心臓麻酔の専門家でおられる筒井冨美先生が、“女医の仕事＆家庭の両立日記”http://clonidine.cocolog-nifty.com/clonidine/というブログをされています。表題からは一見想像がつかないのですが、心臓麻酔、食道エコーに関しての情報が詰まっています。一見の価値あり。
讃井將満
讃井將満
何をいまさら“ちょっと遅いんじゃない”という方が多数だと思いますが、“臨床に直結する感染症診療のエビデンス ベッドサイドですぐに役に立つリファレンスブック 文光堂”をパラパラッと見ましたが、いいですねー。すばらしい。JSEPTIC世話人の林先生も執筆者の１人ですし。JSEPTICでも、集中治療のエビデンス・ブック、いつか作りたいですね。
讃井將満
讃井將満
たぶん毎年やっているのだと思いますが，ハーバート大学主催の以下のような講習会があります。私は「成人感染症コース」を昨年受講しましたが，大変有意義なものでした。このコースもいつかチャンスがあえば受講してみたいと思います。
Perioperative and Critical Care Echocardiography and Echo Boards Review
Thursday - Sunday, Sept 4 - Sept 7, 2008
Fairmont Copley Plaza Hotel, Boston, Massachusetts
http://cme.med.harvard.edu/index.asp?SECTION=CLASSES&ID=00281288&SO=N
林 淑朗
Perioperative and Critical Care Echocardiography and Echo Boards Review
Thursday - Sunday, Sept 4 - Sept 7, 2008
Fairmont Copley Plaza Hotel, Boston, Massachusetts
http://cme.med.harvard.edu/index.asp?SECTION=CLASSES&ID=00281288&SO=N
林 淑朗
下記のような面白い内容の質問が届きました。
最近、ＩＣＵで細菌感染症で有意に増加するというプロカルシトニンをよく測定しています。どのような意義があるのでしょうか。
最近、ＩＣＵで細菌感染症で有意に増加するというプロカルシトニンをよく測定しています。どのような意義があるのでしょうか。
ブログのBOOKMARKのところに“過去ログ”の項目があります。現在のところスレッドごとに整理されておらず、見にくくて申し訳ありませんが、今後整理される予定です。新しくメンバーになられた方で、“あのことは話題になったのかなあ”、と思い悩んでいる方、ちょっと宝探し的に探してみると、いろいろ役立ち情報が詰まっているかもしれません。“こんなの、見にくくてしょうがないや”、という方、ページ冒頭にあるアドレスjseptic@mail.goo.ne.jpに無記名メールで尋ねることもできます。ちなみに、たとえば低体温療法のプロトコールについて知りたければ、メール番号301、417近辺を見て下さい。
メーリングリストに質問はちょっと、という方、日常臨床に素朴な疑問のある方、JSEPTICにご意見のある方、このjseptic@mail.goo.ne.jpにメールくだされば、無記名のまま、メーリングリストの話題として取り上げさせていただくこともできます。質問にはアツイ先生方がすぐにお答えくださるはずです。
讃井將満
メーリングリストに質問はちょっと、という方、日常臨床に素朴な疑問のある方、JSEPTICにご意見のある方、このjseptic@mail.goo.ne.jpにメールくだされば、無記名のまま、メーリングリストの話題として取り上げさせていただくこともできます。質問にはアツイ先生方がすぐにお答えくださるはずです。
讃井將満
集中治療にまったく関係ない話です。
２年ぐらい前だったと思いますが、大西泰斗先生という言語学者、英語教育の専門家が、しばしばNHKの英語教育関連番組に出演していたのを覚えている方いらっしゃいますでしょうか。
私は当時彼の言う、ネイティブの感覚（イメージ）で考える（覚える）英文法や単語シリーズの本にはまり、いくつか通読しました。目からウロコ的な話が満載で、非常に“お得感”があります。読んでみて、“こんな本が高校生時代にあったら、今頃は.....”と思う方はきっと多いはずです。
例えば、不定冠詞のaや定冠詞のtheをネイティブがどのような感覚で使っているか解説し、その感覚を覚えれば100%完璧は無理としても80%は間違えないという件があります。冠詞については中学時代から頭を悩ます大きな問題だった私も、この本を読んだ後、なぜここで不定冠詞aではなく定冠詞theを使わなければいけないか、なぜ昔、“数えられないから不定冠詞のaがついたり複数形にすることはない”、と習った不加算名詞にaがついたり複数形になることがあるのか、理解が深まりました。
このような役に立つ情報が満載ですし、いくつかのシリーズになっていますので、アマゾンで検索してご興味のある方は読んでみて下さい。また、大西先生のホームページもあるようですhttp://www.englishatheart.info/
讃井
２年ぐらい前だったと思いますが、大西泰斗先生という言語学者、英語教育の専門家が、しばしばNHKの英語教育関連番組に出演していたのを覚えている方いらっしゃいますでしょうか。
私は当時彼の言う、ネイティブの感覚（イメージ）で考える（覚える）英文法や単語シリーズの本にはまり、いくつか通読しました。目からウロコ的な話が満載で、非常に“お得感”があります。読んでみて、“こんな本が高校生時代にあったら、今頃は.....”と思う方はきっと多いはずです。
