【Objective】We investigated the significance of early nutritional administration for one week after living donor liver transplantation (LDLT).
【Methods】We retrospectively analyzed 62 patients who underwent adult LDLT in our center from January 2013 to November 2015. We compared nutritional statuses, immunological functions, and muscle masses between patients who received recommended calories (recommendation group, equal or more than 20k cal/kg ideal body weight, n = 38) and patients who did not receive recommended calories (non-recommendation group, less than 20k cal/kg ideal body weight, n = 24) for 1 week after LDLT.
【Results】Psoas muscle mass index (PMI), prealbumin, branched-chain amino acids, eicosapentaenoic acid (EPA), the ratio of EPA to arachidonic acid (EPA/AA ratio), and total lymphocyte count (TLC) on admission did not differ significantly between the recommendation group and the nonrecommendation group. The EPA, EPA/AA ratio, and TLC at 2 weeks after LDLT were significantly higher in the recommendation group than in the nonrecommendation group (p = 0.014, p = 0.040, p = 0.016, respectively). A percent against standard skeletal muscle mass in the recommendation group was significantly higher than that in the nonrecommendation group (p = 0.020). Postoperative hospital stay was significantly shorter in the recommendation group compared with the nonrecommendation group （p < 0.010）. A significant positive relationship was found between the total calories as well as protein administration for one week after LDLT and a percent against standard skeletal muscle mass (p = 0.008, p = 0.013, respectively).
【Conclusion】Sufficient nutritional administration during the early period after LDLT contributed to an early recovery of nutritional status, immunological function, and muscle mass.

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希少がんには多種多様な悪性腫瘍が含まれ, 個々の特徴に着目した新技術開発が望まれるものの, 患者数の少なさから, その治療薬はしばしば高薬価となっている. 海外では, 適正な薬価や, 償還の可否の判断に費用対効果を含めた医療技術評価 (Health Technology Assessment: HTA) が活用され, わが国でも, 費用対効果評価制度が施行され, 薬価調整に用いられている. 本研究は, 希少がん治療薬の価値を評価するうえでのHTAの活用可能性と意義について, 海外での評価事例から示唆を得ることを目的として実施した. 日本で2009〜2019年に承認された42の希少がん治療薬は, 英国, カナダ, オーストラリアでは2.9〜12.5%が, 44のそのほかのオーファンドラッグのうち0〜22.2%が

となっており, の主たる理由は ｢臨床的有効性に関する不確実性｣ であった. となった薬剤には, 原価計算方式で薬価算定された医薬品, すなわち, 比較できる類似薬がないものが多く, 臨床試験には実薬対照が設定されていない, かつ試験当たりの被験者数が少ない傾向が認められた. 臨床的有用性の不確実性を減らすためには, 国際共同試験, 産学協働コンソーシアム, ウェブリクルートなどを活用してより多くのデータ集積が試みられるべきである. 一方, 標準治療が存在しない, あるいは有効性が十分でなく, 倫理性から対照群が置けない限界も存在する. そのため, リアルワールドデータを活用して, 開発段階では対照群データの取得を行い, 市販後にはより多くの症例データを蓄積することなどが試みられるべきである.

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日本臨床麻酔学会第36回大会で講演の機会をいただいた“日本版敗血症診療ガイドライン2016における推奨作成方法・ガイドラインの使用方法”の内容を紹介する．日本版敗血症診療ガイドライン2016では，Clinical questionの立案，Systematic reviewの施行，エビデンスの質の評価，推奨の策定の4つの工程を経て各推奨の策定を行った．ガイドライン上の推奨は，推奨，弱い推奨，弱い

，という4つに分類されている．しかし，これらの推奨は本来4つのカテゴリーに当てはめることが困難な連続的なものを，一定のルールに基づいて半ば強制的にカテゴリー化しているものである．したがって，弱い推奨と弱いは反対の推奨ではないことをよく理解して使用いただきたい．

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To reduce the number of falls caused by hypnotic agents, the standardization of insomnia treatment was carried out at Yamaguchi University Hospital from April 2019. There were concerns that medical costs would increase due to the selected medicines―suvorexant and eszopiclone―being more expensive than conventional benzodiazepines. In this study, the standardization of insomnia treatment was evaluated by pharmacoeconomics. The costs of the hypnotic agents was considered, as was the cost of examination/treatment following falls. Effectiveness was evaluated as the incidence of falls within 24 hours of taking hypnotic agents. This analysis took the public healthcare payer's perspective. Propensity score matching based on patient background, showed that, per hospitalization the medicine costs of the recommended group increased by 1,020 yen, however, the examination/treatment costs following falls decreased by 487 yen when compared with the non-recommended group. Overall, the recommended group incurred costs of 533 yen more per hospitalization for patients prescribed hypnotic agents compared to the non-recommended group, but the incidence of falls for the recommended group was significantly lower than that in the non-recommended group (1.9% vs. 6.3%; p<0.01). These results suggest that in order to prevent the incidence of falls by 1 case, it is necessary to increase costs by 12,086 yen which is the subthreshold cost for switching to the recommended medicine as standardization. The selection of recommended medicines may be a cost-effectiveness option compared with non-recommended medicines.

