伊藤 彰一

BACKGROUND: The standardized T1-weighted/T2-weighted (sT1w/T2w) ratio for the middle cerebellar peduncle (MCP) has been reported to be sensitive for detecting degenerative changes in the cerebellar subtype of multiple system atrophy (MSA-C), even in the early stages. We aimed to investigate the diagnostic value of the MCP sT1w/T2w ratio for differentiating between MSA-C and spinocerebellar ataxia (SCA). METHODS: We included 32 MSA-C, 8 SCA type 3 (SCA3), 16 SCA type 6 (SCA6) patients, and 17 controls, and the MCP sT1w/T2w ratio was analyzed using a region-of-interest approach. The diagnostic performance of the MCP sT1w/T2w ratio in discriminating among MSA-C, SCA3, and SCA6 was assessed and compared with diagnosis based on visual interpretation of MCP hyperintensities and the "hot cross bun" (HCB) sign. RESULTS: MCP sT1w/T2w ratio values were markedly lower in patients with MSA-C than in those with SCA3, those with SCA6, and controls (p < 0.001). The MCP sT1w/T2w ratio showed high diagnostic accuracy for distinguishing MSA-C from SCA3 (area under curve = 0.934), SCA6 (area under curve = 0.965), and controls (area under curve = 0.980). The diagnostic accuracy of the MCP sT1w/T2w ratio for differentiating MSA-C from SCA3 or SCA6 (90.0% for MSA-C vs. SCA3, and 91.7% for MSA-C vs. SCA6) was comparable to or superior than that of visual interpretation of MCP hyperintensities (80.0-87.5% in MSA-C vs. SCA3 and 87.6-97.9% in MSA-C vs. SCA6) or the HCB sign (72.5-80.0% in MSA-C vs. SCA3 and 77.1-93.8% in MSA-C vs. SCA6). CONCLUSIONS: The MCP sT1w/T2w ratio might be a sensitive imaging-based marker for detecting MSA-C-related changes and differentiating MSA-C from SCA3 or SCA6.

千葉大学医学部附属病院呼吸器内科での医師臨床研修における取り組みの効果を検証した。2020年度より指導者間で研修医面談によるニーズ評価と日々の研修内容の情報共有を行い、研修の調整を行った。研修満足度や研修内容に関してアンケートで2019年度と比較した。2019年度と比較し研修満足度が有意に高くなり、経験できた項目や疾患が増加した。呼吸器内科への興味も有意に高かった。指導者間の学習者ニーズ評価、研修内容の情報共有は研修医の満足度を向上させ、研修の充実につながる。(著者抄録)

INTRODUCTION: This study assessed the morphological changes and diffusion tensor imaging (DTI)-derived parameters of the brachial plexus using magnetic resonance neurography (MRN) in patients with anti-myelin-associated glycoprotein (anti-MAG) neuropathy. METHODS: Eight patients with anti-MAG neuropathy underwent MRN of the brachial plexus with 3-dimensional (3D) short tau inversion recovery (STIR) and DTI sequences. Two neuroradiologists and a neurologist qualitatively assessed nerve hypertrophy on 3D STIR MRN. The cross-sectional area (CSA) of the nerve roots was measured. Quantitative analyses of fractional anisotropy (FA) and axial, radial, and mean diffusivity (AD, RD, and MD) were obtained after postprocessing on DTI and manual segmentation. RESULTS: There was nerve hypertrophy in 37.5% of the patients with anti-MAG neuropathy. All patients with anti-MAG neuropathy with nerve hypertrophy were refractory to rituximab therapy. The CSA of the nerve roots was inversely correlated with FA and positively correlated with MD and RD. FA decreased in the nerve roots and inversely correlated with disease duration. CONCLUSIONS: Nerve hypertrophy appears in the proximal portion of peripheral nerves, such as the brachial plexus, in patients with anti-MAG neuropathy. Altered diffusion in the nerve roots might be associated with the loss of myelin integrity due to the demyelination process in anti-MAG neuropathy.

