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Falcom Sound Team jdkについて 目次 [非表示] Falcom Sound Team jdk とは？ Falcom Sound Team jdk の慣習 進捗状況 Falcom Sound Team jdk とは？ + English What is Falcom Sound Team jdk? After Yuzo Koshiro (who succeeded as a composer with Ys I II and Sorcerian) left the company, Mieko Ishikawa (who debuted with the MSX version of Xanadu) became Falcom's sole composer, and worked alone on Sorcerian's additional scenarios, Star Trader and Ys III. The first mention of “J.D.K.” appeared in Star Trader, released in March 1989. According to the official book Falcom Music Chronicle, this unit was founded in late 1988, and all activity by Falcom's sound staff since then has been attributed to this new alias. This same unit was rebranded as “Falcom Sound Team J.D.K.” in 1991, in order to distinguish it from “J.D.K. BAND” – a freelance band that specializes in arranging and performing Falcom music. With the release of Revival Xanadu in March 1995, both “J.D.K.” units were renamed to “Falcom Sound Team jdk” and "jdk BAND”. The meaning of “jdk” and the reasons behind its formation are still shrouded in mystery. Since the formation of the sound team unit, all internal composition and arrangement activities are credited to “Falcom Sound Team jdk”. Its integrants are mentioned during the ending credits, but whoever is in charge of each song is not disclosed at all. In addition, all soundtracks produced prior to the formation of Sound Team jdk (before late-1988) has been retroactively credited as such, including all of Koshiro's Falcom work. Similarly, “J.D.K. (jdk) BAND” also exists as an unit with the name J.D.K (jdk), but they are essentially a separate group specialized in live performances. The sound team is made up of internal employees, while the band consists of a group of freelance musicians who are not Falcom employees. The songs intended to be performed by jdk BAND are arranged by the band's leader/director. · The first generation of J.D.K. BAND (1990~1996) was led by Tomohiko Kishimoto. Kishimoto was the band's leader, lead vocalist, lyricist, synthesizer/drum programmer and in charge of all their arrangements, and also performed guitar and bass at times. · The second generation of jdk BAND (2007~2015) was directed by Yukihiro Jindo, who also composed and arranged music for Falcom as a contractor, along with drummer Toshiharu Okajima and keyboardist Noriyuki Kamikura. · The third generation (2015~Present) is directed by Mitsuo Singa, who also provides compositions and arrangements for Falcom as a contractor. All performers from the second generation were replaced by newcomers. Falcom Sound Team jdk rules Handles not only music composition and arrangement, but also everything else related to sound, such as SE production and voice editing as well. Since Falcom is a small company, it is not uncommon for employees to work concurrently in other tasks and duties. Sound Team jdk members are no exception. If an employee isn't enrolled in Falcom when a game is released, their name will be removed from the in-game credits, no matter how many songs they have composed. In recent years, Falcom has often used previously rejected songs made in the past in newer games, including by former composers after they leave. Contractors usually get an "Arrangement" credit on album booklets. Sometimes this is true, but others is not and the "arrangers" are actually "composers". However, ever since Tokyo Xanadu (or more specifically since Mitsuo Singa appeared), the "Arrangement" (Composition) credit for independent contractors has been lost (except for vocal songs). (English text provided by Josep. I recommend the "Nihon Falcom (Sound Team J.D.K./jdk) Composer Breakdown Project" created by Josep and others to foreigners.) 