2019年の英語原著論文 | 医療関係の方へ | 国立病院機構 熊本医療センター


 Nishikawa T, Ono K, Hashimoto S, Kinoshita H, Watanabe T, Araki H, Otsu K, Sakamoto W, Harada M, Toyonaga T, Kawakami S, Fukuda J, Haga Y, Kukidome D, Takahashi T, Araki E. : One-hour oral glucose tolerance test plasma glucose at gestational diabetes diagnosis is a common predictor of the need for insulin therapy in pregnancy and postpartum impaired glucose tolerance. Journal of diabetes investigation. 2018; 9(6): 1370-7.

Aims/Introduction: Because gestational diabetes mellitus (GDM) is a risk for adverse perinatal outcomes, and patients with a history of GDM have an increased risk of impaired glucose tolerance (IGT). Here, we conducted two non-interventional and retrospective studies of GDM patients in Japan.
Materials and Methods: In the first study, we enrolled 529 GDM patients and assessed predictors of the need for insulin therapy. In the second study, we enrolled 185 patients from the first study, and assessed predictors of postpartum IGT.
Results: In the first study, gestational weeks at GDM diagnosis and history of pregnancy were significantly lower and pregestational BMI, family history of DM, 1- and 2-hour glucose levels in a 75-g OGTT, the number of abnormal values in a 75-g OGTT, and HbA1c were significantly higher in subjects with insulin therapy. In the second study, 1- and 2-hour glucose levels in a 75-g OGTT, the number of abnormal values in a 75-g OGTT, HbA1c, and ketone bodies in a urine test were significantly higher in IGT subjects. Logistic regression analysis showed that gestational weeks at GDM diagnosis, 1-hour glucose levels in a 75-g OGTT, and HbA1c were significant predictors of the need for insulin therapy, and 1-hour glucose levels in a 75-g OGTT at diagnosis and ketone bodies in a urine test were significant predictors for postpartum IGT.
Conclusions: Antepartum 1-hour glucose levels in a 75-g OGTT was a predictor of the need for insulin therapy in pregnancy and postpartum IGT.



糖尿病・内分泌内科部長  西川 武志

 Mima K, Sugihara H, Kato R, Matsumoto C, Nomoto D, Shigaki H, Kurashige J, Inoue M, Iwagami S, Mizumoto T, Kubota T, Miyanari N. : Laparoscopic removal of a fish bone that penetrated the stomach and extended into the pancreas: a case report. Surg Case Rep. 2018; 4: 149

Background: The gastrointestinal tract can occasionally be perforated or penetrated by an ingested foreign body, such as a fish bone. However, there are very few reported cases in which an ingested fish bone penetrated the gastrointestinal tract and was embedded in the pancreas.
Case presentation: An 80-year-old male presented with epigastric pain. Computed tomography of the abdomen showed a linear, hyperdense, foreign body that penetrated through the posterior wall of the gastric antrum. There was no evidence of free air, abscess formation, migration of the foreign body into the pancreas, or pancreatitis. As the patient had a history of fish bone ingestion, we made a diagnosis of localized peritonitis caused by fish bone penetration of the posterior wall of the gastric antrum. We first attempted to remove the foreign body endoscopically, but failed because it was not detected. Hence, an emergency laparoscopic surgery was performed. A linear, hard, foreign body penetrated through the posterior wall of the gastric antrum and was embedded in the pancreas. The foreign body was safely removed laparoscopically, and was identified as a 2.5-cm-long fish bone. Intraperitoneal lavage was performed, and a drain was placed in the lesser sac. The patient recovered without complications and was discharged on the 7th postoperative day.
Conclusion: Laparoscopic surgery could be performed safely for the removal of an ingested fish bone embedded in the pancreas.



外科医長  美馬 浩介

Reiji Muto MD, Hiroaki Miyoshi MD, phD, Kensaku Sato MPH, Takuya Furuta MD, phD, Hiroko Muta MD, Keisuke Kawamoto MD, PhD, Eriko Yanagida MD, Kyohei Yamada MD, and Koichi Ohshima MD, phD : Epidemiology and secular trends of malignant lymphoma in Japan: Analysis of 9426 cases according to the World Health Organization classification. Cancer Med. 2018; 7: 5843–5858.

Aim: This study provides an overview of the epidemiology and secular trends of malignant lymphoma in Japan.
Materials and Methods: Using data from clinics and hospitals throughout Japan, we analyzed 9426 cases of malignant lymphoma diagnosed in 2007-2014.
Results: We show that the proportion of follicular lymphoma and methotrexate-associated lymphoproliferative disorder increased during this time, as did the onset age for follicular lymphoma and diffuse large B-cell lymphoma. Significant increases in onset age for follicular lymphoma and diffuse large B-cell lymphoma were observed in both men and women (all P values <0.0001 except for P = 0.0448 for the latter disease in women).
Conclusions: Further studies are required to determine the reasons for the higher proportion of and onset age for these lymphomas. Additionally, we believe that continued observation of these trends is necessary.

