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ハンカイ シンケイ ドウテイ ニ NIMシステム オ モチイタ Zenkerケイシツ ノ 1レイ
Get PDFZenker憩室はKillian’s間隙に発生した憩室であり，全消化管憩室の0.1%の頻度と稀である．今回われわれは，術中神経モニタリングシステムであるNIMシステム(NERVE INTEGRITY MONITORING SYSTEM；以下，NIMと略記)をZenker憩室の手術で使用し，反回神経を容易に同定することが可能であったので報告する．
症例は67歳，女性．数年前から咽頭部の違和感を自覚し，２カ月前から増悪したため当院外来を受診した．精査の結果，症状を認めるZenker憩室と診断し，手術を施行した．NIMを使用して反回神経の走行を確認しつつ憩室を同定した．憩室を切除後，二層縫合(Albert-Lembert吻合)して閉鎖した．術中内視鏡検査を施行し，食道に狭窄や漏れがないことを確認した．輪状咽頭筋切開を追加し，甲状腺を縫合部の前面で固定して縫合部を補強した．ドレーンを留置して手術を終了した．術後経過は良好で手術から14日目に退院とし，退院後１ヶ月の時点で症状は改善していることを確認した．
Zenker憩室の手術で反回神経損傷は回避すべき合併症のひとつである．甲状腺手術で使用するNIMはZenker憩室の手術においても反回神経の同定に使用することで，神経損傷のリスクを下げる可能性がある．Zenker’s diverticulum is a diverticulum that develops in the Killian’s gap. The frequency of its occurrence is 0.1% of all digestive tract diverticulum. The present study reports that the NIM system can be useful during Zenker’s diverticulum surgery for easily identifying recurrent laryngeal nerve.
The present case is of a 67-year-old woman. She was aware of discomfort in her pharyngeal region for several years. She had been aggrieved for the past 2 months, and therefore was admitted to our hospital’s outpatient clinic. Following examination, we diagnosed Zenker’s diverticulum and performed surgery. We identified recurrent laryngeal nerve using NIM. We dissected the diverticulum and sutured in layers and closed. Intraoperative endoscopy was performed to confirm that there was no stenosis or leakage in the esophagus. We performed ring pharyngeal muscle incision. We fixed the thyroid gland in front of the suture to reinforce it. There was no untoward event postoperatively, and the patient was discharged from the hospital on day 14 after the surgery. We confirmed that the symptom had improved at 1 month after discharge.
NIM used in thyroid surgery is also useful in identifying the recurrent laryngeal nerve during Zenker’s diverticula surgery and may help reduce the risk of nerve damage.departmental bulletin pape
ニューロン ノ ゲノム ノ タヨウセイ
Get PDF組織の再生が極めて限定的な脳では、胎生期から出生後の早い時期にかけて産生された1つ1つのニューロンは個体の生涯を通じて神経ネットワークの中で機能し続ける。脳は膨大かつ多様なニューロンから成っており、一つとして同じ形態や機能を持つニューロンは存在しない。ニューロンではゲノムにも多様性が報告されてきた。染色体数の異常とゲノムDNA配列の突然変異に加え、ニューロンの多様性を作るためのゲノムの積極的な再構成もある。発生期にゲノム異常を持ったニューロンが多く生じるが、それ以降にもニューロンのゲノムは常に不安定な状態にある。そのため脳内でニューロンがゲノムの観点からモザイク状であることは一般的である。複雑な脳機能を担うニューロンにとってゲノムの多様性は重要であり、ヒトでは個性などを生じる原因と考えられる。一方で脳の発生やニューロンの機能に関わる遺伝子に起こるde novo変異が神経発達障害や神経変性症に関与していることが示唆されている。脳では少数もしくは1集団のニューロンに起こるde novo変異でもネットワーク全体の機能に影響を与える可能性があり、近年では脳に起こるde novo変異と神経発達障害の関連が大規模なゲノム解析によって調査されている。個々のニューロンに起きるゲノム変異の広汎な調査によって、神経発達障害や神経変性症の孤発性発症の原因が明らかになることが期待される。Because tissue regeneration is highly restricted in the human brain, the neurons born in the fetal and neonatal periods have extreme longevity. The brain is consisted of huge number of various neurons. Variations in the neuron have been reported in its genome. Such variations include microscopic abnormalities of chromosomes, copy number variations, and single nucleotide mutations. Addition to these, developmentally regulated DNA sequence rearrangements were also reported. During early stage of the brain development, rapid production of neurons causes accidental abnormalities in chromosomes and genome sequence frequently. Mutations in the neuronal genome occur in the mature brain. Thus, generally the brain exhibits variation in the neuronal genome. This mosaicism is suggested to be important for complicated brain functions and contribute to differences of individuals, such as personalities and health indices. Because it is possible that a mutation in the genome of one neuron or a group of neurons affects neuronal network functions, large scale investigations of de novo mutations in the brain are ongoing recently. These efforts are expected to find relationships between variations in the genome of neurons and sporadic neurodevelopmental and neurodegenerative disorders.departmental bulletin pape
Location of the False Lumen Within the Medial Layer in Acute Intramural Hematoma.
