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Visitation restrictions for family members are problematic in intensive care management due to the COVID-19 pandemic. We analyzed the usefulness of an intensive care unit (ICU) diary about the experiences of family members of critical COVID-19 patients. Four family members of 2 COVID-19 patients participated in this report. Both patients were transferred to our ICU after 2 weeks of treatment at another ICU. An ICU diary was given to their family members post-transfer. The family members were interviewed before and after the patients’ discharge; the recorded interviews were analyzed and categorized into several clusters using a text mining method. Five categories regarding their anxious feelings were classified before the use of the ICU diary, and 3 categories were based on their positive feelings after the use of the ICU diary. Intensive care unit diaries may be beneficial for disclosing patients’ information when visitation restrictions are exercised due to the COVID-19 pandemic.

Introduction The medical emergency team enables the limitation of patients’ progression to critical illness in the general ward. The early warning scoring system (EWS) is one of the criteria for medical emergency team activation; however, it is not a valid criterion to predict the prognosis of patients with MET activation. Aim In this study, the National Early Warning Score (NEWS) and Rapid Emergency Medicine Score (REMS) was compared with that of the Acute Physiology and Chronic Health Evaluation II (APACHE II) score in predicting the prognosis of patients who had been treated a medical emergency team. Material and Methods In this single-centre retrospective cohort study, patients treated by a medical emergency team between April 2013 and March 2019 and the 28-day prognosis of MET-activated patients were assessed using APACHE II, NEWS, and REMS. Results Of the 196 patients enrolled, 152 (77.5%) were men, and 44 (22.5%) were women. Their median age was 68 years (interquartile range: 57-76 years). The most common cause of medical emergency team activation was respiratory failure (43.4%). Univariate analysis showed that APACHE II score, NEWS, and REMS were associated with 28-day prognostic mortality. There was no significant difference in the area under the receiver operating characteristic curve of APACHE II (0.76), NEWS (0.67), and REMS (0.70); however, the sensitivity of NEWS (0.70) was superior to that of REMS (0.47). Conclusion NEWS is a more sensitive screening tool like APACHE II than REMS for predicting the prognosis of patients with medical emergency team activation. However, because the accuracy of NEWS was not sufficient compared with that of APACHE II score, it is necessary to develop a screening tool with higher sensitivity and accuracy that can be easily calculated at the bedside in the general ward.

Al-rich Zn/Al/Zn clad solder were developed as Pb-free solder for a die-attachment. The Zn/Al/Zn clad solder was produced by clad rolling of Zn and Al strips in order to prevent Al from oxidation and improve wettability. The Zn/Al/Zn clad solder was melted at 382°C after solid-state interdiffusion of the Zn and Al layers. Bonding was successfully achieved with bonding pressure of a few kilopascals. Thermal cycle life of Invar-to-Cu substrate joint using the Zn/Al/Zn clad solder was longer than that of Pb-Sn-Ag solder. No Kirkendall voids were observed in the vicinity of the bonded interface after ageing at 250 °C for 1000 h.

Three-layer Zn/Al/Zn clad solders have been developed for high-temperature die attachment. The clad structure is used to improve the wettability and bondability of Zn-Al eutectic solder by preventing Al oxidation. The effects of the bonding conditions on the bondability with Zn/Al/Zn clad solder were investigated. Bonding was achieved in the temperature range from 385°C to 420°C under N2 atmosphere with oxygen concentration below 100 ppm. However, the bonding strength of the joint formed under N2 + 4% H2 atmosphere was almost 0 MPa, and stripe defects and air gaps remained in the bond layer. To improve the bondability under N2 + 4% H2 and expand the application range, a five-layer Cu/Zn/Al/Zn/Cu clad solder was developed in an attempt to prevent the Zn layers from being oxidized by the outer Cu layers. Cross-sectional observation of the Cu/Zn/Al/Zn/Cu clad solder revealed that the surface was covered by a Cu layer, and that Cu5Zn8 layers grew between the Cu and Zn layers. This clad solder exhibited high shear strength of over 80 MPa when formed under N2 + 4% H2 atmosphere, and no stripe defects or air gaps were observed in the bond layer.

