Therapeutic Research
Volume 34, Issue 4, 2013
Volumes & issues:
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OPINION
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患者と全人的に向き合う医療を-EBMのピットフォールはサイエンスへの過信にある
34巻4号(2013);View Description Hide Description—— 臨床薬理学が目指してきたものとEBM の考えは一致する部分が多々あると思います。先生が執筆された臨床薬理学会のテキストで,臨床薬理学は「合理的薬物治療を指向する学問領域」であり,合理的薬物治療とは「科学的に裏付けのある薬物治療」とあります。これはEBMそのものとも言えます。現在,EBM といえば,臨床試験の解釈のほうに光が当たりがちですが,もともとの意味は,入手可能な科学的根拠を吟味した上で,個々の患者に最良の医療を当てはめるための方法論,と理解しています。今回は,中野先生がこれまで一貫して心を注いでこられた臨床薬理学的なアプローチから見たEBM,さらには今後の医療の方向性などについてお伺いいたします。
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Symposium:第46回ペーシング治療研究会
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- 一般演題
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2.高齢者におけるペースメーカー感染の姑息的治療
34巻4号(2013);View Description Hide DescriptionWe describe a case of 87-year-old man with cardiac pacemaker infection followed by recurrent fistula. He received a pacemaker implantation due to atrioventricular block in 1995. He had the 2nd generator exchange in 2005. He was suffered from a pocket infection in April 2006. Surgery was performed for the pocket debridement including cutting off the leads as close as possible to the subclavian vein and implanted a new system from the other side later. Ideally, a total removal of the pacemaker system including the leads is recommended for the treatment of device infection;however, he had high risks for open heart surgery because of elderly age, diabetes mellitus and thrombocytopenia. Three months after debridement surgery, he was suffered from a cutaneous fistula at the subclavian region caused by the residual pacemaker leads. Again, surgery for debridement with cutting off the leads was performed. However, recurrence of the fistula occurred at the same site 3 more times within 1 year. We thought that the incomplete sealing of the stump of the lead coil caused the recurrent fistula. So when we performed the 4th operation, we cut the coil shorter than the outer sheath, and covered the end with a silastic tube filled with silastic glue manufactured as a repair kit. No bacteria were found in the culture of the discharge and he had no symptoms of infection. The patient has not suffered from recurrent fistula for the past 10 months. -
3.Sprint Fidelis の断線が ICD ジェネレーター交換翌日に顕在化した 1 例
34巻4号(2013);View Description Hide DescriptionCase:A 27 year-old man was admitted to our hospital for replacement of implantable cardioverter-defibrillator(ICD)generator due to low battery level. At 17 years of age, the patient was suspected of having Brugada syndrome from ECG findings and was observed as outpatient in another hospital. At age 21, he was referred to our hospital for detailed investigations because of syncope. Late potential and pilsicainide provocation test were positive. In electrophysiological study, nonsustained ventricular fibrillation was induced. Because he had a family history of sudden cardiac death, we performed ICD implantation, which was also desired by the patient and family. A Fineline II 4479 atrium lead(Guidant), a Sprint Fidelis 6948 ventricular shock lead(Medtronic)and a Marquis DR 7274 ICD generator(Medtronic)were used. There was no ICD shock after implantation, and generator replacement was necessary at age 27 due to low battery level. On admission, ICD check data showed no significant problems in lead impedance and sensing integrity counter, no noise-induced oversensing episode, and no findings of lead failure. Generator replacement was conducted on the next day of admission. Intraoperative examination showed no macroscopic insulation failure, and no abnormality was detected even at high output pacing(10 V)by the pacing system analyzer(PSA). Without adding shock lead, a new Protecta XT DR(Medtronic)generator was connected. When high output pacing was performed again(8 V/1.5 msec)with the new generator, no lead failure was detected. To confirm the defibrillation threshold, ventricular fibrillation(VF)was inducedby T wave shock, and VF was terminated by ICD shock at 10 J. The operation was thus completed. However, when we performed ICD check on the next day, electrical noise appeared reproducibly after ventricular pacing during measurements of ventricular pacing threshold and lead