Dokkyo Medical University Repository / 獨協医科大学リポジトリ
Not a member yet
2844 research outputs found
Sort by
Food Allergy in Childhood
Get PDF食物アレルギーの診療は日々進歩し，以前は完全除去が基本であった．しかし，近年は安全摂取量の範囲内での摂取が推奨されるように変わってきている．また，アレルゲンコンポーネントを用いた診断技術の発展とともに，感作の原因や管理上の注意点など様々な知見が明らかになった．医療者にとって心構えの基本であるが，常に知識を新しくしなければいけない分野の一つになっている．本稿では，アレルゲンコンポーネントをどのように実臨床へ活かしていくか，モモや小麦の食物アレルギーを例として紹介する．アレルゲンコンポーネントの知見が増える一方で，特異IgE抗体が関与しない消化管アレルギーの症例も増加傾向にある．本疾患の概念は，『食物アレルギーの診療の手引き2023』で整理されたが，未だ治癒まで除去を継続する以外に治療の方法はなく，知見を蓄積していかなければいけない．対照的な管理を要する即時型症状は，安全摂取量の範囲で摂取を継続することが治療のひとつであるが，それも困難な重症例が存在する．そうした症例への対応として，舌下投与を併用することで良好な経過をたどる症例もある．今後も知見を積み重ね，新たな治療の可能性を広げていく必要がある．journal articl
Health Challenges and Contributing Factors for Women in the Medical Field： A Cross-sectional Observational Study
Get PDF目的：医療系就労・就学女性の健康課題と関連要因を明らかにする．
方法：関東圏内の大学病院および医療系大学・看護専修学校に勤務・就学する女性を対象に質問紙調査を行った．健康課題は更年期簡易指数（SMI：Simplified Menopausal Index）及び，月経随伴症状日本語版（MDQ：Menstrual Distress Questionnaire），ストレスチェックリスト・ショートフォーム（PHRF：Public Health Research Foundation）を測定した．属性とPHRF及び，MDQ，SMIとの関連をMann-WhitneyのU検定，Kruskal-Wallis検定で評価した．PHRF，MDQ，SMIに与える関連要因の影響は，ロジスティック回帰分析を行った．有意水準は5％とした．
結果：765名のデータを分析した．PHRF平均値は17.0±9.2，MDQ平均値は29.5±25.1，SMI平均値は40.0±25.6であり，先行研究より高かった．健康課題として，PHRFおよびMDQの【集中力】に最も有意に関連していたのは「所属先のサポート体制に関する認識」であった．MDQの【行動変化】【自律神経失調】【コントロール】に最も有意に関連していたのは年代，MDQの【水分貯留】には運動習慣の有無であった．また，MDQの【否定的感情】には，夜勤の有無，MDQの【痛み】には，平均睡眠時間が最も有意に関連していた．SMIに最も関連していたのは「過去4週間で心身の健康を理由に休暇を取得した経験の有無」であった．
結論：医療系就労・就学女性の健康課題と関連要因が明らかになった．所属先のサポート体制が整っていると回答した女性の方が，有意にストレスが低値であった．
医療現場でのストレスの高い労働環境が女性の月経に関する健康に悪影響を与えることが懸念され，所属のサポート体制整備とその認知を高めることの重要性が示唆された．journal articl
Viral Myalgia in a 6-Year-Old Girl：Calf Pain and Toe-Walking Following an Upper Respiratory Infection
Get PDF良性急性小児筋炎は，学齢期の小児に好発し，インフルエンザウイルスや他のウイルス感染後に一過性の筋痛と歩行障害を呈する稀な疾患である．6歳女児が上気道感染後，両下肢の腓腹筋痛と尖足歩行を主訴に来院した．第5病日から両下肢痛が出現し，第6病日には尖足歩行を呈した．臨床所見および血液検査では，アスパラギン酸アミノトランスフェラーゼ（Asparate aminotransferase：以下AST），乳酸脱水素酵素（Lactate Dehydrogenase：以下LDH）の上昇と高クレアチンキナーゼ（Creatine kinase：以下CK）血症を認めたが，他の神経学的所見や画像検査で異常を認めなかった．経過観察により症状は改善し，第10病日には両下肢痛や尖足歩行は消失，血清CKも正常範囲内に改善した．臨床経過から，足の痛みと歩行障害は，上気道感染後に発症した良性急性小児筋炎と診断した．本例の経過は，適切な観察のみで良好に回復した．journal articl
Up to Date of Adult Bronchial Asthma
Get PDF喘息の有病率は年々増加傾向だが喘息死は減少してきている．喘息死者数は 70 歳以上にピークがあり若年者は少数である．注目されている喘息の病態は，気道上皮傷害により上皮から産生される interleukin（IL）-33, IL-25, thymic stromal lymphopoietin（TSLP）が Th2 細胞，group 2 innate lymphoid cells（ILC2）や dendritic cells（DC）に作用し自然免疫と獲得免疫のクロストークの橋渡しをし病態を形成している機序である．近年の気道上皮の解析の進歩により tuft 細胞が IL-25 産生細胞であることが示唆されている．喘息の治療では，長期管理薬の吸入ステロイド（inhaled corticosteroids, ICS），長時間作用性 b2 刺激薬（long-acting b-agonist, LABA）と長時間作用性抗コリン薬（long-acting muscarinic antagonist, LAMA）が 1 つの吸入容器で 1 日 1 回吸入型の single inhaler triple therapy（SITT）製剤が使用できるようになり，薬剤の相加相乗効果や患者のアドヒアランスの向上による良好な喘息コントロールが期待できる．吸入剤や経口コルチコステロイド治療にてもコントロールができない重症喘息患者はステロイド抵抗性があると考えられ生物学的製剤が使用される．血中好酸球数や呼気一酸化窒素（FeNO）の値が高いタイプ 2 炎症を呈する患者が生物学的製剤の良い適応である．喘息治療の進歩により臨床的寛解，すなわち症状なし，増悪なし，経口ステロイド治療無し，肺機能の安定化といったことが達成されうる患者が約 2〜3 割いる．