Three-layer Zn/Al/Zn clad solders have been developed for high-temperature die attachment. The clad structure is used to improve the wettability and bondability of Zn-Al eutectic solder by preventing oxidation of the Al. The materials were produced by clad-rolling Zn and Al strips. TEM observations revealed that the Zn/Al clad interface was metallurgically bonded and that the Al oxide was almost entirely removed. The melting behavior of Zn/Al/Zn clad solder was examined. Eutectic melting began at the Zn/Al clad interface at 382°C, and all of the material melted within approximately 10 s. Unlike conventional Zn-Al solders, Zn/Al/Zn clad solders were successfully bonded without flux. The shear strength of a Zn/Al/Zn clad solder joint was three times that of a Pb-based solder joint. The bondability of Zn/Al/Zn clad solder was superior because the Al oxide films, which prevent bonding between chip and substrate, were fragmented by clad-rolling, and the outer Zn layers prevented Al oxidation during the bonding process.

Several drawing processes of 3N pure copper (Cu) with ultra high reduction in area have been performed, and the texture has been observed using electron back scattered diffraction. It is well known that the texture of drawn Cu is closely related to its mechanical properties; in particular nanometer scale width fibber shaped grain is interesting. Previously, it was reported that drawing 3N Cu with around 95% reduction in area changes its mechanical properties. In the present experiment, grains have been changed from round to fiber-shaped, and subsequently, submicron-width fiber grains were generated with a 94.546% reduction in area. However, above 94.546% reduction in area, dynamic recrystallization occurred and then, prevented the grains to be finer. Further recrystallized grains influence on the macroscopic mechanical properties of Cu wire. Furthermore, the distribution of the misorientation angle at grain boundaries increased with an increase in the degree of reduction in area; in particular, the distribution drastically increased between 94.546% and 99.997%. Further, the frequency of coincidence of site lattice boundaries increased. The abovementioned variations in texture are closely related to mechanical properties.

Although low-alloyed aluminum has been used as electric line and cable materials to date, there still is a great demand for higher strength with retaining the good electrical conductivity and ductility. In the study, iron has been chosen as an additive element and the addition effect on the strength and electrical has been investigated since iron is reported to have a marked solution-strengthening effect at a given addition amount. Aluminum with 99.99mass% purity and Al-Fe alloys with iron up to 0.9mass% were induction-melted, continuously cast into a rod with 8mm diameter, and cold-drawn into a wire with 0.3mm diameter. Tensile test and electrical resistivity measurement were carried out on the rod and wire after each pass. It was found that, in the rod, the strength increased while the ductility and electrical conductivity decreased as the addition iron amount was increased. Work hardening occurred clearly at an early stage of cold drawing, while it became sluggish as the cold reduction increased in each material. At the early stage, the strengths increased as the iron amount was increased, and at the later stage, the alloy with iron addition of 0.9mass% had higher strengths and larger elongation to failure.

厳密な血糖コントロールは重症患者の予後を改善させると言われているが,頻回の血糖測定が必要で,実際の施行には障害が大きい。今回,経静脈的持続血糖測定器を使用する機会を得たので,精度を動脈血血糖値と比較検討し,さらに施行上の問題点について報告する。【対象と方法】当院集中治療室入院中に同意を得た6例のうち,静脈内に20ゲージ専用留置針を留置できた2例に,人工膵臓STG(R)-22(日機装,東京)に接続して血糖値を持続モニターし,動脈血血液ガス分析装置の血糖値と比較検討した。【結果】動脈血と静脈血,血糖値の間にはr=0.964と非常に高い相関関係が得られた。Bland-Altman plotでは,負の相関関係がみられた。【考察および問題点】血糖値が高くなるにつれ,STG(R)-22による静脈血血糖値が動脈血血糖値に比べて低値となったが,これは機械的な性能ではなく,血糖値の増加に従い,動静脈血較差が広がるためと考えられた。また,ICUのベッドサイドにおける使用に際しては機器が大きい,回路が長くできないといった問題があり,今後,さらなる改良の必要性が示唆された。