<タイトル>日本における悪性リンパ腫の疫学と経年的変遷 -WHO分類に基づく9426例の検討-

 日本のリンパ腫の疫学に関する論文に、Lymphoma Study Group of Japanese Pathologist (LSG)の研究 (n=3194)(1)やAokiらの研究 (n=2260) (2)があります。しかしながら、日本の悪性リンパ腫の疫学の「経年的な変化」を検討した研究はこれまでありませんでした。今回の研究では、久留米大学病理学講座で2006年~2014年までに診断した、初発のリンパ腫9424例を用いて、日本の悪性リンパ腫の疫学および、それらの経年変化を提示しました。本論文は、これまでで最も大きい症例数の日本のリンパ腫の疫学論文となっています。疫学データの大枠は、これまでの研究とあまり変わりありませんでしたが、経年的に濾胞性リンパ腫、びまん性大細胞型B細胞性リンパ腫の発症年齢の高齢化が起こっている点と、濾胞性リンパ腫、メトトレキセート関連リンパ増殖性疾患の増加が示された点が、本論文の something new になっています。Open accessの論文になっていますので、悪性リンパ腫の症例で論文を書かれる際に、introductionにでも引用いただけますと幸いです。
(1)Pathology international 2000; 50: 696-702. The World Health Organization classification of malignant lymphomas in Japan: Incidence of recently recognized entities.
(2)Pathol Int. 2008; 58: 174-82. Distribution of malignant lymphoma in Japan: analysis of 2260 cases, 2001-2006.

病理診断科医師  武藤 礼治

Reiji Muto MD, Sugita Yasuo MD, phD, Seiya Momosaki MD, phD, Yuriko Ito MD, Yoshiyuki Wakugawa MD, phD, Koichi Ohshima MD, phD : An autopsy case of progressive multifocal leukoencephalopathy after rituximab therapy for malignant lymphoma. Neuropathology. 2019; 39: 58–63.

Introduction: Progressive multifocal leukoencephalopathy (PML) is a rare fatal demyelinating disease of the central nervous system caused by reactivation of the JC virus, which is named after the initials of the patient from whom the virus was first isolated. JCV is highly prevalent worldwide, infects humans in early childhood, and the infection persists throughout the course of life in latent form. The present paper deals with the second autopsy case report of rituximab-associated PML in Japan.
Case: A 63-year-old woman who had undergone chemotherapy for non-Hodgkin lymphoma developed progressive dysarthria and cerebellar ataxia. Head MRI revealed small, scattered, hyperintense areas in the midbrain, pons and thalamus, and the patient was first diagnosed as having cerebral infarction. Follow-up MRI showed tendency toward cerebellar atrophy and multiple system atrophy cerebellar type was suggested, which we concluded must have coincidentally occurred. It was challenging to perform biopsy due to the location of the foci and the patient's condition. Twelve months later she died of aspiration pneumonia caused by the bulbar lesion. At autopsy, the histological examination suggested the presence of demyelinating foci with numerous foamy macrophages. In the foci, oligodendrocytes with enlarged ground-glass like nuclei were found in a scattered manner and astrocytes with bizarre nuclei were also detected. These findings verified the case as PML. The first diagnosis of cerebral infarction was later withdrawn, although appropriate disorders were not recalled even after testing with various antibodies.
Conclusions: The rate of PML development tends to increase after treatment with molecular-targeted therapies, which directly or indirectly attenuate the cellular-mediated immune system. Various novel molecular-targeted and immunosuppressive drugs have been released on the market; the cases of PML have consequently increased. Accordingly, pathologists should keep this disease in mind in the differential diagnosis when neural symptoms newly emerge in patients who are treated with these drugs.



病理診断科医師  武藤 礼治

Masahiro Harada, Takeshi Takahashi, Yoshio Haga, Takeshi Nishikawa. : Comparative study on quick sequential organ failure assessment, systemic inflammatory response syndrome and the shock index in prehospital emergency patients: single‐site retrospective study. Acute Med Surg. 2019; 6(2): 131-137.

