐dwelling older adults
Authors: Kurita Satoshi , Doi Takehiko , Tsutsumimoto Kota , Nakakubo Sho , Kiuchi Yuto , Nishimoto Kazuhei , Shimada Hiroyuki 
Published: April 2022

AbstractBackgroundA physically active lifestyle, including physical and social activities, is needed to maintain muscle mass, strength, and physical performance. A large life space characterizes an active lifestyle, but the association between life space with physical and social activities and sarcopenia is unclear. This study aimed to examine the association between life space with physical and social activities, assessed using the Active Mobility Index (AMI), and sarcopenia in community‐dwelling Japanese older adults.MethodsThis study used a large, cross‐sectional cohort dataset from the National Center for Geriatrics and Gerontology‐Study of Geriatric Syndromes (NCGG‐SGS). Between 2013 and 2018, community‐dwelling Japanese adults aged ≥60 years participated in the NCGG‐SGS. Sarcopenia was identified by measuring muscle mass and strength based on the clinical definition. The secondary outcomes were sarcopenia indices, including lower muscle mass, lower muscle strength, and lower gait speed. AMI assessed life space with physical and social activities in each life space (distance from the respondent's home: <1, 1–10, or >10 km) during the past month by noting the frequency, primary purpose, type of transportation, interaction with others, and physical activity. The associations between quartile groups of AMI total, physical, and social scores and sarcopenia were examined using a logistic regression model.ResultsFrom all participants, 21 644 participants (age 73.5 ± 5.8 years, 54.7% female) were included in the analysis. The prevalence of sarcopenia was 4.1% (n = 894). For the AMI total score, referred to Q1 group, Q3 and Q4 groups were significantly associated with a reduced odds ratio (OR) of sarcopenia after adjusting for all covariates [adjusted OR (aOR) (95% confidence interval), Q3: 0.71 (0.57–0.89), Q4: 0.69 (0.55–0.87)]. Q3 and Q4 of the AMI physical score groups were also significantly associated with reduced OR of sarcopenia [Q3: 0.71 (0.57–0.89), Q4: 0.67 (0.54–0.84)]. For the AMI social score, only the Q4 group showed reduced OR for sarcopenia [0.79 (0.62–1.01)]. Q3 and Q4 of the AMI total score and physical score were associated with reduced OR of all sarcopenia indices (aOR 0.55–0.82, all P < 0.05), whereas Q4 of AMI social score was associated with all indices (aOR 0.85–0.81, all P < 0.05).ConclusionsThe extent of life space with physical activity was associated with sarcopenia in community‐dwelling older adults. A longitudinal study is needed to examine whether life space with physical and social activities affect the development of sarcopenia.
電撃性紫斑病に対麻痺を合併した肺炎球菌感染症の1例(A case of pneumococcal infection with paraplegia and purpura fulminans as complications)
Authors: (Kohei Ishikawa) 石川 浩平 , (Yoshiaki Inoue) 井上 貴昭 , (Yuka Sumi) 角 由佳 , (Shigeru Matsuda) 松田 繁 , (Ken Okamoto) 岡本 健 , (Hiroshi Tanaka) 田中 裕 
Published: April 2022

要旨脾摘後重症感染症（overwhelming post–splenectomy infection: OPSI）を来し，敗血症に至る症例は本邦でも散見される。OPSIの発症時期は脾摘後2年から38年までと様々であるが，一度罹患すると死亡率の高い疾患である。さらに脾摘後に髄膜炎や脊髄炎を来す症例が稀にみられる。我々は，脾臓摘出後10年目に肺炎球菌性髄膜炎，電撃性紫斑病を発症し，続発性脊髄炎より対麻痺を来した症例を経験したので報告する。患者は38歳の男性。28歳時に血小板減少性紫斑病に対して脾摘術を受けた。肺炎球菌ワクチンは未接種であった。前日からの発熱・倦怠感を主訴に近医を独歩受診し，感染源不明の重症感染症と診断され，精査加療目的に当科に転送された。入院当日，四肢に散在性紫斑と全身性硬直性痙攣を認め，髄膜炎の診断で人工呼吸管理など集中治療を開始した。敗血症からは速やかに回復し，第7病日に人工呼吸器を離脱したが，第11胸髄レベル以下の完全対麻痺を認めた。腰椎造影MRI検査所見から脊髄炎が考えられ，血液培養と尿培養から肺炎球菌を検出し，肺炎球菌性髄膜炎に続発した脊髄炎と診断した。抗生剤投与により速やかに髄膜炎所見は改善したが，ステロイドパルス療法を行うも完全対麻痺が残存した。第63病日にリハビリ目的に転院となった。脾臓摘出後の電撃性紫斑病発症時には，髄膜炎および脊髄炎の合併にも注意し，早期診断に努める必要がある。
大腸Crohn病の後腹膜穿通により骨盤腔から下肢に至る広範囲膿瘍を形成した1例(A case of Crohn’s disease complicated by a diffuse abscess extending from the retroperitoneum to the left crus)
Authors: (Masahito Tachi) 館 正仁 , (Hisaaki Kato) 加藤 久晶 , (Yoshito Tanaka) 田中 義人 , (Takahito Miyake) 三宅 喬人 , (Shiho Nakano) 中野 志保 , (Kazuhiro Yoshida) 吉田 和弘 , (Shinji Ogura) 小倉 真治 
Published: April 2022