胸腹部大動脈瘤(thoraco-abdominal aortic aneurysm, TAAA)術後の腸管虚血の診断に血清乳酸値が有用であった症例を経験した。症例は73歳,女性。胸腹部大動脈瘤の診断にてステント挿入術と,腹部分枝に対する人工血管を用いたバイパス術を施行した。術中およびICU入室後,低酸素血症やショックに陥ることがなかったが,腹部分枝バイパス終了6時間後から血清乳酸値の上昇と代謝性アシドーシスが進行した。代謝の亢進や肝不全,循環不全,呼吸不全を示唆する所見がなかったため,腸管虚血を疑った。試験開腹術を行ったところ,上腸間膜動脈にバイパスしたグラフトが屈曲し,血流が遮断されていた。直ちに虚血を解除し,新たにバイパス術を追加した。ICU帰室後,血清乳酸値は4時間で正常化し,患者は合併症を併発せず,第5病日には一般病棟へ退室した。大動脈疾患に伴う腸管虚血の診断は臨床症状以外では困難な場合が多い。血清乳酸値の特性を十分に把握した上での連続モニタリングは,大動脈疾患に伴う腸管虚血の診断に有用な補助手段となることが示唆された。

Guillain-Barre症候群(GBS)は,先行感染に遅れて1-3週間後に四肢の筋力低下,深部腱反射の消失などの症状が出現するが,先行感染による急性炎症反応亢進は軽度であることが多い。一方,critical illness polyneuropathy (CIP)は敗血症,多臓器不全,呼吸不全,SIRSからの回復期に,人工呼吸器からの離脱困難,四肢の筋力低下,腱反射の消失の症状を呈する。重複する感染症の程度によって,両者の鑑別は比較的容易であると考えられる。今回,先行感染があったが,敗血症性ショックからの回復期に四肢の運動障害,意識障害を呈し,CIPとの鑑別に苦慮した軸索型GBSの一例を経験したので報告する。症例は64歳の男性で,2週間前より発熱がみられ,内服薬が処方されていたが,症状の改善がみられず重症肺炎と急性腎不全を合併したため,当院へ緊急搬送された。敗血症性ショックを合併し,抗生物質,人工呼吸管理と持続血液濾過透析などの治療を行った。入院9日目より酸素化能の改善がみられ,ショックから離脱したが,人工呼吸器の圧補助を下げることができなかった。そこでGBSを疑ったが,髄液検査ではタンパク細胞解離はなかった。末梢神経伝導速度では運動神経の軸索型障害がみられた。後日判明した入院4日目のマイコプラズマ抗体価は2560倍であったため,マイコプラズマ肺炎による運動神経障害(acute motor axonal neuropathy; AMAN)型GBSと診断した。CIPは敗血症などの重症急性疾患の治療中に発症し,全身状態の改善とともに症状が改善する。しかし,GBSでは神経障害の回復には血漿交換や大量ガンマグロブリン投与が確立しており,本症例のように敗血症治療後に人工呼吸器からの離脱困難や四肢筋力の低下などのCIPを疑う症状がみられた場合には電気生理学的検査などを行い,GBSを除外する必要があると考えられる。

経皮二酸化炭素分圧(PtcCO2)測定とパルスオキシメータの小型センサーを同時に搭載した耳朶センサーを用いた測定装置TOSCA(R)(Linde社,スイス)の集中治療室での使用経験を報告した。対象はICUに入室した12症例の重症患者とし,左右いずれかの耳朶にセンサーを装着し,PtcCO2およびSpO2を測定した。適宜動脈血ガス分析を行い,PaCO2とPtcCO2とを比較検討したところ,相関係数0.95と良好な相関関係が得られたが,PaCO2が50mmHg以上ではPtcCO2がPaCO2よりも高くなり解離していく傾向があった。測定に伴う重篤な合併症はなく,体位変換に伴う体動でも測定が可能であった。ノルエピネフリン投与後PtCO2とPaCO2とが解離する症例があった。TOSCA(R)を用いたPtcCO2は,実測値と比べ若干高値に表示されるものの追従性も良く有用と考えられるが,重症患者における低灌流状態でのSpO2を含めた検討がさらに必要である。