今後の課題として，臨床的な寛解が得られない患者は依然として多いため，さらに精度の高い治療選択を行うためのバイオマーカーと薬剤開発が求められているPrevalence of asthma is increasing each year, but asthma deaths are declining. A peak in the number of asthma deaths is observed in people over 70 years of age, with a small number of deaths among younger people. Highlighted pathogenesis of asthma is mediated by interleukin（IL）-33, IL-25, and thymic stromal lymphopoietin（TSLP）, which are released from the epithelium after airway epithelial injury, acting on Th2 cells, group 2 innate lymphoid cells（ILC2）and dendritic cells（DCs）, bridging the crosstalk between innate and acquired immunity and promoting inflammation. Recent advances in the analysis of airway epithelium have suggested that tuft cells are IL-25 producing cells. In the treatment of asthma, inhaled corticosteroids（ICS）, long-acting beta-agonists（LABA）, and longacting muscarinic（long-acting muscarinic antagonist, LAMA）in a single inhaler triple therapy（SITT）, which is a once-daily inhaler in a single inhaler container, is expected to provide better asthma control through synergistic effects of the drugs and improved patient adherence. Patients with severe asthma that is not controlled by inhaled or oral corticosteroid therapy are considered steroid-resistant and are treated with biologics. Patients with type 2 inflammation with high blood eosinophil counts and fraction of exhaled nitric oxide（FeNO）levels are good candidates for biologics. With advances in asthma treatment, clinical remission, i.e., no symptoms, no exacerbations, no oral corticosteroid therapy, and stabilization of lung function, can be achieved in about 20〜30% of patients. The challenge for the future is to develop biomarkers and drugs for more precise treatment selection, since many patients still do not achieve clinical remission.journal articl
Useful MRI Case of Acute Focal Bacterial Nephritis in Infant
Get PDFMRI が診断と治療効果判定に有用だった急性巣状細菌性腎炎（AFBN）の乳児例を報告する．症例は生後 4か月の男児．発熱と哺乳不良を主訴に入院した．膿尿は認めないが炎症反応高値を認めたため抗菌薬を開始した．解熱しないため第 4 病日に MRI を施行したところ，拡散強調像で右腎に楔状の高信号域を認め AFBN と診断した．第 5 病日に解熱し，第 11 病日の MRI 再検で病巣の縮小を確認し抗菌薬を内服に変更した．抗菌薬は計 3 週間投与し，慢性期 DMSA シンチグラフィで腎瘢痕を認めなかった．AFBN の発症年齢は比較的年長児に多いが，本症例のような乳児期早期でも発症し得るため，乳児の不明熱では AFBN の鑑別が必要である．AFBN を疑うときは超音波検査を行い，腎臓に異常所見を認める際は MRI の検討が必要だろう．We present a case of an infant diagnosed with acute focal bacterial nephritis（AFBN）, where magnetic resonance imaging（MRI）played a crucial role in both the diagnosis and treatment response. The patient was a four-month-old boy admitted to the hospital due to fever and poor feeding habits. Despite the absence of pyuria, his inflammatory markers were elevated；therefore, antibiotics were administered. However, as the fever persisted until the fourth day, an MRI scan was conducted. The MRI revealed a characteristic wedge-shaped high signal in the right kidney on diffusion-weighted images, confirming the diagnosis of AFBN. Subsequently, the fever resolved by the fifth day of illness. Upon reevaluation on the 11th day, MRI demonstrated shrinkage of the lesion, leading to the switch to oral antibiotics. A three-week course of antibiotics and a follow-up dimercaptosuccinic acid scintigraphy performed in the chronic phase revealed the absence of renal scarring. While AFBN is relatively common among older children, it can also occur in infants, as in this case. Therefore, MRI should be considered even in cases of fever with unknown etiology in infants.journal articl