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We compared the location of the false lumen within the medial layer between acute intramural hematoma (AIH) and acute aortic dissection (AAD) using microscopic images of aortic specimens and examined the associations with patient characteristics, CT findings, and late outcomes.Methods and Results: Among 293 patients undergoing surgery for Stanford type A acute aortic syndrome between 2008 and 2018, 45 patients had neither an identifiable intimal tear, flow to the false lumen on preoperative CT or intimal tear by intraoperative observation (AIH group), and 98 patients with patent false lumen were enrolled (AAD group). The AIH group had a significantly thinner outer media thickness (OMT) than the AAD group. The AIH group showed more pericardial effusion, but distal progression of dissection and branch vessel involvement were limited. The change in aortic diameter after surgery was insignificant in the AIH group, whereas in the AAD group it continued to increase. Cumulative incidence of aortic adverse events was significantly higher among AAD patients, but no significant difference was observed in survival between groups.Conclusions:
The AIH group had a significantly thinner OMT than the AAD group, which was significantly associated with a large amount of pericardial effusion, greater false lumen diameter, and limited progression of aortic dissection.Journal Articlejournal articl
Limited cutaneous systemic sclerosis with myositis showing drug-induced liver injury and thrombotic microangiopathy.
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ガクホウ センキンショウ ノ チリョウチュウ ニ DIC オヨビ ジョウブ ショウカカン シュッケツ オ ヘイハツシタ イチレイ
Get PDF顎放線菌症の治療中に播種性血管内凝固症候群(Disseminated Intravascular Coagulation：DIC)および上部消化管出血を併発した症例を報告する. 患者は89歳女性. 2021年10月中旬に左側下顎8部歯肉の排膿および左側頬部腫脹のため当科を紹介受診した. 初診時, 著しい開口障害と左側頬部腫脹および疼痛を認め, 左側下顎8番智歯周囲炎および左側頬部蜂窩織炎と診断した. その後, 切開排膿時に採取した膿の細菌検査にてActinomyces meyeriおよびその菌塊が検出されたため, 顎放線菌症と最終診断した. 処置および経過：初診日に入院し, 入院3日目の血液検査にて血小板数の低値およびFDP, アンチトロンビン, TATの高値を認め, 日本血栓止血学会の定める診断基準より感染症型DICと診断した. 入院4日目に口腔外切開排膿術およびメロペネム投与を開始し，入院11日目に感染症型DICからの離脱を認めた. また入院9日目より顎放線菌症に対しスルバシリン3.0 g /日を15日間静脈内投与し左側頬部腫脹の軽減を認めていたが, 入院18日目に吐血と著しい貧血を認め内視鏡検査にて上部消化管出血と診断しクリッピングおよび焼灼止血を行い止血した. その後全身状態および開口障害と左側頬部腫脹の改善を認めたため入院43日目に軽快退院となった.Actinomycosis of the jaw, which is slightly rare disease at the oral and maxillofacial region, progress to the disseminated intravascular coagulation irregularly. Here, we report a rare case of the actinomycosis of the jaw complicated with disseminated intravascular coagulation (DIC) accompanied by intestinal hemorrhage. The patient was an 89-years-old woman who had the swelling of the left buccal region and lower-left mandibular gingiva. Above the findings of imaging and bacteriological examination, diagnosis of the actinomycosis of the jaw was made. During antibacterial treatment, her general condition deteriorated rapidly, and the blood test results met the diagnostic criteria of DIC. Moreover, the hematemesis and significant anemia developed during the intensive care, and endoscopy findings showed the hemorrhage at the greater curvature of stomach. Watchful general care should be needed during treatment actinomycosis of the jaw, in particular, affect the elderly.departmental bulletin pape
Autoimmune Gastritis with a Long-term Course of Type B Gastritis : A Report of Two Cases
Get PDFapplication/pdfutoimmune gastritis (AIG) typically exhibits the characteristics of type A gastritis and has been classified as a separate disease from type B gastritis that corresponds to Helicobacter pylori gastritis. However, many reports have suggested the involvement of H. pylori infection in the pathogenesis of AIG. In our two cases, the patients' previous gastritis exhibited a clear pattern in which H. pylori gastritis had progressed over many years, but ultimately transitioned to AIG with its spontaneous disappearance. These findings suggest that some cases of AIG might originate from long-standing H. pylori gastritis.Journal Articlejournal articl
Indication Criteria of Hysteroscopic Surgery for Secondary Infertility due to Symptomatic Cesarean Scar Defect Based on Clinical Outcomes : A Retrospective Cohort Study.
