背景：大量出血時に伴う希釈・消費性凝固障害に対するクリオプレシピテート（クリオ）の使用が近年広がっている．クリオはフィブリノゲン補充効率が高く止血効果に優れるが，作製時に生じるクリオ上清血漿（乏クリオ）は推奨・提言がない．そこで，当院における乏クリオの使用状況を調査し検討を行った．

We aimed to clarify the changes in respiratory mechanics and factors associated with them in artificial pneumothorax two-lung ventilation in video-assisted thoracoscopic esophagectomy in the prone position (PP-VATS-E) for esophageal cancer. Data of patients with esophageal cancer, who underwent PP-VATs-E were retrospectively analyzed. Our primary outcome was the change in the respiratory mechanics after intubation (T1), in the prone position (T2), after initiation of the artificial pneumothorax two-lung ventilation (T3), at 1 and 2 h (T4 and T5), in the supine position (T6), and after laparoscopy (T7). The secondary outcome was identifying factors affecting the change in dynamic lung compliance (Cdyn). Sixty-seven patients were included. Cdyn values were significantly lower at T3, T4, and T5 than at T1 (p < 0.001). End-expiratory flow was significantly higher at T4 and T5 than at T1 (p < 0.05). Body mass index and preoperative FEV 1.0% were found to significantly influence Cdyn reduction during artificial pneumothorax and two-lung ventilation (OR [95% CI]: 1.29 [1.03–2.24] and 0.20 (0.05–0.44); p = 0.010 and p = 0.034, respectively]. Changes in driving pressure were nonsignificant, and hypoxemia requiring treatment was not noted. This study suggests that in PP-VATs-E, artificial pneumothorax two-lung ventilation is safer for the management of anesthesia than conventional one-lung ventilation (UMIN Registry: 000042174).

septal defect, presenting with partial atelectasis and consolidation of left lower lobe and left upper lobe bronchiectasis due to obstruction from the enlarged left pulmonary artery.Case Presentation: A 32-year-old gentleman with a history of an ostium secundum atrial septal defect with severe pulmonary hypertension and secondary polycythemia presented to us with one episode of mild hemoptysis, persistent cough and worsening shortness of breath over two weeks.Examination revealed occasional coarse crepitations in the left lung, in addition to cardiovascular findings.Chest X-ray showed prominent bilateral pulmonary arteries with multiple opacities in the left lung.HRCT revealed enlarged left main pulmonary artery leading to bronchial obstruction resulting in bronchiectasis in the left upper lobe and partial atelectasis and consolidation of left lower lobe in addition to hemorrhages in both upper lobes.Inflammatory markers were normal and tuberculosis workup was negative.Sputum pyogenic cultures were positive for Pseudomonas aeruginosa and the patient was treated with antibiotics.Conclusion: Even though it is extremely rare adults can also have bronchial obstruction due to enlarged vascular structures giving rise to complications.In patients with pulmonary hypertension, respiratory symptoms could be secondary to bronchial obstruction caused by enlarged pulmonary arteries.

Rationale: Chronic disseminated intravascular coagulation (DIC) associated with thoracic aortic aneurysm is characterized by enhanced fibrinolysis and is thought to be stable in the compensated/asymptomatic stage, with few bleeding symptoms. However, DIC can lead to decompensated/hemorrhagic stage disseminated intravascular coagulation, resulting in severe bleeding diathesis, and there is currently no established strategy for treatment of DIC in aortic aneurysms. Patient concerns: A 77-year-old woman underwent angiography and cardiac catheterization, before descending aortic replacement surgery. She developed DIC in postprocedure week 2 with extensive, uncontrollable massive subcutaneous hemorrhage. Diagnoses: Her acute-phase DIC score was 7 points, and the risk of mortality within 30 days after surgery according to the JapanSCORE was estimated to be 33.6%. Interventions: Therapy was a combination of recombinant human soluble thrombomodulin (rhTM) and an aortic stent-graft treatment. Outcomes: Short-term improvements were seen in both DIC and bleeding diathesis. The thoracic aortic aneurysm with severe DIC was eventually corrected by administration of rhTM. Lessons: We report the use of rhTM as an effective, novel anticoagulant drug with anti-inflammatory activity for treating DIC with suppressed fibrinolysis, which is typically associated with sepsis. In patients with a high hemorrhagic diathesis, in whom preoperative control of DIC cannot be achieved with conventional anticoagulation and radical surgical repair cannot be performed, a combination of rhTM and endovascular therapy may be a powerful new treatment option.