要旨症例は54歳の男性。基礎疾患に大腸Crohn病と難治性痔瘻があり，ステロイド内服治療を受けていた。左大腿部の腫脹と疼痛を主訴に近医を受診したところ，CT検査で同部位にガス像を伴う膿瘍を認めたため，チューブドレナージを施行し，二次医療機関へ転院搬送された。同病院で，チューブドレナージの継続と抗菌薬投与が行われたが，膿瘍のさらなる進展を認めたため，当センターへ再転院搬送となった。当院来院時，急性期DIC診断基準スコア5点，acute physiology and chronic health evaluation（以下APACHE）IIスコア17点であった。CT検査では，S状結腸に後腹膜への穿通を疑う所見を2か所認め，左腸腰筋から骨盤腔，左大腿，左下腿の広範にガス像を伴う膿瘍腔を認めた。DICを合併した重症敗血症であり，緊急開腹ドレナージと横行結腸人工肛門造設術，左下肢開放ドレナージ術を直ちに行った。出血傾向を認めたため，S状結腸穿通部に対しては全身状態の改善した入院3日目にS状結腸切除術を実施した。その後は下肢の開放ドレナージを継続し，入院13，22日目に創部の一部縫合と植皮を行い，同40日目にリハビリテーション目的で転院となった。大腸Crohn病の後腹膜穿通により，骨盤腔から下腿に至る広範な膿瘍を形成した例は稀であり報告する。
自己転倒により発症した左横隔膜破裂の1例(Left diaphragmatic rupture due to a fall: case report)
Authors: (Yoshizumi Deguchi) 出口 善純 , (Takayuki Sato) 佐藤 孝幸 , (Hiroyasu Suga) 須賀 弘泰 , (Takao Nakagawa) 中川 隆雄 , (Eiji Isotani) 磯谷 栄二 
Published: April 2022

要旨自己転倒で発症した外傷性横隔膜破裂を経験したので報告する。症例は93歳，女性。老人施設に入所中。2013年9月に発熱，呼吸苦を主訴に救急搬送された。胸部CTで左胸腔内に胃，小腸を認め，左下葉が圧排され無気肺を呈しており，横隔膜破裂と診断した。1週間ほど前に施設内で自己転倒し胸部を打撲，近医受診し胸骨骨折の疑いと診断されたという。外傷性横隔膜破裂の唯一の治療法は手術である。横隔膜の修復術は容易でありながら放置すると増悪し致死的であるため，全症例で緊急手術の適応となる。上腹部正中切開で開腹すると左横隔膜の腱中心に前後に約7cm長の破裂部位を認め，胃，大網の一部，大腸が胸腔内に脱出していたため，直視下にヘルニア門を縫合閉鎖し手術を終了した。横隔膜破裂の症状としては胸痛，呼吸困難，腹痛などを訴えることが多い。しかし本症例は認知症を有する超高齢者であり病歴聴取が困難で，強い円背により理学的所見も不明瞭だったため受傷時の確定診断が困難だったと考えられる。外傷性横隔膜破裂は交通事故や転落事故が原因で多発外傷の形態をとることが多いが，本症例では施設内転倒以外は目立った外傷の既往がなく，その他の合併損傷も認めなかった。小柄な超高齢者であるために横隔膜の組織が脆弱で転倒程度の外力で損傷したものと思われた。
集中治療室のない病院における医師の重症患者管理に対する意識調査(An attitude survey on doctors treating critically ill patients in hospitals without ICU facilities)
Authors: (Yoshiaki Iwashita) 岩下 義明 , (Masamitsu Sanui) 讃井 將満 , (Hiroshi Imai) 今井 寛 
Published: April 2022