Pediatric Multisystem Inflammatory Syndrome with Transient Coronary Artery Dilation： A 2-year-old Boy Report
Get PDF症例は 2 歳男児．同日に家族内に発熱者が本人を含め 3 人いたため，発熱初日に新型コロナウイルス迅速検査を行い，陽性であった．児の発熱は 1 日で解熱したが，18 日後に再発熱を認めた．再発熱の第 3 病日に眼球結膜充血，両側頚部リンパ節腫脹，口唇発赤が出現し，川崎病の暫定診断で免疫グロブリン大量療法（IVIG）を行なった．その後も発熱が遷延したため，COVID-19 の先行感染を背景に川崎病と類似する多系統炎症性症候群（MIS-C）を疑い（後に診断基準である COVID-19 IgG 陽性が判明），追加治療として IVIG＋ステロイドパルス療法を行った．第 9 病日に右冠動脈近位部の拡張（＋2.9SD）を認めたため，IVIG＋メチルプレドニンパルス療法を行った．第 12 病日に左前下行枝，13 病日に左主幹部の一過性拡張を認めたが，その後の経過は良好であった．乳児の川崎病症状に対しては新型コロナウイルスの既感染に留意し，早期から MIS-C にともなう冠動脈病変のリスクに対して適切な治療を実施する必要がある．The case is a 2-year-old boy. Because there were three family members with fever on the same day, including the boy himself, a rapid coronavirus antigen test was performed on the first day of fever, and the test was positive. The child’s fever resolved within one day, but 18 days later, he developed a recurrent fever. On the third day of the recurrent fever, ocular conjunctival hyperemia, bilateral cervical lymphadenopathy, and lip erythema appeared, and immunoglobulin immunotherapy（IVIG）was administered with a tentative diagnosis of Kawasaki disease. The patient continued to have prolonged fever, and we suspected multisystemic inflammatory syndrome in children （MIS-C）similar to Kawasaki disease against the background of prior COVID-19 infection（later found to be positive for COVID-19 IgG, the diagnostic criteria）, and IVIG plus steroid pulse therapy was administered as additional treatment. On the ninth day, the patient was treated with IVIG＋methylprednisolone pulse therapy because of a dilatation of the right coronary artery（＋2.9 SD）. Transient dilatation of the left anterior descending artery on the 12th day and the l left main coronary artery on the 13th day was observed, but the patient’s subsequent course was good. We need to be aware of previous infection with novel coronaviruses in infants with Kawasaki disease symptoms and provide appropriate treatment for the risk
of coronary artery lesions associated with MIS-C from the early stage of the disease.journal articl
Anti-neutrophilic Antibody-positive Systemic Lupus Erythematosus with Acute Kidney Injury and Diffuse Alveolar Hemorrhage with Concomitant Coronavirus Disease 2019 (COVID-19)
Get PDFA Japanese woman in her 30s with a six-month history of ANCA-positive SLE was admitted because of acute kidney injury (AKI). Three weeks before admission, her condition was well-controlled. On admission, the test for SARS-CoV-2 was positive; she showed marked renal dysfunction but no pulmonary abnormalities, suggesting COVID-19 infection. She underwent continuous hemodiafiltration and received glucocorticoid pulse therapy and remdesivir. The next day, she developed diffuse alveolar hemorrhage (DAH) and cytokine storm. She died despite intensive care. We assumed that AKI and DAH were caused by SLE exacerbation triggered by the COVID-19 infection in addition to the COVID-19 infection itself.journal articl
Relationship between Details in Fiberoptic Endoscopic Evaluation of Swallowing Dysfunction and Clinical Outcomes