To determine the prophylactic effect of using combined 1% alcoholic chlorhexidine gluconate and chlorhexidine gel-impregnated dressings (CGCD) on catheter-related thrombosis (CRT) in critically ill patients. This retrospective cohort study was performed in an intensive care unit from November 2009 to August 2014. The CRT incidence diagnosed with ultrasound examination was compared between patients applying CGCD and combined 10% aqueous povidone-iodine and standard transparent dressings (PITD) after central venous catheter insertion into the internal jugular vein for ≥ 48 h. CRT was stratified into early (within 7 days) and late (days 8–14) thromboses. Multivariate analyses using logistic regression models clarified the relationships between early- and late-CRT risks and skin antiseptic and catheter site dressing combinations. CRT occurred in 74 of 134 patients (55%), including 52 with early CRT and 22 with late CRT. Patients receiving CGCD had a significantly lower incidence of early CRT than those receiving PITD (odds ratio = 0.18; 95% confidence interval = 0.07–0.45, p < .001). No significant association was evident between using CGCD and late CRT (p = .514). Compared to PITD, CGCD reduced the CRT risk over 7 days in critically ill patients. UMIN Clinical Trials Registry: UMIN000037492.

Before surgery and other invasive treatments, decisions must be made on whether to discontinue drugs and provide appropriate drug holidays especially for antithrombotic drugs, and this is made difficult by the large number of available drugs and associated guidelines. We have therefore developed an online application for perioperative drug discontinuation and resumption management, named Saga Application for Management of Drug Holidays in PeriOperative Periods (SAMPOP). Multidisciplinary medical staff at Saga University Hospital (SUH) worked together to build an evidence-based Perioperative Drug Discontinuation Management Database (PDDMD) and developed the user-friendly SAMPOP online application via preliminary verification at SUH. From September 2018 to February 2020, 420 medical staff at SUH, including physicians, nurses, and pharmacists, installed and tested SAMPOP. Rate per surgical procedure for forgetting to discontinue antithrombotic drugs preoperatively decreased from 0.18% to 0.09% as of August 2019, 12 months after the introduction of SAMPOP (P = .1359). In addition, six months later, it decreased further to 0.03% as of February 2020 (P = .0436). Forgetting to resume antithrombotic drugs postoperatively decreased from 0.20% to 0.02% as of August 2019, 12 months after the introduction of SAMPOP (P = .0008). There was no case of forgetting to resume the medication in the last 6 months. SAMPOP may be useful for management of drug holidays in the clinic and warrants further evaluation of its safety and efficacy.

硬膜外穿刺に伴う合併症のうち，感染症は診断・治療が遅れると重篤な神経障害を生じることがある．われわれは1993年から2013年に硬膜外穿刺後に生じた硬膜外膿瘍12例の発症時期，治療，予後を後ろ向きに検討した．症状発現が穿刺から3週以上経過していた症例が3例あり，それらの症例では病期が進行していた．治療は全例に抗菌薬投与が行われた．4例に外科的治療を施行し，うち2例は麻痺が残存した．穿刺から長期間経過後に症状が顕在化する場合，症状発現時には病期が進行している可能性があるため，硬膜外穿刺後に発熱や背部痛を認める場合には，穿刺の時期にかかわらず硬膜外膿瘍を念頭に置いて診断，治療にあたる必要がある．

Argatroban was used as the anticoagulant during cardiopulmonary bypass (CPB) in a patient with heparin-induced thrombocytopenia (HIT) type II undergoing mitral valve replacement. Dosage was reduced because of preoperative congestive liver disorder. Perioperative coagulability was poor, and, ultimately, failure of hemostasis led to a fatal outcome. Although argatroban use as an anticoagulant for HIT is reported, the optimal dose has not been established. During long-term CPB, increasing the total dosage may extend anticoagulant ability, leading to dose dependence. Because no antagonist for argatroban exists, failure of hemostasis might occur.