Aim: The Quick Sequential Organ Failure Assessment (qSOFA) score, Shock Index (SI), and Systemic Inflammatory Response Syndrome (SIRS) criteria are simple indicators for the mortality of patients in the Emergency department (ED). These simple indicators using only vital signs, may be more useful in prehospital care than in the ED due to their quick calculation. However, these indicators have not been compared in prehospital settings. The aim of the present study is to compare these indicators measured in prehospital care and verify whether the qSOFA score is useful for prehospital triage.
Methods: We performed a single-site retrospective study on patients transferred by ambulance to the Kumamoto Medical Center ED between January 2015 and December 2016. We compared areas under the receiver operating characteristic (AUROC) curves of the qSOFA score, SI, and SIRS criteria measured in prehospital care. We also performed sensitivity and specificity analyses using Youden Index.
Results: A total of 4,827 patients were included in the present study. The AUROC (95% confidence interval) of the qSOFA score for in-hospital mortality was 0.64 (0.61 – 0.67), which was significantly higher than those of the SIRS criteria; 0.59 (0.56 – 0.62) and SI; 0.58 (0.54 – 0.62). According to the optimal cut-off values (qSOFA≥2) decided on as the Youden Index, the sensitivity of the qSOFA score was 52.3% and its specificity was 69.9%.
Conclusions: The qSOFA score had the highest AUROC among three indicators. However, it may not be practical in actual prehospital triage due to its low sensitivity.

<タイトル>病院前救急患者におけるqSOFA、SIRS、Shock Indexの比較検討:単施設後方視的研究

目的:quick SOFAスコア(qSOFA)、ショック指数(Shock Index)、Systemic Inflammatory Response Syndrome(SIRS)診断基準は救急部門において患者の死亡率を予測するシンプルな指標として用いられる。これらのバイタルサインのみを用いるシンプルな指標は、迅速な計算という観点では救急外来よりも病院前の方がより有用である可能性がある。しかしながら、これらの指標が病院前においてはいまだ比較されていない。本研究の目的は病院前で測定されたこれらの指標を比較し、qSOFAが病院前トリアージで有用であることを検証することとした。
方法:2015年1月から2016年12月に国立病院機構熊本医療センター救急外来に救急車で搬送された患者様について単施設後方視的研究を行った。救急車内で測定されたバイタルサインから算出されたqSOFA、Shock Index、SIRSの院内死亡に関するROC曲線下面積を比較した。また、Youden Indexを用いて感度特異度分析を行った。
結果:4,827名の患者が本研究に組み入れられた。qSOFAの院内死亡に関するROC曲線下面積(95%信頼区間)は0.64 (0.61 – 0.67)であり、SIRSの0.59 (0.56 – 0.62)、Shock Indexの0.58 (0.54 – 0.62)より有意に高かった。Youden Indexに基づき決定したカットオフ値(qSOFA≧2)によると、qSOFAの感度は52.3%で特異度は69.9%であった。

救急科医長  原田 正公

Makino Koji, Aoi Jun, Egashira Sho, Honda Noritoshi, Kubo Yosuke, Kawakami Yoko, Hayashi Hideyuki and Mochizuki Takashi. Multiple Skin Abscesses Caused by Rhizopus sp. Infection after Candida albicans Infection in an Immunocompromised Patient. Med Mycol J. 2019; 60(1): 17-21. doi: 10.3314/mmj.18-00002.

A 66-year-old woman with diabetes who was treated with prednisolone (15 mg/day) for autoimmune hepatitis developed multiple erythematous nodules with retention of purulent fluid on her lower right limb. Candida albicans was cultured from the nodules. She was started on oral fluconazole, and the lesions subsided. However, multiple dark-red abscesses and indurations newly appeared on the left crus. Histopathological examination showed numerous branched hyphae, and tissue culture yielded a Rhizopus microsporus-related fungus. She was treated with liposomal amphotericin B combined with drainage and debridement. However, she died because of poor control of the infection and hepatic disorder.


 症例は66歳、女性。自己免疫性肝炎に対しPSL15mg/日を内服中だった。右下腿の発赤と腫脹を生じ、有痛性硬結も多発し、抗菌薬が奏功しなかったため当院へ入院した。皮膚生検と膿汁培養検査より多発性カンジダ膿瘍と診断した。FLCZ100mg/日を内服し、状態は改善したので前医へ転院したが、左下腿発赤・熱感を生じて全身状態も急激に悪化したので再入院した。β-Dグルカン上昇と壊死脂肪織の菌糸より侵襲性アスペルギルス症を疑ったが、膿汁の培養検査および遺伝子検査にてRhizopus microsporus近縁菌を検出したため播種性ムコール症と診断した。抗真菌薬をL-AMB200mg/日に変更し、適宜切開排膿やデブリドマンを行ったが、入院43日目に死亡した。

皮膚科医長  牧野 公治