要旨【目的】本邦の一般病床数あたりの集中治療室（ICU）病床数は諸外国に比べ少なく，重症患者がICUのない病院で管理されている。しかし，その実態を示すデータはほとんどない。本研究の目的は，ICUのない病院における重症患者対応，高次施設への転送，その他診療上の問題に関する医師の意識を調査することである。【方法】医師を対象に施設や属性を限定しない無記名アンケート調査を行い，ICUの有無で回答を比較した。【結果】1,025名から回答があり，そのうち651名（63.5%）がICUのない病院に勤務していた。ICUのある病院と比べその頻度は低いものの，ICUのない病院勤務の医師のうち65名（10%）が年間11名以上の人工呼吸器装着患者を診療していた（p<0.01）。ICUのない病院に勤務する医師のうち523名（80.3%）が重症患者管理に不安を感じていると答え，その割合はICUのある病院と同程度であったが，ICUのない病院で管理上の困難さや専門医の不在を指摘する医師が多かった（p<0.01）。ICUのない病院の医師のうち，転院させる重症患者の割合は半数以下と回答した医師は298名（45.8%）にのぼった。【結語】医師に対する意識調査により，ICUのない病院にも重症患者が入院し，不安や困難を感じているが，転院は多くないことが示された。この結果が患者の予後にどのように影響するか，さらなる調査が必要である。
換気障害と肝酵素の異常高値を呈した鈍的外傷性右横隔膜破裂の1例(Ventilation failures and high liver enzymes following blunt trauma are signs of right diaphragm ruptures: a case report)
Authors: (Keiko Ohashi) 大橋 景子 , (Akinori Osuka) 大須賀 章倫 , (Kazuhiro Yoneda) 米田 和弘 , (Shinya Onishi) 大西 伸也 , (Hiroshi Matsuura) 松浦 裕司 , (Daiki Miyao) 宮尾 大樹 , (Masashi Ueyama) 上山 昌史 
Published: April 2022

要旨外傷性右横隔膜損傷は稀であり，確定診断が困難とされている。今回，右肺の換気障害，肝酵素の異常高値および心外閉塞性ショックを呈し，絞扼性肝ヘルニアを伴う外傷性右横隔膜破裂を経験した。症例は28歳男性，交通事故を契機にショック状態となり当院へ搬入された。胸部X線写真（臥位）で右血胸および右横隔膜挙上を認めた。胸部超音波検査で右横隔膜と肝臓が右胸腔方向へ挙上していた。CT画像では，右横隔膜・肝臓の挙上に加え，右横隔膜の不連続性や右横隔膜破裂を疑う所見を認めた。右胸腔ドレーン挿入するも，AaDO2の開大を伴う低酸素血症が遷延し，血液生化学検査所見でCT所見では説明のつかない著しい肝酵素の上昇を認めた。これらの所見より外傷性右横隔膜破裂・絞扼性肝ヘルニアと診断し，緊急で右横隔膜破裂修復術を施行した。術後は経過良好であり，術後2日後のCTで右横隔膜に嵌頓していた肝臓に三日月状の造影不良域を認めた。外傷性右横隔膜損傷の診断は困難であるが，本症例では特徴的な画像所見だけでなく，換気障害やCT所見からは説明がつかない著しい肝酵素の上昇，循環血液量を補正しても残存する心外閉塞性ショックという右横隔膜破裂に関連する病態を捉え，術前に診断することが可能であった。
救急医療における終末期症例登録の解析結果について－日本救急医学会委員会報告(End of life practices with critical care patients in Japan)
Authors: (Yoshihiro Kinoshita) 木下 順弘 , (Toru Aruga) 有賀 徹 , (Hiroyuki Yokota) 横田 裕行 , (Kaoru Koike) 小池 薫 
Published: April 2022