急性膵炎と急性肝不全に陥った急性バルプロ酸(valproate sodium; VPA)中毒の1例を経験した。症例は53歳の男性で妻とともに倒れているところを発見され,当院に搬入された。搬入時意識レベルはJCS 300で嘔吐,尿失禁がみられた。血液検査では,高ナトリウム血症と高乳酸血症,高アンモニア血症があった。搬入8時間後に妻がVPAを処方されていたことが判明し,搬入6時間後のVPA血中濃度1,555(治療域100μg/ml以下)μg/ml,アセチルサリチル酸(acetylsalicylate; ASA)濃度114μg/ml(治療域150-300μg/ml)だった。臨床症状と併せて急性VPA中毒と診断し,搬入15時間後に直接血液灌流を施行した。第2病日には膵酵素と肝逸脱酵素の上昇,DICを認めた。腹部造影CT上,肝部分壊死と重症急性膵炎であることが判明した。患者は多臓器不全が進行し,第3病日死亡した。他院に搬入された妻も搬入6時間後のVPA血中濃度は1,534μg/mlだった。搬入8時間後に直接血液灌流を施行し,意識レベルの改善がみられた。経過中,膵酵素の上昇,DICがみられたものの肝障害や急性膵炎の所見は認めず,順調に回復し第18病日ICUを退室した。本症例のようにVPAの大量服用にASAを同時に服用した場合には,VPAの中毒症状が増強される可能性が示唆された。また,重症急性VPA中毒では早期の血液浄化が救命に繋がるのではないかと考えられた。

症例は73歳の男性。大量下血による出血性ショックのため来院した。腹部造影CT,血管造影にて内腸骨動脈瘤の破裂とその下部消化管穿破を疑い,止血と再破裂を防ぐために経カテーテル動脈塞栓術(TAE)を2度,施行した。5日後,腹部造影CTにて腹腔内遊離ガスが認められたため緊急開腹術を施行した。術中所見で直腸前壁に穿孔を認めたため,同部位を切除し,直腸断端を閉鎖して人工肛門を造設した(Hartmann手術)。この穿孔部位が血腫の消化管への穿破部位と考えられた。さらに4日後,腹腔内ドレーンから便臭を伴う多量の排液が観察されたため,再開腹下に直腸を再切断し,腹腔内洗浄ドレナージ術を施行した。その後,数度の腹腔内膿瘍を繰り返したが,第48病日に外泊可能となった。しかし外泊中に右下腹部痛が出現し,第50病日には救急車で搬送され,センター到着時は心肺停止であった。内腸骨動脈瘤再破裂による出血性ショックと思われた。心肺蘇生法を行ったが心拍再開せず,永眠された。近年,内腸骨動脈瘤破裂にTAEが有効な治療として用いられているが,消化管穿破例ではTAEのみでは生命予後を改善しないと考えられる。

We have evaluated the interfacial reactions of SiC fibre reinforced Al electrical power cable using low oxygen SiC fibre (Si : 62.4, C : 37.1, 0 : 0.5 mass%), and determined the relationship between the tensile strength and the amount of reaction products at the interface. The following are occurring at the SiC/Al interface: i) diffusion of Al atoms into the SiC fibre, ii) formation of needle–shape Al4C3 compounds, and iii) formation of Al9Si compounds. Formation of Al4C3 and Al9Si compounds at the interface causes the strength of SiC/Al composite electric power cable to deteriorate.

A case of transfusion-related acute lung injury (TRALI) that was successfully treated with extracorporeal membranous oxygenation (ECMO) is reported. A 58-year-old male patient underwent hepatectomy, and pulmonary edema occurred after the administration of fresh-frozen plasma and packed red cells. In the postoperative period, the impaired oxygenation progressively worsened, resulting in life-threatening hypoxemia, despite vigorous treatments. ECMO was therefore applied to the patient as a method of safe emergency support. Aggressive treatments under ECMO led to the successful improvement of the impaired oxygenation. TRALI is recognized as part of acute respiratory distress syndrome (ARDS). As a treatment for ARDS, ECMO does not cure the underlying disease of the lungs, however, with ECMO, TRALI, usually improves within 96 h with respiratory support. ECMO for TRALI-induced lethal hypoxemia is useful for providing time to allow the injured lung to recover. It is suggested that ECMO might be a useful option for the treatment of TRALI-induced, potentially lethal hypoxemia.