BACKGROUND: This study aimed to investigate the frequency and risk factors for cerebral artery stenosis and occlusion in patients with polyneuropathy, organomegaly, endocrinopathy, M-protein, and skin changes (POEMS) syndrome. METHODS: We reviewed results of magnetic resonance angiography (MRA) or computed tomography angiography (CTA) in 61 patients with POEMS syndrome seen between 2010 and 2017. Stenosis or occlusion was assessed in the initial MRA/CTA. Multivariate analysis was used to identify risk factors for artery stenosis/occlusion. In an autopsy case, pathologic examination was conducted of the occluded middle cerebral arteries. RESULTS: Stenosis (> 50 %) or occlusion of the major cerebral arteries was found in 29 (47.5 %) patients on the initial MRA/CTA. The internal carotid artery was involved most frequently (32.8 %), followed by the anterior (21.3 %) and middle (16.4 %) cerebral arteries. The basilar (1.3 %) and vertebral (3.6 %) arteries were rarely affected. Cerebral infarction developed in eight (13.1 %) patients. The serum vascular endothelial growth factor (VEGF) level was an independent predictor for stenosis/occlusion (odds ratio, 1.228; 95 % confidence interval, 1.042-1.447; P = 0.014). An autopsy study showed occluded middle cerebral arteries by fibrous and myxomatous thickening of intima with splitting of the internal elastic lamina. Follow-up MRA in 23 patients showed improved, worsened, and unchanged stenosis in 20.7 %, 8.7 %, and 69.6 %, respectively. CONCLUSIONS: Cerebral large-vessel stenosis or occlusion is frequently seen in approximately half of patients with POEMS syndrome. Vasculopathy was related to serum VEGF levels and thereby disease activity. Assessment of cerebral vessels is recommended in these patients to improve management.

OBJECTIVE: We aimed to investigate the use of a myelin-sensitive MRI contrast, the standardized T1-weighted/T2-weighted (sT1w/T2w) ratio, for detecting early changes in the middle cerebellar peduncle (MCP) in cerebellar subtype multiple system atrophy (MSA-C) patients. METHODS: We included 28 MSA-C patients, including a subset of 17 MSA-C patients within 2 years of disease onset (early MSA-C), and 28 matched healthy controls. T1w and T2w scans were acquired using a 3-T MR system. The sT1w/T2w ratio in MCP was analyzed using SPM12 by utilizing a region-of-interest approach in normalized space. The diagnostic performance of the MCP sT1w/T2w ratio in discriminating MSA-C and the subgroup of early MSA-C from the matched controls was assessed. Correlation analyses were performed to evaluate the relationship between the MCP sT1w/T2w ratio and other clinical parameters including the International Cooperative Ataxia Scale (ICARS) score for quantifying cerebellar ataxia. RESULTS: Compared to controls, the sT1w/T2w ratio in the MCP was markedly lower in all (p < 0.001) MSA-C patients and 17 early (p < 0.001) MSA-C patients. The MCP sT1w/T2w ratio had high sensitivity (96%) and specificity (100%) to distinguish MSA-C from controls (area under the curve = 0.99), even for the early MSA-C group (area under the curve = 0.99; sensitivity = 94%, specificity = 100%). The MCP sT1w/T2w ratio correlated with the ICARS score in early MSA-C. CONCLUSIONS: The sT1w/T2w ratio can detect MSA-C-related changes in the MCP, even in the early stages of the disorder, and could be a sensitive biomarker for MSA-C. KEY POINTS: • The sT1w/T2w ratio can detect MSA-C-related changes in the middle cerebellar peduncle, even in the early stages of the disorder. • The middle cerebellar peduncle sT1w/T2w ratio correlated with a cerebellar ataxia score in early MSA-C patients.

BACKGROUND: The COVID-19 pandemic has created a need for educational materials and methods that can replace clinical clerkships (CCs) for online simulated clinical practice (online-sCP). This study evaluates the impact of using simulated electronic health records (sEHR) for inpatients, and electronic problem-based learning (e-PBL) and online virtual medical interviews (online-VMI) for outpatients, for an online-sCP using a learning management system (LMS) and online meeting system facilitated by a supervising physician. METHODS: The sEHR was reviewed by medical students and subsequently discussed with a supervising physician using an online meeting system. In the e-PBL, medical students reviewed the simulated patients and discussed on the LMS. For the online-VMI, a faculty member acted as an outpatient and a student acted as the doctor. Small groups of students discussed the clinical reasoning process using the online meeting system. A mixed-method design was implemented. Medical students self-assessed their clinical competence before and after the online-sCP. They answered questionnaires and participated in semi-structured focus group interviews (FGIs) regarding the advantages and disadvantages of the practice. RESULTS: Forty-three students completed the online-sCP during May and June 2020. All students indicated significant improvement in all aspects of self-evaluation of clinical performance after the online-sCP. Students using sEHR reported significant improvement in writing daily medical records and medical summaries. Students using e-PBL and online-VMI reported significant improvement in medical interviews and counseling. Students also indicated CCs as more useful for learning associated with medical interviews, physical examinations, and humanistic qualities like professionalism than the online-sCP. Eight FGIs were conducted (n = 42). The advantages of online-sCP were segregated into five categories (learning environment, efficiency, accessibility, self-paced learning, and interactivity); meanwhile, the disadvantages of online-sCP were classified into seven categories (clinical practice experience, learning environment, interactivity, motivation, memory retention, accessibility, and extraneous cognitive load). CONCLUSIONS: Online-sCP with sEHR, e-PBL, and online-VMI could be useful in learning some of the clinical skills acquired through CC. These methods can be implemented with limited preparation and resources.

