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BACKGROUND: Necrotizing soft tissue infection (NSTI) caused by group A Streptococcus (GAS) is a life-threatening disease with high morbidity and mortality. Recently, group G Streptococcus (GGS) is increasingly reported as a cause of NSTI, which shows a similar fatality rate. A rapid antigen detection test (RADT) was used for GAS-induced NSTI to assist in the immediate diagnosis when judging the need for debridement surgery. METHODS: We describe 2 NSTI cases in which an RADT for GAS was negative, and in which GGS-induced NSTI was subsequently diagnosed. Both cases involved patients over 80 years of age whose medical histories included multiple conditions, including cardiac disorder and lower leg disease. After making a 1-cm skin incision at the central part of erythema, samples for both a wound culture and an RADT for GAS were taken from the subcutaneous layer. RESULTS: The RADTs were negative; however, the rapidly progressing clinical courses suggested the need for immediate debridement surgeries under general anesthesia. Removal of the skin and subcutaneous tissue and an incision for drainage achieved limb salvage. Wound cultures identified Group G Streptococcus (Streptococcus dysgalactiae) without other bacteria. Negative pressure wound therapy and split-layer mesh skin graft surgery cured the severe wounds without the need for amputation. CONCLUSIONS: Surgeons must be aware of the limitations of the RADT for GAS and determine the appropriate initial treatment based on comprehensive physical and laboratory findings.

4, KJ00006251279, シンポジウム 田園の生き物を考える

本研究の目的は、終末期ケアの啓蒙活動への高齢者の関心とその規定要因を明らかにすることである。対象は中国地方の老人クラブ会員258名で、医療保健専門家による終末期ケアに関する教育講演については58.9%に関心がみられた。関連要因として年齢があり、前期高齢者に感心が高い傾向であった他、終末期ケアに関する家族や医療従事者との話し合いをはじめ、かかりつけ医の有無、家族機能、手術経験などが関連していた。一方、延命治療の意向では医師や家族に判断を任すとした非自己決定群が58.6～61.1%であり、リビング・ウイルをよく知っているものは12.2%であった。以上のことから、前期高齢者の世代から家族や医療従事者との関係に配慮した上で、自分の意向を事前に周囲と話し合っておくことやアドバンス・ディレクティブについて啓蒙活動を行うことの重要性が示唆された。, The purpose of this study was to clarify elderly interest in medical professional's lecture as to terminal care, and related factors. Subjects were 258 Senior Citizens' Club Members, 58.9% were interested. Age was a related factor, that is, younger elderly were more interested. Other factors such as discussion about terminal care with family or medical staff, consulting family physician, family function, and experience in surgery were associated with their interest. On the other hand, more than half rely on doctor or family to do decision-making about life-sustaining treatment, if impossible to recover and only 12.2% understood living wills well. Therefore it is important to educate younger elderly to have discussion about end-of-life issues and advance directives in consideration of the relationship with their relatives.

自分で意志決定できなくなった時に受ける医療に対する事前指示であるアドバンス・ディレクティブについて、在宅高齢者313名を対象にその支持と関連要因について調査を行った。調査内容は基本属性、健康・医療状況、終末期ケアに関する意向、価値観としての自律性、家族機能、向宗教性、死に対する態度であった。アドバンス・ディレクティブの支持は72.9%にみられ、そのうち54.9%が法制化に賛成していた。項目ごとに累積ロジスティック分析を行い、有意差のあった項目を独立変数として検討した結果、「リビング・ウイルの認知度」、「延命治療について人工呼吸器装着の拒否」、「向宗教性」、「死に対する積極的受容」が支持に関連していた。以上のことから、医療施設や療養の場に高齢者が急増する中、終末期ケアに関する啓蒙活動や価値観に配慮した上で死の準備教育を行うことなどにより、高齢者の自己決定を支援していく必要性が示唆された。, Advance directives are legal documents that enable a person to make decisions about medical intervention in advance. We conducted a questionnaire survey to examine factors related to supporting advance directives. Of the 313 Senior Citizen's Club members, 72.9% supported advance directives, and 54.9% agreed to enshrine into law. Regression analysis revealed that members who support advance directives were more likely to have higher levels in recognizing living wills, wish to refuse receiving mechanical respiration in the terminal stage, strong attitudes towards religion, and approach-oriented death acceptance. These results suggest the need to educate the elderly about terminal care and to provide death education to help them in their decision-making processes that reflect their values.

(主査) 教授 瀬名波 栄潤, 准教授 竹内 康浩, 教授 高橋 英光, 文学研究科（言語文学専攻）

(主査) 教授 瀬名波 栄潤, 准教授 竹内 康浩, 教授 高橋 英光, 文学研究科（言語文学専攻）

2型糖尿病患者の特性に応じた教育・支援を行うためのアセスメントツールの開発を目指して,自己管理に影響する要因を文献から抽出した.検索方法は,2型糖尿病の自己管理に関連したキーワードを設定し,MEDLINE,CINAHL,医学中央雑誌のデータベース過去10年間を検索した.ヒット件数は,各々1162,860,691件であった.次いで,ADA(American Diabetes Association)Evidence guideline(2002年)の水準を参考に研究デザインを吟味した.その結果,該当する文献は71件で,国内文献が20件あった.有意差を認めた因子を整理したところ86因子あり,「知識・教育」「心理面」「満足度」「個人的要因」「治療」「収入・保険」「関係」の7カテゴリーに分類できた.しかし,介入方法の分類に結びつく因子(特性)や因子間の関係性は不明であり,効果的な介入を導くためのアセスメントツールを開発するためには,これらを検討する必要性が示唆された., To develop an assessment tool for education and follow-up for type 2 diabetes patients related to their characteristics, a structured literature review was conducted. The method of the review was by key words related to self-management/self-care for type 2 diabetes taken from the database for the past 10 years of MEDLINE, CINAHL, and Japan Medical Abstract Society. One-thousand one- hundred and sixty-two articles were obtained from MEDLINE, 860 from CINAHL, and 691 from the Japan Medical Abstract Society. Research designs were then examined, based on the ADA (American Diabetes Association) Evidence guideline (2002) evidence level. As a result, 71 articles, of which 20 were domestic, were retained. Eighty-six factors were found statistically significant, and were categorized in groups under the headings “knowledge/education", “psychological aspects", “level of satisfaction", “personal factors",“therapy/treatment", “income/insurance", and “family/relationship". Factors/characteristics lead toselecting interventional strategies. However, their overall relations have not been examined yet, whichsuggests that these need to be tested to develop an assessment tool which leads to an effectiveintervention program.