例えば、不定冠詞のaや定冠詞のtheをネイティブがどのような感覚で使っているか解説し、その感覚を覚えれば100%完璧は無理としても80%は間違えないという件があります。冠詞については中学時代から頭を悩ます大きな問題だった私も、この本を読んだ後、なぜここで不定冠詞aではなく定冠詞theを使わなければいけないか、なぜ昔、“数えられないから不定冠詞のaがついたり複数形にすることはない”、と習った不加算名詞にaがついたり複数形になることがあるのか、理解が深まりました。
このような役に立つ情報が満載ですし、いくつかのシリーズになっていますので、アマゾンで検索してご興味のある方は読んでみて下さい。また、大西先生のホームページもあるようですhttp://www.englishatheart.info/
讃井
どこかの整形外科でおきたセラチア敗血症が世間を騒がせています。これに関連して，IDATENのメーリングリストでもエンドトキシンの話題がでてました。日本の病院ではエンドトキシンがよくオーダーされます。私自身はいまだかつて一度もオーダーしたことがありませんし，解釈の仕方を知りません。しかし，多くの診療科の医師がオーダーしてます。臨床的に敗血症を強く疑う状況で，エンドトキシンが陽性の場合と陰性の場合で，治療方針でどのような変更があるのでしょうか？もちろんこの質問に答えられるような臨床研究は存在しません。治療方針の決定に影響を与えない検査は無駄以外の何物でもありません（臨床研究目的を除いて）。医療費はかかりますし，患者は血液を採られますし，検査技師も労働を強いられます。さらに解釈方法が定まっていない検査なのに，個人的経験や勘，その施設の習慣に基づいて，判断が下されるとするならば，患者に害が及ぶ可能性があります。これはβＤグルカン，CMVアンチゲネミア，ガラクトマンナンなどの近年登場した他のバイオマーカーにも言えることです。もちろんこれらの検査に全く利用価値の可能性がないとは私も思っていません。中にはある特定の母集団では，これらの結果が治療方針に影響を与える例もあります（エンドトキシンにはありませんが）。また，検査特性を知るための臨床研究などは行う価値が十分あると思います。しかしその場合は，しっかりと臨床研究のために必要な手続きを経なければなりませんし，研修医や学生には「臨床研究のために測定していて，現時点での臨床的意義は不明である」と正しく教えてあげる必要があります。
皆さんがもしこれらの検査をオーダーすることがあるとするなら，オーダーする前に「陽性ならこうする」とか「陰性ならこうする」とかの方針をすでに持っていますか？結果を見てから「さぁどうしよう」と悩んでいますか？それともしっかりと計画された臨床研究ですか？
このような問題は，最近医学書院から出版された下記の本を読むとすっきりします
野口善令，福原俊一著
「誰も教えてくれなかった診断学」
http://www.amazon.co.jp/%E8%AA%B0%E3%82%82%E6%95%99%E3%81%88%E3%81%A6%E3%81%8F%E3%82%8C%E3%81%AA%E3%81%8B%E3%81%A3%E3%81%9F%E8%A8%BA%E6%96%AD%E5%AD%A6%E2%80%95%E6%82%A3%E8%80%85%E3%81%AE%E8%A8%80%E8%91%89%E3%81%8B%E3%82%89%E8%A8%BA%E6%96%AD%E4%BB%AE%E8%AA%AC%E3%82%92%E3%81%A9%E3%81%86%E4%BD%9C%E3%82%8B%E3%81%8B-%E9%87%8E%E5%8F%A3-%E5%96%84%E4%BB%A4/dp/4260004077/ref=pd_bbs_sr_1?ie=UTF8&s=books&qid=1213364723&sr=8-1
林 淑朗
皆さんがもしこれらの検査をオーダーすることがあるとするなら，オーダーする前に「陽性ならこうする」とか「陰性ならこうする」とかの方針をすでに持っていますか？結果を見てから「さぁどうしよう」と悩んでいますか？それともしっかりと計画された臨床研究ですか？
このような問題は，最近医学書院から出版された下記の本を読むとすっきりします
野口善令，福原俊一著
「誰も教えてくれなかった診断学」
http://www.amazon.co.jp/%E8%AA%B0%E3%82%82%E6%95%99%E3%81%88%E3%81%A6%E3%81%8F%E3%82%8C%E3%81%AA%E3%81%8B%E3%81%A3%E3%81%9F%E8%A8%BA%E6%96%AD%E5%AD%A6%E2%80%95%E6%82%A3%E8%80%85%E3%81%AE%E8%A8%80%E8%91%89%E3%81%8B%E3%82%89%E8%A8%BA%E6%96%AD%E4%BB%AE%E8%AA%AC%E3%82%92%E3%81%A9%E3%81%86%E4%BD%9C%E3%82%8B%E3%81%8B-%E9%87%8E%E5%8F%A3-%E5%96%84%E4%BB%A4/dp/4260004077/ref=pd_bbs_sr_1?ie=UTF8&s=books&qid=1213364723&sr=8-1
林 淑朗
無料でAHA guidelineが読めますよ。本日、関連のあるところをpdfにおとしました。
http://www.americanheart.org/presenter.jhtml?identifier=2158
藤谷茂樹
http://www.americanheart.org/presenter.jhtml?identifier=2158
藤谷茂樹
飯塚病院つながりで白井敬祐先生（サウスカロライナ医科大学血液腫瘍内科）に教えてもらった、Dr. Brian Drukerというグリベック（慢性骨髄性白血病の薬）を発見した人の、医科大学卒業式での卒業生向けのスピーチです。元気が出ます。長くて済みませんが。
讃井將満
Dr. Brian Druker's OHSU commencement speech