目的:クリニカルクラークシップ(CC)における文献検索の現状と講義の効果を検証した。方法:対象は2019年5〜12月に呼吸器内科CCに参加した医学生67名。CC中に文献検索に関するアンケートと講義を実施した。結果:医学生はPubMedの使用頻度が多いが、利用する文献は日本語教科書、ガイドラインが多く、文献の吟味、英語読解に困難を感じていた。また、講義の前後で文献検索リテラシーの自己評価は有意に向上し、課題への引用文献数が前年度から増加した。結論:医学生は英語も含め文献検索は行うが文献の吟味や英語読解に困難を感じていた。また、講義でも文献検索リテラシーの向上が得られる可能性が示唆された。(著者抄録)

BACKGROUND: The "hot cross bun" (HCB) sign, a cruciform hyperintensity in the pons on magnetic resonance imaging (MRI), has gradually been identified as a typical finding in multiple system atrophy, cerebellar-type (MSA-C). Few reports have evaluated the sensitivity of an HCB, including a cruciform hyperintensity and vertical line in the pons, which precedes a cruciform hyperintensity, in the early stages of MSA-C. Moreover, the difference in frequency and timing of appearance of an HCB between MSA-C and spinocerebellar ataxia type 3 (SCA3) has not been fully investigated. METHODS: This study investigated the time at which an HCB and orthostatic hypotension (OH) appeared in 41 patients with MSA-C, based on brain MRI and head-up tilt test. The MRI findings were compared with those of 26 patients with SCA3. The pontine signal findings on T2-weighted MRI were graded as 0 (no change), 1 (a vertical T2 high-intensity line), or 2 (a cruciform T2 high-intensity line), with grades 1 or 2 considered as an HCB. OH 30/15 was defined as a decrease in systolic blood pressure of > 30 mmHg or diastolic blood pressure of > 15 mmHg. RESULTS: Among the 24 patients with MSA-C within 2 years from the onset of motor symptoms, an HCB was detected in 91.7%, whereas OH 30/15 was present in 60.0%. Among the 36 patients with MSA-C within 3 years from the onset of motor symptoms, a grade 2 HCB was detected in 66.7% of those with MSA-C but in none of those with SCA-3. CONCLUSIONS: HCB is a highly sensitive finding for MSA-C, even in the early stages of the disease. A grade 2 HCB in the early stage is an extremely specific finding for differentiating MSA-C from SCA-3.

身体診察は、医師の診療実践に不可欠な重要なスキルであるが、臨床実習では症例経験が場当たり的になる傾向にあり、系統立ててトレーニングする機会は十分ではない現状がある。そこで、疾患仮説に基づく身体診察の実践を目的に、臨床実習に参加している医学部4・5・6年生を主体とするサークル「General Medicine Interest Group(GMIG)」の取り組みを行なった。活動では近接性が高い反転授業と学習者相互学習による教育理論を取り入れ、発達の最近接発達領域、スキャフォールディングによる学習者の自律性を促し、効果的な身体診察スキル向上に有用な取り組みとなるため報告をする。(著者抄録)

<p>目的 : クリニカルクラークシップ (CC) における文献検索の現状と講義の効果を検証した. 方法 : 対象は2019年5〜12月に呼吸器内科CCに参加した医学生67名. CC中に文献検索に関するアンケートと講義を実施した. 結果 : 医学生はPubMedの使用頻度が多いが, 利用する文献は日本語教科書, ガイドラインが多く, 文献の吟味, 英語読解に困難を感じていた. また, 講義の前後で文献検索リテラシーの自己評価は有意に向上し, 課題への引用文献数が前年度から増加した. 結論 : 医学生は英語も含め文献検索は行うが文献の吟味や英語読解に困難を感じていた. また, 講義でも文献検索リテラシーの向上が得られる可能性が示唆された.</p>

Background: Role-play (RP) and peer review (PR) are occasionally used in training and evaluating communication skills in clinical clerkship (CC). Thus, we evaluated the effect of combining RP and PR during student-oriented CC rounds.Methods: Clerkship students conducted medical interviews with and performed physical examinations on their patients, which were reviewed by five peer students who observed their performance while role-playing as senior physicians or patients' families. The peer reviewers then provided feedback to the students. The performance of the students was evaluated based on a mini-clinical evaluation exercise (Mini-CEX) and a professionalism mini-evaluation exercise (P-MEX) before and after the rounds by two attending physicians. After the CC, the students responded to questionnaires about the rounds.Results: Seventy-five students completed the rounds, and the duration of each round was 41.7 ± 7.1 min. Their communication skills and professionalism abilities on Mini-CEX and P-MEX showed significant improvement after the rounds. Improvements in medical interviewing and physical examinations were also noted. Additionally, the students recognized the importance of multiple viewpoints in patient care through experiences of the rounds.Conclusions: Combining RP and PR with CC rounds improves the students' clinical performance and professionalism and promotes their awareness of the importance of multiple viewpoints in patient care.