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【目的】膝周囲骨切り術（AKO）が膝蓋大腿関節（PFJ）に与える影響から，術前のPFJの軟骨損傷の評価は重要である．しかし術前にPFJの変性を評価するモダリティについての研究は少ない．本研究ではAKO術前CT及びMRI所見と関節鏡所見の相関を調査しPFJの変性を正確に評価するモダリティについて検討した．【対象と方法】2019年1月から2021年4月までに当科でAKOを施行した62例を対象とした．MRI所見（modified-Outerbridge分類）及びCT所見と関節鏡所見（ICRSグレード）の相関及びその検者内・検者間信頼性を検定した．MRIは画像診断ガイドライン2016年版で推奨されるシーケンス（3D GRE T1強調像）を含む群（推奨MRI群）と含まない群（

MRI群）に分けて検討した．【結果】ICRSグレードとの相関係数は推奨MRI群，MRI群，CT群の順に0.64，0.23，0.43であった．検者内信頼性は同様の順序で0.70，0.39，0.60，検者間信頼性は0.65，0.31，0.59であった．【考察】3D GRE T1強調像はPFJの軟骨の形態の評価に有用と考えられた．

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The “Definitions of terms relating to mass spectrometry [IUPAC (International Union of Pure and Applied Chemistry) recommendations 2013]” define the term “MS/MS spectrum” as “a mass spectrum obtained using tandem mass spectrometry.” The semantic content of the term “MS/MS spectrum” is not only a product ion mass spectrum but also a precursor ion spectrum and a neutral loss spectrum. However, the term “MS/MS spectrum” is frequently used as a synonym of a product ion spectrum. An “MS/MS spectrum of the peptide angiotensin I” does not convey the same meaning as the “product ion spectrum of the peptide angiotensin I.”

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Acetaminophen (APAP) is a major drug that causes acute poisoning, including severe liver damage. In cases of overdose, the serum APAP concentration is used as an indicator for administering the antidote N-acetylcysteine (NAC). However, measuring APAP levels in clinical settings is often challenging; a threshold of 7,500 mg or 150 mg/kg is commonly used for NAC administration. This guideline was developed for Westerners, and its applicability to Japanese individuals is unclear. This study aimed to explore factors other than serum APAP concentration that could quickly lead to NAC administration. We analyzed patients (n = 25) who visited the emergency department of Ogaki Municipal Hospital and had their APAP levels measured between April 2014 and March 2024. Patients were divided into NAC-recommended and non-recommended groups based on the NAC administration line in the Rumack–Matthew nomogram, and APAP intake amounts were compared. The cutoff value was calculated using the receiver operating characteristic (ROC) curve. The median APAP intake (interquartile range) was 9,500 (7,380 – 14,400) mg in the NAC-recommended group and 4,000 (3,925 – 6,250) mg in the non-recommended group (P = 0.045). The calculated cutoff value using the intake curve was 5,200 mg (120 mg/kg). The area under the ROC curve for APAP intake was 0.792, indicating moderate accuracy in event detection (95％ confidence interval: 0.583 – 1), with sensitivity and specificity for detecting NAC administration at 91.7％ and 70.0％, respectively. This study suggests that Japanese patients who ingest more than 5,200 mg or 120 mg/kg of APAP may qualify for NAC administration.

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We developed a flowchart for standardizing insomnia treatment to prevent falls associated with hypnotic drug dosing in Yamaguchi University Hospital, and implemented it from April 2019. The first recommended drug was suvorexant, followed by eszopiclone. In November 2019, we conducted a questionnaire survey involving doctors and nurses regarding the effectiveness and convenience of the flowchart. Eighty-one percent of the participants responded positively. We also investigated the incidence of falls within 24 h after dosing hypnotics. The fall rate before and after the introduction of the flowchart was no significant difference as determined by propensity score matching of the patient background. However, the fall rate for patients who received the recommended drugs was 3.1％ and that for patients who received the deprecated drugs was 5.7％. Therefore, the fall rate of patients receiving the recommended drugs was significantly lower than that of patients receiving the deprecated drugs. The introduction of this flowchart may thus help prevent patient falls.