Posted by The Oregonian June 07, 2007 16:01PM
Targeting Hope When Nobody Believes in You
OHSU Commencement 2007
Brian J. Druker, MD
JELD-WEN Chair of Leukemia Research
Director of the OHSU Cancer Institute Leukemia Center
Howard Hughes Medical Institute Investigator
Elected to National Academy of Sciences
Elected to Institute of Medicine of the National Academies
Dr. Brian Druker: You don't have a future. You're not going to succeed.
I hope you never pursue a career in science.
Those are just a few of the words of encouragement I've heard in my career.
At the time, the words stung. They caused me to doubt myself, but they
were not fatal. And strangely, I now look on them as gifts. They
helped shape who I am today. Those low expectations made me more
determined. Now, I'm not going to thank those people who dismissed me
and I'm certainly not going to dedicate this speech to them. But they
helped me define my goals and who I am.
This is an exciting time for you. You have persevered and made it to
graduation. You have made your teachers and families proud. But along
the way, someone will doubt you. Maybe they already have. What matters
is that you listen to your inner voice that tells you anything is
possible.
Fifteen years ago I was a young scientist at a critical juncture in my
career looking for my first faculty appointment. At the time, I was at
Harvard's Dana-Farber Cancer Institute where I had completed my
training in Oncology and had spent seven years working in the lab
developing my skills as a scientist. I had shown some promise by
developing one of the most widely used tools to study the regulation
of cell growth. I was making significant strides in leukemia research
and had published numerous papers, mostly as a collaborator. I was
feeling pretty good about my work. So I met with the man running
Dana-Farber to ask for some lab space and a promotion. He sat behind
his desk, thumbing through my papers. He told me I didn't have enough
independently- authored papers and that I didn't have a future at
Dana-Farber. But I had a back up. I had been negotiating with the
Chief of Medicine across the street at Beth Israel Hospital. When I
went back to close the deal, I was told the job had been given to
someone else with more promise.
I was devastated. Two of the most prominent leaders in the medical
field had told me I was not worth the investment. But as I look back,
this was a turning point. It was like someone knocked me in the head.
I had gone into cancer research to find a better way to treat cancer.