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Hysteroscopic surgery criteria for patients with cesarean scar defect (CSD) are unclear. Therefore, this study aimed to explore the indication of hysteroscopic surgery for secondary infertility owing to CSD.Design:
Retrospective cohort study.Setting:
Single university hospital.Patients:
Seventy patients with secondary infertility owing to symptomatic CSD who underwent hysteroscopic surgery under laparoscopy between July 2014 and February 2022 were included.Interventions:
Clinical data, including basic patient information, preoperative residual myometrial thickness (RMT), and postoperative pregnancy status, were collected from medical records. Patients were divided into postoperative pregnancy and nonpregnancy groups. A receiver operating characteristic curve was drawn, and the optimal cutoff value was calculated based on the area under the curve to predict pregnancy after hysteroscopic surgery.Measurements and main results:
No complications were observed in any cases. Among the 70 patients, 49 patients (70%) became pregnant after hysteroscopic surgery. There was no significant difference in patient characteristics between the pregnancy and nonpregnancy groups. In the receiver operating characteristic curve analysis for patients aged <38 years, the value of the area under the curve was 0.77 (sensitivity, 0.83; specificity, 0.78) when optimal cutoff of RMT was 2.2 mm. There was a significant difference in preoperative RMT between the pregnancy and nonpregnancy groups (3.3 mm and 1.7 mm, respectively) in patients aged <38 years.Conclusion:
For RMT ≥2.2 mm, hysteroscopic surgery was reasonable for secondary infertility owing to symptomatic CSD, particularly in patients aged <38 years.Journal Articlejournal articl
Affecting Factors of Prostate Volume in Forensic Autopsied Decedents
Get PDFapplication/pdfBecause decedents undergoing forensic autopsies would have behaved normally before death, prostate volume according to age group can be confirmed with forensic autopsy materials. The objectives of this study were to first confirm the current prostate volume by age and then determine diseases that can influence prostate volume using forensic autopsy materials. Prostate specimens were collected from forensic autopsies performed at Shiga University of Medical Science, Japan, between January 2015 and December 2019. Overall, 207 decedents were included in the study. Prostate volume was measured by the Archimedes' principle. Concomitant diseases were determined by the past medical histories and autopsy results. The mean crude prostate volume was 29.1 ± 10.3 mL (range, 2.8-88.0 mL). The crude prostate volume increased with age. The mean corrected prostate volume (divided by body surface area) was significantly higher in patients with atherosclerosis than in those without. However, multiple regression analysis revealed that only age influenced the corrected prostate volume. Age was the only significant influencing factor for prostate volume. We propose applying age estimation using prostate volume for forensic medicine purposes. Because prostate volume was not influenced by concomitant disease, it would be valuable to estimate the decedent's age using the prostate volume.Journal Articlejournal articl
Prevalence, definition, and etiology of cesarean scar defect and treatment of cesarean scar disorder : A narrative review
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Cesarean scar defects (CSD) are caused by cesarean sections and cause various symptoms. Although there has been no previous consensus on the name of this condition for a long time, it has been named cesarean scar disorder (CSDi).
Methods:
This review summarizes the definition, prevalence, and etiology of CSD, as well as the pathophysiology and treatment of CSDi. We focused on surgical therapy and examined the effects and procedures of laparoscopy, hysteroscopy, and transvaginal surgery.
Main findings:
The definition of CSD was proposed as an anechoic lesion with a depth of at least 2 mm because of the varied prevalence, owing to the lack of consensus. CSD incidence depends on the number of times, procedure, and situation of cesarean sections. Histopathological findings in CSD are fibrosis and adenomyosis, and chronic inflammation in the uterine and pelvic cavities decreases fertility in women with CSDi. Although the surgical procedures are not standardized, laparoscopic, hysteroscopic, and transvaginal surgeries are effective.
Conclusion:
The cause and pathology of CSDi are becoming clear. However, there is variability in the prevalence and treatment strategies. Therefore, it is necessary to conduct further studies using the same definitions.journal articl
看護師特定行為研修における研修教育・支援を考える－ろう孔管理関連（胃ろうカテーテル若しくは腸ろうカテーテル又は胃ろうボタンの交換）について－
Get PDF滋賀医科大学修士（看護学）application/pdfThesis or Dissertation令和4年度thesi