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The treatment and prevention of osteoporosis is crucial as fragility fractures, the clinical outcome of osteoporosis, are a common cause of bed confinement. We organized a multidisciplinary care team composed of physicians, nurses, pharmacists, physical therapists, dietitians, radiologists, and laboratory technicians in September 2020 to establish the Fracture Liaison Service (FLS) in April 2021. The attending pharmacist was dedicated to FLS, different from the one dedicated to orthopedic beds, where the pharmacist’s task is to ensure compliance with osteoporosis medication before and after admission. Alternatively, the pharmacist must propose prescriptions for osteoporosis medications according to the guidelines. In this study, we retrospectively evaluated the rate of osteoporosis medication initiation for secondary fracture prevention and the type of prescription drugs administered to patients with fragility fractures before and after FLS initiation in patients over 50 years of age admitted with proximal femur and vertebral compression fractures. Although pharmacists have been performing pharmaceutical services in wards, no drug prescriptions for osteoporosis have been proposed. The rate of osteoporosis medication initiation increased from 21.2％ to 83.3％ during the start of FLS activity. Moreover, the ratio of the continuing prescriptions not recommended by the osteoporosis guidelines decreased and that of the recommended prescriptions, such as eldecalcitol and bisphosphonate significantly increased. The study findings revealed that pharmaceutical care in FLS provided by pharmacists facilitated the initiation of osteoporosis medications according to the guidelines for secondary fracture prevention in patients with fragility fractures.

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In the outpatient setting, pharmacists at community pharmacies play a crucial role by working closely with physicians to ensure appropriate antimicrobial use. This study aimed to clarify the actual condition of pharmaceutical inquiries by community pharmacists regarding the appropriate use of outpatient antibiotic therapy. Based on public data released by the Japan Council for Quality Health Care, we performed a retrospective analysis on 757 inquiries related to antibiotics among inquiries recorded by community pharmacists from March 2022 to July 2022. The most common inquiries were about the prevention of adverse effects of antibiotics (70.5％), followed by inquiries about the prevention of decrease in the effectiveness of antibiotics (10.0％). On the other hand, we found that pharmaceutical interventions to reduce unnecessary antibiotic prescriptions for the common cold and to promote the appropriate selection of antibiotics for empirical treatment through the implementation of clinical guidelines, and to optimize the dosage in cases of renal insufficiency estimated from the results of a creatinine test remained as important problems that still need to be solved. In conclusion, our findings suggest that although community pharmacists’ inquiries contribute substantially to the safety and treatment effectiveness of outpatient antibiotic therapy, pharmacists may need to better identify problems before their onset in order to promote the appropriate use of antibiotics.

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理化学研究所では、研究データの保存・解析・公開のためにデータ科学基盤HOKUSAI SailingShipを2020年6月から運用している。利用者はプライベートIaaSとしてシステムを構築して利用することになるが、さまざまな研究用のシステムを簡単に構築できるようにAnsibleを用いたシステム構築支援を利用者に提供している。本稿では、データ科学基盤とその上でのシステム構築支援について紹介する。

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国民医療費が 40 兆円を超え，毎年 1 兆円前後増加している．その要因としては人口の高齢化だけでなく，医療技術の進歩も影響していると考えられる．新規の医薬品もその1つであり，これにより今まで以上に延命できたり，症状が改善したりといった多くのメリットがもたらされている．一方で，最近発売されている医薬品等の中には高額なものも少なくない．そこで医療費を効率的に使用していくことが重要となる．そこで，公的医療保障制度を有する国においては，医薬品等の費用対効果の評価を行い，公的医療保障制度で給付する範囲や償還価格の設定に応用している国がある．
日本でも医療の効率的な提供が重要となるため，2012 年に中央社会保険医療協議会の下に費用対効果評価専門部会が設置され，評価対象とする技術や評価手法，評価結果の活用方法などの議論がされている．2015 年には ⌈経済財政運営と改革の基本方針⌋ の中で， 2016 年度診療報酬改定時に医薬品・医療機器について費用対効果の評価を試行的に導入し，その後速やかに本格的な導入をすることを目指すという方針が示されたことにより， 2016 年度から試行的導入が開始された．対象品目は過去4年間に保険収載された品目のうち，加算や売上金額などの要件を満たすもので，医薬品7品目，医療機器6品目である．これらについて，まず企業が費用効果分析のデータを提出し，それに対して公的な専門体制により中立的な立場から再分析を実施する．分析に関しては基本的に ⌈中央社会保険医療協議会における費用対効果評価の分析ガイドライン⌋ に沿って行うこととされている．企業の分析および再分析の結果については費用対効果専門組織で総合的評価が行われる．ここでは分析結果の妥当性を検討するだけでなく，倫理的・社会的側面といった費用対効果以外の要素についても考慮する．評価された結果を基に，2018 年度診療報酬改定時に償還価格の調整に用いられる予定である．
今後は，試行的導入で明らかになった技術的課題への対応策を整理したうえで，制度化については平成 30 年度中に議論される見込みである．技術進歩を促進しつつ，国民皆保険制度を維持していくため，新規医薬品等の費用対効果の適切な評価とそれに基づく合理的な意思決定が期待される．

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