I was tired of giving chemotherapy and often making my patients sicker
rather than better. And I had promised my patients I would go into the
lab until I found a better way to treat cancer. Had I stayed at
Dana-Farber, I would have had a cushy job at a prestigious
institution. I would have played it safe.
But these events awakened and invigorated my desire to make a
difference. It was an opportune time. I believed targeted therapies
were the future. We were discovering what drives the growth of cancer
cells. I believed as we gathered more information about our cells and
how they malfunctioned we could develop drugs that act as cruise
missiles, destroying the cancer but leaving healthily cells alone.
Those setbacks gave me focus. I just needed lab space and a fresh
start. I accepted a job at OHSU and moved to Oregon. I had one goal. I
wanted to find a drug that worked in my disease models and get that
drug into the clinic for my patients. I was fortunate to find a boss
like Grover Bagby. He said recently, "Sometimes the best thing you can
do for a researcher is to give them an opportunity and leave them
alone." And he did just that for me.
Within six weeks of arriving in Oregon I started working with
compounds, one of which killed leukemia cells without harming normal
cells. I had exactly what I had been looking for. This compound would
later become the drug Gleevec. It's now considered a revolutionary
cancer treatment but at the time the drug company didn't think it was
worth the investment. They thought the drug wouldn't work, would be
too toxic, and would never make enough money to warrant the investment
in its development. Nor were they willing to take a chance on an
unheard of investigator from Oregon. It was a five-year crusade to get
this drug to patients.
And though I had felt abandoned by some people I once respected, there
was one group of people who never doubted me; my patients.
I'm always amazed at how patients believe in you, even when you're
just starting out. Even when you're just out of medical school,
pretending to be a doctor, but deep inside you don't feel like one.
Bud Romine was one of those patients who believed in me. Bud was a
newly retired railroad engineer. Four years earlier he had been
diagnosed with chronic myeloid leukemia, or CML, the disease I was
working on. He was 65 and had few options. He had tried interferon,
but it didn't work and left him with little energy. He was too old for
a transplant. His wife of 42 years, Yvonne, a retired bank clerk, kept
a meticulous folder filled with charts of his blood counts. The lines
fluctuated dramatically from 15,000 to 150,000. She drew another line
at 10,000 for the top of the normal range, something Bud hadn't seen
in over three years. But for Bud the numbers didn't mean much. He only
knew that he didn't have any energy to play golf and he often felt too
weak to get out of bed.
Bud read the story in the newspaper about our laboratory studies. He
contacted me immediately and put his life in my hands. The average
life expectancy for a CML patient was five years and Bud's time was
running out. But Bud put his faith in me and trusted that I would be
able to help him.
That faith bolsters you. It emboldened me to take on the biggest drug
company in the world and get this drug to them.
We had tested the drug in the lab and were pretty sure it was safe.
But until you give it to patients, you don't really know. Bud was
incredibly courageous. He stepped forward and wanted to be the first
patient to be given the drug. Within three weeks on Gleevec, his
counts returned to normal. But again the numbers didn't give the real
picture. For Bud, it meant he could play golf and spend his winters in
California.
Now, nine years later, this previously fatal leukemia has a 95%
five-year survival.
Let me put five years in a different perspective.
LaDonna, a retired dietician from SW Washington, came to my clinic
seven years ago. She could barely walk because her spleen, normally
the size of a fist, had swelled to the size of a football. Her spleen
compressed her stomach so that she couldn't hold down any food. She
was losing 2 to 3 pounds a day. She had only weeks left when she came
to see me. LaDonna had bought a burial plot and picked out the music
for her funeral. Within a week on Gleevec, she was able to walk again.
Her spleen shrunk and after a month her blood counts had returned to
normal.
I have a picture of LaDonna from five years ago where she is playing
with her grandchildren, age 16, 13 and a three year old she wasn't
supposed to meet, named Will, because he was her will to live. She
recently gave me a new picture. It was from her eldest grandchild's
wedding, now 21. Her 13 year old is now 18 and has graduated from high
school and her 3 year old is now 8 and just completed 3rd grade.
I owe the greatest debt to my patients who have put their faith in me
as we have gone on this journey to find better cancer treatments. I
have learned the importance of listening to your patients. Some of
best lessons come from them. And perhaps the greatest lesson they have
taught me is this; the greatest gift in life is hope.