要旨日本救急医学会「救急医療における終末期医療のあり方に関する特別委員会」は「救急医療における終末期医療に関する提言（ガイドライン）」の初版を2007年に公表した。同委員会の活動の一環として，本提言が臨床現場でどのように活用されているかを調査するため，会員医師を対象に，2010～2016年にかけて学会のHP上で，終末期に該当した自験例の登録を呼びかけ，会員の任意により159例が登録された。年齢では80歳代が44例と最も多く，70歳代が次に多かった。疾病分類では脳・神経が最多で，呼吸器系，CPA蘇生後，MOF，消化器系となり，内因性疾患が大多数であった。終末期と判断された理由は全脳機能不全が59%で最多であった。人工呼吸器は76%に装着され，カテコラミンは47%に使用されていた。患者本人の事前指示があったのは3例のみで，残りは不明もしくは指示なしであった。選択された治療方針はwithdraw 31%とwithhold 36%，DNR 25%で，医療チームの提案と家族の希望はおよそ8割で一致していた。会員の協力により，救急医療における終末期医療の実態を調査し，初めて報告した。終末期ガイドラインは救急，集中治療，循環器の3学会合同に進化した。終末期医療についてより詳細で正確な調査が行われ，公表されることが期待される。
ミノサイクリンによる薬剤性肺障害とダニ媒介性感染症の鑑別にダニの同定と媒介能評価が有効であった1例(A difficult distinction: a case of drug–induced pneumonitis or a tick–borne infection with lung involvement?)
Authors: (Yugo Soga) 曽我 雄吾 , (Tatsuo Takama) 高間 辰雄 , (Koki Umeda) 梅田 幸希 , (Ryota Kuroda) 黒田 亮太 , (Michiaki Kaku) 賀久 道明 , (Shinji Yotumoto) 四元 真司 , (Yoshihiko Sakamoto) 坂本 喜彦 
Published: April 2022

要旨今回，ダニ媒介性感染症による肺病変と薬剤性肺障害の鑑別に難渋し，刺咬したダニの形態学的評価と媒介能を検討し診断の一助とした症例を経験した。症例は50歳の男性。マダニ刺咬後にミノサイクリンの経口投与を開始された。2週間後に発熱，呼吸困難感を認め当院受診。紅斑はなく，好酸球の軽度増多を伴う白血球数の上昇とCRPの上昇，両側肺に非区域性のすりガラス陰影を認め，ミノサイクリンによる薬剤性肺障害とダニ媒介性感染症による肺病変が考えられた。画像上，両者の鑑別は困難であったため，ダニの同定とその媒介能の評価を各種検査と並行して行い，診断することとした。患者が持参したダニはタカサゴキララマダニであり，その媒介能から重症熱性血小板減少症候群（severe fever with thrombocytopenia syndrome，以下SFTS）と日本紅斑熱による急性呼吸窮迫症候群の可能性は否定できないため，精査を行った。SFTSウイルス，Rickettsia japonicaはいずれも陰性であり，薬剤性障害と判断し薬剤を中止したところ，症状と肺病変の消失を認めた。臨床医と研究者との緊密な連携による，ダニの同定とその媒介能の評価がダニ媒介性感染症の鑑別に有用であった。今後は両者による知見の集積を行い，より正確な媒介能の評価を行うことが重要である。
腸管と腸内微小生態系の変化が重症病態に及ぼす役割(Crucial effects of an altered gut and intestinal micro–ecosystem in critically ill patients)
Authors: (Akinori Osuka) 大須賀 章倫 , (Kazuhiro Yoneda) 米田 和弘 , (Daisuke Kudo) 工藤 大介 , (Kentaro Shimizu) 清水 健太郎 , (Hiroshi Ogura) 小倉 裕司 
Published: April 2022

要旨腸管が多臓器不全を引き起こす“motor”である，という仮説は30年程前から提唱されてきた。腸管は生体内にありながら生体外と接し，常に病原菌にさらされている。腸管には生体のリンパ球のおよそ80%が存在し，常に腸管内容物を監視し，免疫寛容と異物排除の両面の役割を担っている。重症病態では腸管上皮細胞のアポトーシスの進行，タイトジャンクションの脆弱化，粘液の減少などにより腸管のバリア機能が崩壊する。さらに腸内細菌叢は多様性を失い，常在細菌叢は消失して病原微生物が異常増殖する。この微生物叢の変化はdysbiosisと呼ばれる。これらの病原菌，または毒素は崩壊したバリアを超え，生体の全身状態にも様々な影響を及ぼす。近年，メタゲノム解析技術の進歩に伴い，腸内細菌叢を含む腸内微小環境に注目が集まり，dysbiosisが生体に及ぼす影響が明らかになりつつある。腸内微生物環境がヒトの健康に与える影響は大きく，微生物叢と生体との間のホメオスタシスの破綻が各種病態を引き起こす。集中治療領域では急性肺障害，急性腎障害，肝機能障害，不穏などとの関連性が指摘されるが，現在のところdysbiosisに対する標準治療は存在しない。本総説では，高度侵襲による腸管と腸内微小生態系の破綻のメカニズムとそれが生体に及ぼす影響，さらに現行の治療法とその限界を概説し，腸管および腸内微小生態系を“積極的に”保護する治療戦略をまとめる。