<p>現在の心音・呼吸音の聴診訓練は，模擬患者と聴診訓練用マネキンを併用して行われている．この方法は様々な生体音で訓練が行える一方で，リアリティの欠如や，移動・設置が困難であるという欠点がある．我々は拡張現実技術を用いて模擬患者上に様々な症例の心音・呼吸音を再現し，医療面接と聴診手技を模擬患者に対して訓練可能とするシステムEARSを提案してきた．EARSは，聴診器に設置された赤外LEDと模擬患者に張り付けた反射マーカを，カメラユニットで検知することで聴診位置を取得する．しかし従来のEARSには，設置が煩雑，診察動作によって動作不良が発生する恐れがある，といった問題点があった．そこで本研究では，システム設置の煩雑さの解消と聴診器位置検出性能の向上を目的として，カメラユニットを聴診器に搭載したカメラ一体型聴診器デバイスの開発を行った(図参照)．さらに，聴診器位置検出に用いるチェストピースや反射マーカが遮蔽された際の聴診位置の検出法を考案した．提案システムの設置の簡便さ，聴診器検出性能について評価を行い，従来型と比較して性能向上を確認した．また，実際の医学教育現場に導入しアンケートによる評価を行った．</p>

Objective: To evaluate a short-time simulation training seminar on how to handle difficult patients using professional simulated patients (SPs) such as actors. Participants: Sixty-three second-year residents at Chiba University Hospital between 2015 and 2017 who only attended the seminar once. Intervention: The participants were divided into small groups, each of which was assigned a supervisory doctor as facilitator. Those who were playing the doctor's role enacted a medical interview with an SP. After the interview, the facilitator, the SP, and the observing residents participated in a debriefing while watching a recorded video of the interview. Outcome measures: Pre- and post-seminar questionnaires using a 7-point Likert scale (from 1: strongly disagree to 7: strongly agree) were used to examine the differences in "confidence in ability to handle difficult patients" and "learning motivation to handle difficult patients". The two items examined by both pre- and post-seminar questionnaires, were analyzed by a paired t-test. The residents were also surveyed on their satisfaction with the seminar, acquisition of new knowledge, and impressions and comments (free-text answers). Results: The findings of the questionnaire showed a significant post-seminar increase in confidence (3.1±1.6 to 4.0±1.5 [p<0.01]) and learning motivation (5.3±1.8 to 5.8±1.5 [p<0.01]) as well as high levels of satisfaction (5.8±1.1) with the seminar and acquisition of knowledge (5.7±1.3). Some residents further reported that the seminar led to self-review and was valuable for their future clinical practice. Conclusion: Our seminar on how to handle difficult patients was perceived as effective, as evaluated by the questionnaire, despite the short duration of the session. Factors potentially contributing to this effectiveness include the use of actors as SPs and the post-interview debriefing with feedback from the SP, colleagues, and facilitator.

Background: The optimal chemotherapy regimen for non-small cell lung cancer patients with interstitial lung disease is unclear. We therefore investigated the safety and efficacy of carboplatin plus nab-paclitaxel as a first-line regimen for non-small cell lung cancer in patients with interstitial lung disease. Methods: We retrospectively reviewed advanced non-small cell lung cancer patients with interstitial lung disease who received carboplatin plus nab-paclitaxel as a first-line chemotherapy regimen at Hyogo Cancer Center between February 2013 and August 2016. interstitial lung disease was diagnosed according to the findings of pretreatment chest high-resolution computed tomography. Results: Twelve patients were included (male, n = 11; female, n = 1). The overall response rate was 67% and the disease control rate was 100%. The median progression free survival was 5.1 months (95% CI: 2.9-8.3 months) and the median overall survival was 14.9 months (95% CI: 4.8-not reached). A chemotherapy-related acute exacerbation of interstitial lung disease was observed in one patient; the extent of this event was Grade 2. There were no treatment-related deaths. Conclusions: Carboplatin plus nab-paclitaxel, as a first-line chemotherapy regimen for non-small cell lung cancer, showed favorable efficacy and safety in patients with preexisting interstitial lung disease.