We are at an important juncture in medicine. We are so close to
eradicating many fatal diseases, such as cancer, or at least turning
them into manageable, chronic conditions. I have stood on the
shoulders of researchers who laid out the path for me. Some of you
will continue that work. Some of you will help us reach the goal of
curing cancer or other diseases. But all of you will bring hope to
your patients through the work you do.
I want to leave you with one last parting gift.
You will never succeed.
I can't wait to see how you prove me wrong.
讃井將満
Dr. Brian Druker's OHSU commencement speech
Posted by The Oregonian June 07, 2007 16:01PM
Targeting Hope When Nobody Believes in You
OHSU Commencement 2007
Brian J. Druker, MD
JELD-WEN Chair of Leukemia Research
Director of the OHSU Cancer Institute Leukemia Center
Howard Hughes Medical Institute Investigator
Elected to National Academy of Sciences
Elected to Institute of Medicine of the National Academies
Dr. Brian Druker: You don't have a future. You're not going to succeed.
I hope you never pursue a career in science.
Those are just a few of the words of encouragement I've heard in my career.
At the time, the words stung. They caused me to doubt myself, but they
were not fatal. And strangely, I now look on them as gifts. They
helped shape who I am today. Those low expectations made me more
determined. Now, I'm not going to thank those people who dismissed me
and I'm certainly not going to dedicate this speech to them. But they
helped me define my goals and who I am.
This is an exciting time for you. You have persevered and made it to
graduation. You have made your teachers and families proud. But along
the way, someone will doubt you. Maybe they already have. What matters
is that you listen to your inner voice that tells you anything is
possible.
Fifteen years ago I was a young scientist at a critical juncture in my
career looking for my first faculty appointment. At the time, I was at
Harvard's Dana-Farber Cancer Institute where I had completed my
training in Oncology and had spent seven years working in the lab
developing my skills as a scientist. I had shown some promise by
developing one of the most widely used tools to study the regulation
of cell growth. I was making significant strides in leukemia research
and had published numerous papers, mostly as a collaborator. I was
feeling pretty good about my work. So I met with the man running
Dana-Farber to ask for some lab space and a promotion. He sat behind
his desk, thumbing through my papers. He told me I didn't have enough
independently- authored papers and that I didn't have a future at
Dana-Farber. But I had a back up. I had been negotiating with the
Chief of Medicine across the street at Beth Israel Hospital. When I
went back to close the deal, I was told the job had been given to
someone else with more promise.
I was devastated. Two of the most prominent leaders in the medical
field had told me I was not worth the investment. But as I look back,
this was a turning point. It was like someone knocked me in the head.
I had gone into cancer research to find a better way to treat cancer.
I was tired of giving chemotherapy and often making my patients sicker
rather than better. And I had promised my patients I would go into the
lab until I found a better way to treat cancer. Had I stayed at
Dana-Farber, I would have had a cushy job at a prestigious
institution. I would have played it safe.
But these events awakened and invigorated my desire to make a
difference. It was an opportune time. I believed targeted therapies
were the future. We were discovering what drives the growth of cancer
cells. I believed as we gathered more information about our cells and
how they malfunctioned we could develop drugs that act as cruise
missiles, destroying the cancer but leaving healthily cells alone.
Those setbacks gave me focus. I just needed lab space and a fresh
start. I accepted a job at OHSU and moved to Oregon. I had one goal. I
wanted to find a drug that worked in my disease models and get that
drug into the clinic for my patients. I was fortunate to find a boss
like Grover Bagby. He said recently, "Sometimes the best thing you can
do for a researcher is to give them an opportunity and leave them
alone." And he did just that for me.
Within six weeks of arriving in Oregon I started working with
compounds, one of which killed leukemia cells without harming normal
cells. I had exactly what I had been looking for. This compound would
later become the drug Gleevec. It's now considered a revolutionary
cancer treatment but at the time the drug company didn't think it was
worth the investment. They thought the drug wouldn't work, would be
too toxic, and would never make enough money to warrant the investment
in its development. Nor were they willing to take a chance on an
unheard of investigator from Oregon. It was a five-year crusade to get
this drug to patients.
And though I had felt abandoned by some people I once respected, there
was one group of people who never doubted me; my patients.
I'm always amazed at how patients believe in you, even when you're
just starting out. Even when you're just out of medical school,
pretending to be a doctor, but deep inside you don't feel like one.