Electrical power demands are increasing every year, meaning that lightweight electric cable is needed which has high transmission capacity, high thermal resistance and low sag. Tokyo Electric Power Co., Chubu Electric Power Co. and Hitachi Cable Ltd. have been breaking new ground in the field of electric cable through the development of a SiC fiber reinforced aluminum conductor. In this work, the SiC/Al interface reaction during the manufacturing process and the electricity transmission temperature were studied by transmission electron microscopy (TEM), energy dispersive X-ray spectroscopy (EDX) and field emission-Auger electron spectroscopy (FE-AES) for long-term reliability assessment. No reaction products were detected at the SiC/Al interface of elemental wire consisting of 7 SiC/Al preformed wires, indicating that the wire manufacturing process was reliable. An Al4C3 product was detected locally at the SiC/Al interface of the wire which had been thermally treated in molten Al under unfavorable conditions. The activation energy, Q, of Al4C3 growth at the SiC/Al interface was about 190 kJ/mol. In the temperature range of electricity transmission, Al atoms diffused into SiC fiber during heat treatment, and the amount of the diffused Al increased with increasing treatment temperature and holding time. The activation energy of Al diffusion through the SiC/Al interface to SiC fiber was about 78 kJ/mol. Strength deterioration was not induced by Al diffusion into SiC fiber, but strength strongly depended on the formation of Al2SiO5 compound at the SiC/Al interface above 400°C transmission temperatures. Kinetics calculations indicated that the rate of strength deterioration of the composite cable, held at 300°C for 36 years, was about 5%, so that practical use of SiC/Al composite cable should not be far in the future.

If electrical power is transmitted by a power cable made of SiC fiber-reinforced aluminum, Al atoms diffuse into the reinforcement fiber at the transmission temperature. In this study, the diffusion coefficients of Al atoms in Hi-NicalonTM/Al system and NicalonTM/Al system were calculated. The outcomes of this study can be summarized as follows: (1) Diffusion coefficient of Al atoms in the Hi-NicalonTM SiC fiber is 10-3 times smaller than that of NicalonTM SiC fiber at transmission temperature between 300°C and 600°C. (2) Activation energy Q of Al diffusion in the two different SiC fibers are the same, but frequency factor D0 of Hi-NicalonTM SiC fiber is smaller than that of NicalonTM SiC fiber. (3) Diffusion coefficient of Al in the SiC fiber is related to the microcrystallite of the SiC fiber.

As electrical power demands increase every year, the need becomes stronger for light weight electric cables which have high transmission capacity, high thermal resistance and low sag. We have developed a SiC fiber reinforced aluminum electrical cable to meet this need. Mechanical properties of the SiC/Al composite conductor are very susceptible to iron impurity which becomes mixed in the Al matrix during manufacture of the composite conductor. In this work, we studied the effects of Fe impurity in Al on fracture behavior of the composite conductor. A preformed wire was prepared by dipping a bundle of 1500 pieces of SiC fiber (Si: 63.7, C: 35.8, O: 12.3 mass %) into molten Al in which 0.36 mass % Fe and 0.5 mass % Ti were mixed. The Ti was added to improve the wetting property. Test samples were prepared by bundling seven preformed wires together. A tensile test was carried out for the composite conductor, and pull-out behavior of SiC fiber at the fracture surface was observed by scanning electron microscopy (SEM), energy dispersive X-ray spectroscopy (EDX) and electron probe micro analysis (EPMA). Pull-out of SiC fiber was observed at the fracture surface of the composite conductor using Fe-free Al. However, pull-out of SiC fiber was not observed at the fracture surface of the composite conductor using Fe-containing Al since Al was combined inseparably with the SiC and Fe. The fracture origin of the Fe-containing sample was a precipitated Fe-compound at the SiC/Al interface. Tensile strength of the Fe-containing sample was a half of that of the Fe-free sample. We propose the following the precipitation mechanism for the Fe compound. In manufacturing of the preformed wire, molten Al solidifies from the surface to the SiC/Al interface because of the low thermal conductivity of the SiC fiber. In the cooling process, Fe-free Ti-compound precipitates in the molten Al by a peritectic reaction. This leads to a higher concentration of Fe in the molten Al near the interface, and finally, FeAl3 compound precipitates at the SiC/Al interface.