BACKGROUND AND AIMS:Vibrio vulnificus causes an infectious disease that has extremely poor convalescence and leads to necrotic fasciitis. In this study, we sought to define the characteristic epidemiology of V. vulnificus infection and clarify its diagnosis at the global level.METHODS:Over a period of 10 years, we investigated the appearance of symptoms, underlying conditions, treatment, and mortality in 12 patients (eight men, four women; >50 years old; average age, 66 years,) infected with V. vulnificus.RESULTS:The development of symptoms occurred primarily between June and September, a period during which seawater temperature rises and the prevalence of V. vulnificus increases. All patients had underlying diseases, and seven patients reported a history of consuming fresh fish and uncooked shellfish. The patients developed sepsis and fever with sharp pain in the limbs. Limb abnormalities were observed on visual examination. All patients underwent debridement; however, in the survival group, the involved limb was amputated early in 80% patients. The mortality rate was 58.3%.CONCLUSION:Recognition of the characteristic epidemiology and clinical features of this disease is important, and positive debridement should be performed on suspicion. When the illness reaches an advanced stage, however, amputation should be the immediate treatment of choice.

Forestier's disease accompanies difficult airway management with the ossification of the anterior longitudinal ligament of the spine. The abnormalities include limited cervical mobility, constrained epiglottic elevation, exclusion of the part of aryepiglottic, recurrent nerve paralysis and thinning of respiratory tract mucosa. We planned endotracheal intubation using both AWS and bronchofiberscope in a patient with Forestier's disease. We could easily confirm his glottis by using AWS and evaluate his respiratory tract below the glottis by bronchofiberscope. We could intubate an enforced tube (internal diameter 7.5 mm) with the bronchofiberscope guidance without any complications. This procedure seems to be safe for intubation in a Forestier's disease patient.

BACKGROUND:Fresh frozen plasma (FFP) should be thawed in a water bath at 30-37 degrees C. Suitable temperature, the prevention for bacterial contamination, and the efficiency of the process are necessary for a thawing procedure. In this study, we compared the clotting factor activity and thawing time in different thawing procedures; a water bath, the thermostatic thawing chamber (FP-40, Hokuyo ; Kawasumi, Japan), and the microwave system (Transfusio-therm 2000 AMCO; Zeipel, Germany).METHODS:Thawing time and the clotting factor activity (prothrombin time: PT, prothrombin time-international normalized ratio: PT-INR, activated partial thromboplastin time: APTT, fibrinogen, andfactors V) of thawed FFP-5 units were measured.RESULTS:Thawing time using Transfusio-therm 2000 was 11.4 minutes, which was faster than that using the water bath and FP-40 of about 39.5 and 27.3 minutes, respectively (P<0.01). There were no differences between the three methods in terms of the clotting factors.CONCLUSIONS:The microwave system is useful in shortening the time safety, and maintaining the clotting factor activity in thawed FFP

経口補水液（OS-1）と高濃度炭水化物含有飲料（AW）の術前水分補給効果と飲水量に関する比較検討を行った．手術当日2例目以降予定の脊髄くも膜下麻酔下に施行される人工股関節全置換術症例を対象とし，封筒法にて各群20例（OS-1 1,000ml群，AW 1,000ml群，AW 250ml群の3群）に分け水分補給効果を前向きに調査した．OS-1 1,000ml vs AW 1,000ml群，AW 1,000ml vs AW 250ml群ともΔFENa（fractional excretion rate of Na）に有意差なく，効果は同等であった．術前摂取飲料に両飲料水とも適することが示唆された．