Bud Romine was one of those patients who believed in me. Bud was a
newly retired railroad engineer. Four years earlier he had been
diagnosed with chronic myeloid leukemia, or CML, the disease I was
working on. He was 65 and had few options. He had tried interferon,
but it didn't work and left him with little energy. He was too old for
a transplant. His wife of 42 years, Yvonne, a retired bank clerk, kept
a meticulous folder filled with charts of his blood counts. The lines
fluctuated dramatically from 15,000 to 150,000. She drew another line
at 10,000 for the top of the normal range, something Bud hadn't seen
in over three years. But for Bud the numbers didn't mean much. He only
knew that he didn't have any energy to play golf and he often felt too
weak to get out of bed.
Bud read the story in the newspaper about our laboratory studies. He
contacted me immediately and put his life in my hands. The average
life expectancy for a CML patient was five years and Bud's time was
running out. But Bud put his faith in me and trusted that I would be
able to help him.
That faith bolsters you. It emboldened me to take on the biggest drug
company in the world and get this drug to them.
We had tested the drug in the lab and were pretty sure it was safe.
But until you give it to patients, you don't really know. Bud was
incredibly courageous. He stepped forward and wanted to be the first
patient to be given the drug. Within three weeks on Gleevec, his
counts returned to normal. But again the numbers didn't give the real
picture. For Bud, it meant he could play golf and spend his winters in
California.
Now, nine years later, this previously fatal leukemia has a 95%
five-year survival.
Let me put five years in a different perspective.
LaDonna, a retired dietician from SW Washington, came to my clinic
seven years ago. She could barely walk because her spleen, normally
the size of a fist, had swelled to the size of a football. Her spleen
compressed her stomach so that she couldn't hold down any food. She
was losing 2 to 3 pounds a day. She had only weeks left when she came
to see me. LaDonna had bought a burial plot and picked out the music
for her funeral. Within a week on Gleevec, she was able to walk again.
Her spleen shrunk and after a month her blood counts had returned to
normal.
I have a picture of LaDonna from five years ago where she is playing
with her grandchildren, age 16, 13 and a three year old she wasn't
supposed to meet, named Will, because he was her will to live. She
recently gave me a new picture. It was from her eldest grandchild's
wedding, now 21. Her 13 year old is now 18 and has graduated from high
school and her 3 year old is now 8 and just completed 3rd grade.
I owe the greatest debt to my patients who have put their faith in me
as we have gone on this journey to find better cancer treatments. I
have learned the importance of listening to your patients. Some of
best lessons come from them. And perhaps the greatest lesson they have
taught me is this; the greatest gift in life is hope.
We are at an important juncture in medicine. We are so close to
eradicating many fatal diseases, such as cancer, or at least turning
them into manageable, chronic conditions. I have stood on the
shoulders of researchers who laid out the path for me. Some of you
will continue that work. Some of you will help us reach the goal of
curing cancer or other diseases. But all of you will bring hope to
your patients through the work you do.
I want to leave you with one last parting gift.
You will never succeed.
I can't wait to see how you prove me wrong.
http://www.ccm.upmc.edu/education/journal_club/jcinstr.htmlに論文の評価法がのせてあります。かなり厳密ですし、基礎知識がないと、ワークシートの中の英語の質問の内容が今一つピンと来ないものがあり、そのまま導入すると挫折する施設があるかもしれません。そんな方のために、JSEPTIC総会で“正しいジャーナルクラブのやり方”について講義がありますので、乞うご期待。ちなみに、http://ccforum.com/articles/browse.asp?sort=Journal+club+critiqueで、UMPCで行われたジャーナルクラブのサマリーを見ることができます。
マイアミ大学外傷/外科系集中治療部で使用していたワークシートはもっと簡単で、内科系集中治療と外科系集中治療の違いを如実に表しているような気がしますが、お見せ出来ないのが残念。そのうち、自治医大さいたま医療センター麻酔科・集中治療部のホームページからアクセス出来るようにしたいと思っていますが、in the meantime、見たい方は私までメールmsanui@mac.comを下さい。
マイアミ大学外傷/外科系集中治療部で使用していたワークシートはもっと簡単で、内科系集中治療と外科系集中治療の違いを如実に表しているような気がしますが、お見せ出来ないのが残念。そのうち、自治医大さいたま医療センター麻酔科・集中治療部のホームページからアクセス出来るようにしたいと思っていますが、in the meantime、見たい方は私までメールmsanui@mac.comを下さい。