Low oxygen SiC fiber/Al interfacial reactivity was evaluated in comparison with that of an usual SiC fiber/Al interface. Chemical composition of low oxygen SiC fiber was Si: 62.4, C: 37.1, O: 0.5mass% and that of a usual SiC fiber was Si: 63.7, C: 35.8, O:12.3mass%. The outcomes of this study can be summarized as follows: (a) No product was detected at the low oxygen SiC fiber/Al interface. (b) The low oxygen SiC fiber-reinforced Al composite was higher corrosion resistance, and lower strength deterioration on compared with the usual SiC fiber-reinforced Al composite. (c) Al atoms diffuse into low oxygen SiC fiber during dipping into a molten Al with the diusivity of 6×10-15m2/s. (d) In the initial stage of interfacial reaction, low oxygen SiC fibers are not eroded, but a needle-shape Al4C3 phase forms on the fiber surface. On the other hand, the SiC fiber can be eroded by the Al4C3 formation, when long time dipping in the molten Al under unfavorable conditions.

Reduction of silver nitrate solution with some reducing agents was studied to obtain fine silver powder suitable for conductive paste.In ammoniacal solution, sub-micron spherical silver particles were obtained by use of hydroquinone, pyrogallol, and 3, 4-dihydroxytoluene; uene as a reducing agent. Reduction rates with the reductants were very fast and completed within a few seconds with almost 100% yields.From the result of X-ray diffraction and the observations of internal structure by transmission electron microscope, it was considered that the spherical particles were resulted from the agglomeration of crystallittes about 20nm in size.

We report a case of laxatives induced severe hypermagnesemia complicated with cardiopulmonary arrest. A 55-year-old woman, with nephritic syndrome and anorexia nervosa, was later transported to our emergency room (ER) because of oliguria and consciousness disturbance. During transfer to the intensive care unit from the ER, cardiopulmonary arrest suddenly occurred. Cardiopulmonary resuscitation was immediately performed, and spontaneous circulation was restored after 3 min. Thereafter, administration of dopamine, norepinephrine, and epinephrine was required to maintain systolic blood pressure at 80 mmHg. Arterial blood gas analysis showed severe metabolic alkalosis, and blood biochemical tests revealed hypermagnesemia (serum magnesium concentration, 18.5 mg/dl) and renal dysfunction. Continuous infusion of diuretics followed by massive hydration and continuous hemodiafiltration (CHDF) was started. Five days after starting CHDF, magnesium concentration was almost normalized and administration of catecholamine was stopped. It was thought that progression of renal dysfunction that occurred in the patient taking a magnesium product for chronic constipation caused reduction in magnesium excretion ability, resulting in hypermagnesemia-induced cardiopulmonary arrest. To avoid a rebound phenomenon following magnesium flux from cells, continuous blood purification seems to be an effective treatment for symptomatic hypermagnesemia.

大腸の原発性悪性リンパ腫はまれな疾患である.今回われわれは上行結腸原発悪性リンパ腫を1例経験したので, 若干の文献的考察を加え報告する.症例は18歳の男性.主訴は虫垂切除後の腹痛, 発熱で, 右下腹部に鶏卵大の腫瘤を触知した.注腸X線検査, 腹部超音波検査, computed tomography検査で右側結腸の腫瘤性病変を疑い手術を施行した.手術所見では盲腸から上行結腸にかけて弾性硬の腫瘤状の壁肥厚と多数の腫大した腸間膜リンパ節を認め, 悪性疾患と判断し右半結腸切除術とリンパ節郭清術を施行した.病理組織学的には非Hodgkin悪性リンパ腫で, Lymphoma Study Group分類ではdiffuse large ceoll typeであった.そのcell surface markerは抗B-cell抗体陽性細胞がびまん性に増殖し, IgG, γ型の単クローン性発現を認めた.術後CHOP-Pepleomycin療法を行い現在外来で経過観察中である.

The inhibitory mechanism of dopamine (DA) on rat gastric motility was investigated in association with DA receptors. Gastric movement was assessed according to the method of Jacoby et al and was expressed with the system of Ludwick et al. (1968). DA inhibited gastric movement in both the corpus and antrum in a dose-dependent manner. Domperidone, a specific antagonist of DA2 receptor, suppressed DA-induced inhibition of gastric movement in a dose-dependent manner. SCH23390, a specific antagonist of DA1 receptor did not affect DA-induced inhibition of gastric movement. LY171555, a specific agonist of DA2 receptor, inhibited gastric movement in both the corpus and antrum in a dose-dependent manner. SKF38393, a specific agonist of DA1 receptor, did not affect gastric movement. These results indicate that DA plays an important role in the inhibitory regulation of gastric motility, through DA2 receptor but not DA1 receptor.