Get PDFSevere dysphagia causes aspiration pneumonia, oral intake discontinuation, and even death. To select appropriate interventions, the impaired function must be identified. Endoscopic evaluation has been popular to evaluate dysphagia, and various evaluation methods have been developed. The Hyodo score is widely used in Japan and subdivides the swallowing function into four categories, making it possible to identify impaired functions in detail. Few studies have analyzed the relationship between the severity of dysphagia assessed by the Hyodo score and clinical outcomes, such as aspiration pneumonia, oral intake, and mortality.
We conducted a retrospective study of 66 hospitalized patients for dysphagia or aspiration pneumonia and evaluated all four items of the Hyodo score. Patients' information, the severity of dysphagia, onset of aspiration pneumonia, nutritional status, and final outcomes were collected and analyzed.
Patients with clinical outcomes, such as aspiration pneumonia, oral intake, and mortality were found to have more severe dysfunction in subdivided items of Hyodo score, such as saliva pooling in the pharynx, glottic closure reflex, swallowing reflex, and pharyngeal clearance. Furthermore, differences in Body Mass Index and comorbidity rates of diabetes and malignant tumors outside of head and neck region were found depending on whether these clinical outcomes occurred.
Our study reveals that differences in the severity of dysphagia assessed by the Hyodo score influence clinical outcomes, such as the onset of aspiration pneumonia, oral intake discontinuation, and mortality rate. In the future, prospective clinical studies are required to include larger number of cases and for more accurate analysis.journal articl
Anesthetic Management for Intraventricular Thrombectomy and Biventricular Assistive Device Insertion in a Patient with COVID-19 Requiring Percutaneous Cardiopulmonary Assistance
Get PDFA 47-year-old male patient with COVID-19 was scheduled for intraventricular thrombectomy and biventricular assistive device insertion. As he was staying in a special intensive care unit for patients with COVID-19 (COVID-ICU) at the time, transporting the patient a long way along a complex pathway was necessary. He was transported from COVID-ICU, through the corridor, and into a negative pressure operating room in the surgical center by staff wearing appropriate personal protective equipment, using a portable negative pressure clean dome for the patient, and plastic sheets for various pieces of equipment. During anesthesia and surgery (which involved many hours and advanced techniques), each member of staff, that is, the surgeons, anesthesiologists, nurses, and clinical engineers, was replaced as needed. The surgeries consisted of removing a thrombus filling a wide area from the pulmonary vein to the ascending aortic artificial vessel and biventricular assistive device insertion. The duration of the operation and anesthesia were 16 h and 15 min and 19 h and 1 min, respectively. Fortunately, no staff members tested positive for COVID-19 after the surgery. However, such thorough infection control measures may be difficult to implement in many situations.journal articl
