相馬 孝博

In the original publication, the name of fourteenth author was published incorrectly as Nagayasu Takeshi, the correct name is Takeshi Nagayasu.

PURPOSE: The anatomical site of resected lobes may influence postoperative cerebral infarction. The objective of the current study was to determine if left upper pulmonary lobectomy is a risk factor for postoperative cerebral infarction. METHODS: This was a retrospective case-control study in patients undergoing pulmonary lobectomy from 2004 to 2013 in Japan. We retrospectively identified 610 patients from 153 institutions who had developed postoperative cerebral infarction following pulmonary lobectomy. The control group consisted of 773 patients who underwent lobectomy without cerebral infarction during a randomly selected single month in 2009 at the same institutions. RESULTS: Factors associated with cerebral infarction were age [10-year intervals, odds ratio (OR): 1.46; 95% confidence interval (CI): 1.23-1.73; p < 0.001], male sex (OR 1.92; 95% CI 1.29-2.86; p = 0.001), presence of comorbidities (OR 1.82; 95% CI 1.35-2.44; p < 0.001), perioperative anti-platelet or anti-coagulant drug use (OR 1.71; 95% CI 1.20-2.45; p = 0.003), and lobectomy. Subgroup analyses revealed that cerebral infarction was strongly associated with left upper lobectomy. CONCLUSIONS: Our findings suggest that left upper lobectomy is associated with a higher risk of cerebral infarction than other types of lobectomy, particularly in the early postoperative period.

OBJECTIVES: We sought to clarify how large a proportion of fatal medical accidents can be considered to be caused by poor non-technical skills, and to support development of a policy to reduce number of such accidents by making recommendations about possible training requirements. DESIGN: Summaries of reports of fatal medical accidents, published by the Japan Medical Safety Research Organization, were reviewed individually. Three experienced clinicians and one patient safety expert conducted the reviews to determine the cause of death. Views of the patient safety expert were given additional weight in the overall determination. SETTING: A total of 73 summary reports of fatal medical accidents were reviewed. These reports had been submitted by healthcare organisations across Japan to the Japan Medical Safety Research Organization between April 2010 and March 2013. PRIMARY AND SECONDARY OUTCOME MEASURES: The cause of death in fatal medical accidents, categorised into technical skills, non-technical skills and inevitable progress of disease were evaluated. Non-technical skills were further subdivided into situation awareness, decision making, communication, team working, leadership, managing stress and coping with fatigue. RESULTS: Overall, the cause of death was identified as non-technical skills in 34 cases (46.6%), disease progression in 33 cases (45.2%) and technical skills in two cases (5.5%). In two cases, no consensual determination could be achieved. Further categorisation of cases of non-technical skills were identified as 14 cases (41.2%) of problems with situation awareness, eight (23.5%) with team working and three (8.8%) with decision making. These three subcategories, or combinations of them, were identified as the cause of death in 33 cases (97.1%). CONCLUSIONS: Poor non-technical skills were considered to be a significant cause of adverse events in nearly half of the fatal medical accidents examined. Improving non-technical skills may be effective for reducing accidents, and training in particular subcategories of non-technical skills may be especially relevant.

FMEA(Failure Mode and Effects Analysis:故障モード影響解析手法)を用い、手術室における胃切除術を例として問題点の摘出方法と対策優先項目を明らかにし、FMEAの医療分野への適用を検討した。手術室における標準的な胃切除術の手術工程を対象とし、術者の手術手技自体は解析対象外とした。失敗モードは術前146、術中32、術後15項目で、重要失敗モードは術前48、術中15、術後7であり、「ガーゼ・器械・針・医療材料のカウントミス」等が摘出された。様々な職種で構成されたブレーンストーミングにより解析したところ、医療へのFMEA適用は有効であることが示唆され、ブレーンストーミングにより失敗モードへ繋がる医療行為自体の必然性や各失敗モードの対策の必要性が問われ、職場分化の向上に繋がった。あらゆる事故を想定した上での安全対策、相対的定量評価による効果的・効率的なアプローチに加え、術者の手術手技、患者の精神的側面の検討、評価点算出時の重み付けの検討、FMEA適用効果の認識と簡便化の工夫等が課題であると思われた。

病院内における総合的患者安全マネジメントの観点から, 入院患者に対する誤薬予防のシステム構築の方法を検討した。各種の有効方策をリストアップした上で, 重要度と導入のしやすさから並べ直し, 投薬の業務過程 (プロセス) との関係を見直した。<BR>院内誤薬予防システム構築にあたっては, 以下のような手順を推奨したい。 (1) 医療安全委員会を設置し, 報告制度により, システムの脆弱な部分を洗い出す。 (2) できればFMEA手法を使用して, プロセスごとの単位業務を解析する。 (3) 利用できる医療資源の多寡に関わらず, どの病院でも有効方策として,(1) 手書き転記の廃止,(2) 輸液ポンプ使用法,(3) 高リスク薬別途使用法,(4) 使用薬剤の限定,(5) (臨床) 薬剤師の参画, などをまず検討する。<BR>また, オーダエントリ・システムなどの機械化を進めていく場合, 自動調剤や個人識別システムと効率よく連動させるためには,(製造元による) 薬剤のソースマーキングは必須なので, 早期実施が望まれる。

The fine structure and distribution of the epithelial cells of the airway in the rat were studied continuously from the trachea to terminal bronchioles by scanning electron microscopy (SEM). The airway could be divided into three different regions according to cell population: 1) the trachea and extrapulmonary bronchi; 2) intrapulmonary bronchi (larger than 500μm in caliber); and 3) bronchioles (smaller than 500μm in caliber). From their surface structures, the epithelial cells could be classified into ciliated and non-ciliated cells, the latter including brush cells, Clara cells and other non-ciliated (secretory) cells.<br>1. Ciliated cells. The cilia are longer, thicker and more numerous in the trachea; they decrease in length, thickness and number toward the periphery.<br>2. Brush cells. They possess thin microvilli (0.2μm in thickness) in the trachea and extrapulmonary bronchi, with a rounded end. In the bronchioles they possess thick microvilli (0.3μm in thickness) abruptly ending in a right angle edge. The brush cells are distributed sparsely but rather uniformly, and apt to be grouped in two or more cells.<br>3. Clara cells. Their apical cytoplasm shows a domed or papillary swelling and possesses a few microvili. The Clara cells are distributed in the bronchioles and can already be found some distance proximal to the bronchial furcations into bronchioles.<br>4. Other non-ciliated (secretory) cells. Their apical cytoplasm seems to contain secretory granules immediately beneath the cell surface. They often gather in groups in the trachea and extrapulmonary bronchi, tending to form large areas corresponding to sites supported by tracheal or bronchial cartilage.<br>There were found several orifices in tracheal or bronchial glands whose long axes paralleled the tracheal or bronchial axes.<br>Dome-shaped elevations sometimes appear near the branching points of the intrapulmonary bronchi. There were regarded as bronchus-associated lymphoid tissue (BALT).