impedance. Although procedural complication was a possibility, we suspected incomplete Fidelis lead failure and decided to re-operate. During reoperation, we detected no insulation failure of the shock lead and no noise from the lead in the pocket even by stress test. However, noise was induced reproducibly after the pacing spike, which is characteristic of incomplete failure near the tip of the lead reported for the Fidelis lead. We placed a new shock lead Durata 7122Q(SJM)and completed the reoperation. The postoperative course was uneventful, and the patient was discharged on day 6 after reoperation. High output pacing has been reported to be effective for the detection of Sprint Fidelis lead failure. We report a rare case in which incomplete failure of a Fidelis lead undetectable even by high output pacing manifested one day after replacement operation. -
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6.LV リード留置が困難であった 3 例
34巻4号(2013);View Description Hide DescriptionCardiac resynchronization therapy is useful modality for heart failure with motion dyssynchrony within left ventricle. But locating the LV lead in appropriate site has sometimes procedural difficulty and sometimes causes unpredicted complications. There are three cases in which we could not locate the LV leads with various reasons and we examine troubleshooting. -
7.ペースメーカー刺激閾値の変動に Phase 4 ブロックが関与していると考えられた洞不全症候群の 1 例
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8.術前のペースメーカーチェックで R 波高が低値であるにもかかわらず,術中アナライザーでは十分な波高値が記録された電池交換症例―R 波ピークの認識方法についての考察―
34巻4号(2013);View Description Hide Description
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原著
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アトルバスタチン特定使用成績調査(ALWAYS)最終報告―「動脈硬化性疾患予防ガイドライン(2012 年版)」の指針に則した検討―
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アトルバスタチン特定使用成績調査(ALWAYS)追加報告―腎機能低下例に対するアトルバスタチンの有用性の検討―
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直接的レニン阻害薬アリスキレンの臨床評価―ARESE(Aliskiren Retrospective Survey on Efficacy and Safety)研究―
34巻4号(2013);View Description Hide DescriptionARESE 研究として,直接的レニン阻害薬アリスキレンの使用実態下でのデータから,臨床的特性を分析した。分析対象 87 例でのアリスキレン(1 日 150 mg)の投与方法は,単独投与6 例,既存の降圧薬への追加投与 72 例および既存の降圧薬からの切替え投与 9 例であった。いずれの群ともアリスキレン投与後有意な血圧低下を示し,全例では投与前 146.7±21.9/78.8±14.8 mmHg から投与 6 ヵ月で 134.6±17.7/70.9±12.0 mmHg に有意に低下した。また,投与 12 ヵ月あるいは投与 18 ヵ月後でも投与 6 ヵ月後と同程度の血圧低下を維持していた。脈拍数には有意な変化はなかった。また,腎機能,脂質代謝指標,糖代謝指標および尿酸はいずれの指標とも有意な変化はなかった。アリスキレンは投与方法にかかわらず長期間安定した血圧低下作用を示し,腎機能や脂質代謝に影響を与えず高い忍容性を示した。 -
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日本人 2 型糖尿病患者に対するインスリン分泌促進系薬剤の臨床検討―DPP-4 阻害薬シタグリプチンとSU 薬グリメピリドの 1 年間比較―
34巻4号(2013);View Description Hide Descriptionスルホニル尿素薬(SU 薬)は主にインスリン分泌の惹起経路に,DPP-4 阻害薬は増幅経路に作用するが,現時点ではともにインスリン分泌促進系に分類されている。今回,代表的薬剤であるグリメピリドとシタグリプチンを 1 年間継続投与した 2 型糖尿病患者のデータを後ろ向きに調査し,血糖改善状況とインスリン分泌との関係,体重・体組成への影響,各種代謝マーカーの変化を比較した。結果,シタグリプチンでは血糖改善におけるインスリン分泌への依存度が低く,代謝全般の改善,腎機能改善,抗炎症効果が認められた。薬剤選択の優位性に格段の差があり,DPP-4 阻害薬はインスリン分泌促進系薬と同じ範疇には入れられない薬剤であると考えた。 -
糖尿病患者におけるしびれ症状の発現頻度について―外来患者 122 例を対象としたアンケート調査に基づく解析―
34巻4号(2013);View Description Hide DescriptionThe symptom prevalence of numbness caused by the diabetic neuropathy as one of three major complications of diabetes is estimated as approximately 20% in overseas studies, which means it is not a rare symptom. However, in Japan, probably due partly to the Japanese mental attitudes, not many diabetic patients complain about numbness and the reality about it has yet to be clarified. A questionnaire was conducted on 122 diabetic outpatients visiting the Department of Diabetes Metabolism and Endocrinology at Chiba University Hospital. The results suggested that a higher percentage of patients had numbness than overseas figures, that there is a possibility of miscommunication about numbness between physicians and patients in their regular consultations, that there are considerable number of patients with numbness even when their glycemic control is successful, and that there is a possibility of diabetic neuropathy manifesting in diabetic patients even in the preclinical phase. It is important to ascertain the existence of numbness in medical interviews with diabetic patients and more detailed glycemic control is necessary for those who have numbness. -
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