【目的】中心静脈カテーテル（central venous catheter, CVC）によるカテーテル関連血栓症（catheter-related thrombosis, CRT）の発症頻度と経過，発症要因，合併症と転帰を調査した。【方法】2009年11月～2010年11月にCVCを用いた患者を対象に，超音波を用いCRTを観察した。【結果】CRTの頻度は患者100人中67人，カテーテル205本中107本（52％）であり，大腿静脈に比べ内頸静脈で多かった（63％対28％，P＜0.001）。CRT発症群では，非発症群に比べ感染性併発症を多く認めた（67％対45％，P＝0.04）。中心静脈カテーテル関連血流感染症は，CRT非発症例に比べ発症例で多く合併した（9％対1％，P＝0.008）。ICU滞在日数はCRT発症群で延長したが死亡率に有意差はなかった。【結論】CRTは52％と高頻度に発症し，感染症との関連性が示唆された。

血友病A合併の61歳，男性．急性大動脈解離による緊急弓部大動脈人工血管置換術に対し，第VIII因子製剤（FVIII）を持続および間欠的投与で管理した症例を経験した．術前にFVIII3,000単位を単回投与することで，活性化部分トロンボプラスチン時間（APTT），第VIII因子凝固活性（F8）を正常値に補正し，以降はAPTTとF8を指標にFVIIIを4単位/kg/hrで継続投与した．ヘパリン投与でAPTT，F8は著明に低下し，プロタミン投与でACTは改善するもAPTT，F8は改善を認めず，止血に難渋した．F8が測定不能となり，途中からAPTTのみを指標にFVIIIの間欠的投与および持続投与量を調整した．結果，APTTは改善し，止血に成功した．術後も再出血や血栓症の合併はなく良好な経過を得た．術中の第VIII因子補充の指標としてF8のみならずAPTTも可能と考えられた．

Arginine-specific ADP-ribosyltransferase (Art) catalyzes the mono-ADP-ribosylation, in which it transfers a single ADP-ribose moiety of NAD to the arginine residue(s) of target proteins, and may regulate the function of the proteins or peptides in cellular processes. In vertebrates, Art family is consisted of seven members (Arts1-7), and these Arts are distributed among various tissues except B lymphocytes. Previously, we described molecular cloning, characterization and distribution of glycosylphosphatidylinositol (GPI)-anchored Arts, Art7.1 and Art7.2 (formerly, we referred as cgArt1 and cgArt2, respectively) in chicken tissues (Terashima et al (2005) Biochem J 389:853-861). Here, we demonstrate for the first time that Art7.1 was predominantly expressed on the surface of B cells from the bursa of Fabricius as a GPI-anchored form, as well as on T cells from the thymocytes. Furthermore, we show that the expression of Art7.1 molecules on B cells could modulate the B cell receptor (BCR) signalling and direct the B cell fate to maturation. Thus, our present observation sheds light on the Art molecule expressed on B cells and its possible functional role in BCR signalling.

Cystatin C, a cysteine protease inhibitor, is implicated in pathogenesis of late-onset Alzheimer's disease and other neurological disorders. Our recent study showed that cystatin C injection into rat hippocampus induced neuronal cell death in granule cell layer of dentate gyrus in vivo. We further confirmed that cystatin C neurotoxicity was inhibited by simultaneous coapplication of cathepsin B, a cysteine protease. In vitro cytotoxicity was also studied in cultures of human CNS neurons, mixed cultures with astrocytes and A1 human hybrid neurons. Cystatin C induced neuronal cell death in a dose-dependent manner, which accompanied increased number of TUNEL (+) cells, up-regulation of active caspase-3 and DNA ladder. The results of the present study indicate that cystatin C participates in the process of apoptotic neuronal cell death in experimental conditions by means of inhibitory activity of cysteine proteases, and that cystatin C might be involved in the pathogenesis in human neurological disorders including Alzheimer's disease.