「イース」や「ソーサリアン」で作曲者として大成功を収めた古代祐三氏が「イースII」で退社後、ファルコムのサウンドスタッフは「イース」でデビューをした石川三恵子氏ただ一人となる。ソーサリアンの追加シナリオなどで石川氏が一人孤軍奮闘したのち1989年3月発売の「スタートレーダー」のクレジットにて初めて『J.D.K.』の名前が世に出ることになりこのタイトルからサウンドスタッフは全員ひと括りにされチーム制度となる。1991年に曲のアレンジと演奏を専門とする『J.D.K.BAND』の発足を機にそれぞれのチームを区別するため『Falcom Sound Team J.D.K.』へ改名。1995年3月に発売された「リバイバルザナドゥ」以降から『Falcom Sound Team jdk』へさらに改名された。"jdk"の意味、結成した理由などはいまだ謎に包まれたままである。 2013年6月当時のボイスや効果音の入れ込み作業風景 左からjdkメンバーの萩生田朋克氏, 宇仁菅孝宏氏, 園田隼人氏, 籾山紗希氏 (情報源YouTube) Voice and sound effects working in June 2013 From left to right, jdk members Mr.Hagiuda, Mr.Unisuga, Mr.Sonoda, Ms.Momiyama サウンドチームが結成されて以降、ファルコム社内での作編曲は全て『Falcom Sound Team jdk』及び『J.D.K.』の名のもとにおこなわれるようになった。ただしエンドロールクレジットなどでそのゲームタイトルに関わったメンバーだけは最低限公表されるが曲別の担当はサウンドトラックでも一切明かされない。またサウンドチーム結成以前の曲でも結成以降に発売されたタイトルやサウンドトラックなどは全て『Falcom Sound Team jdk』名義に変更されている。 このことに関して海外メディアからインタビューを受けた白川篤史氏によると”「個々のメンバーの名前がクレジットされないのはチームとしての総合的な働きに焦点を当てたかったからだと思います。また個人の仕事量が公平かどうかで揉めるのを防ぐためでもあったのでしょう。」(*1)”と答えている。実際この方針を通じて幾ら年月が経ってもメンバー構成が変わっても「ファルコムサウンド」というブランドイメージを継続して維持出来たこともまた事実である(*2)。 ただ、誠実なスタッフクレジットをしてくれないことは消費者の立場からみてかなり不親切なこともまた確か。比較対象としては適切ではないが2017年にコナミが自社のサウンドスタッフを「BEMANI Sound Team」名義に変更しようとしてファンから猛反発を買い撤回した例があるほど。それだけゲーム音楽においてファンがクリエイターの個性を重視している証と言える。Falcom Sound Teamが発足した三十数年前ならいざ知らず、情報公開が進んだ今の時代、作曲者の曲別クレジットをしないゲーム会社は非常に稀であり時代に反しているように思える。ただこの秘密主義のお陰でそのヴェールを剥がそうとするマニア層コミュニティが中国や欧米を中心に形成されていき(*3)結果様々なリークに繋がることになったのは皮肉な話だがある意味当然の成り行きでもあったのだろう。 ちなみに同じくJ.D.K.(jdk)の名を持つチームとして『J.D.K.(jdk)BAND』が存在するが彼らは基本的に演奏を専門とするチームである。『Falcom Sound Team jdk』はファルコム社員で構成されるがバンドチームは社員ではないフリーのミュージシャンの集まりである。なので彼らはサウンドチームの正式メンバーではない。演奏をする曲は原則的にバンドチームのリーダーが編曲をおこない初代jdkBANDリーダーでは岸本友彦氏によって様々な編曲がなされライブなどが開かれた。さらに神藤由東大氏をリーダーとする2代目jdkBANDでは編曲だけでなくタイトルによっては作曲もおこなうようになり神藤氏、岡島俊治氏、上倉紀行氏が精力的に活動をした。3代目ではリーダーの真我光生氏のみが作曲をおこなうようになっている。 ↑PAGE TOP Falcom Sound Team jdk の慣習 ※過去に存在した公式企画「ふぁるコラム」やスタッフインタビューなどからの情報による。 音楽の作編曲だけでなくSE制作、音声編集など音にまつわることはなんでもおこなっている。 ファルコムでは音楽スタッフを含めて社員が他の分野の仕事を兼任していることは珍しくない。 ゲーム発売時にファルコムに在籍していなかった場合は採用された曲があったとしてもエンドロールクレジットには載らない。 現行・退社音楽スタッフが過去に作った曲の再利用をおこなっている場合が多い。 外注の音楽スタッフは基本的に編曲としてクレジットされるが本当に編曲のときもあれば実際には作曲を行っていることもある。 東亰ザナドゥ以降、さらに言うと外注の音楽スタッフ真我光生氏が参加し始めて以降は外注スタッフの編曲(作曲)クレジットは歌もの以外載らなくなっている。 ↑PAGE TOP 進捗状況 ゲーム内のサウンドクレジットが「Falcom Sound Team jdk (J.D.K.)」となって以降、また編曲者が公式に明らかにされていない作品のみを取り上げる。 （ = 解明済み / = 大凡解明しているが一部不明瞭 / = 当Wikiにより推測済み / = 未解明） 発売年 タイトル 1989 03 スタートレーダー 07 ワンダラース・フロム・イース 12 ドラゴンスレイヤー英雄伝説 1990 12 ダイナソア 1991 03 ロードモナーク 10 ブランディッシュ 11 アドバンスド ロードモナーク 1991 12 ぽっぷるメイル 1992 03 ドラゴンスレイヤー英雄伝説II 1993 03 ブランディッシュ2 -THE PLANET BUSTER- 11 イースIV -MASK OF THE SUN- 12 イースIV -The Dawn of Ys- 1994 02 風の伝説ザナドゥ 03 英雄伝説III -白き魔女- 06 ぽっぷるメイル SFC版 11 ブランディッシュ3 1995 04 リバイバルザナドゥ 06 風の伝説ザナドゥII 12 イースV -失われた砂の都ケフィン- 12 リバイバルザナドゥII 1996 05 英雄伝説IV -朱紅い雫- 10 ブランディッシュVT 12 ロードモナーク・オリジナル 1997 04 新英雄伝説 Win版 06 ソーサリアン・フォーエバー 1997 11 ファルコムクラシックス 12 ヴァンテージマスター 1998 03 英雄伝説III -白き魔女- PS版 04 イース エターナル 08 英雄伝説IV -朱紅い雫- PS版 10 モナークモナーク 12 ブランディッシュ4 -眠れる神の塔- 1999 04 英雄伝説III -新・白き魔女- Win版 12 英雄伝説V -海の檻歌- 2000 07 イースII エターナル 12 英雄伝説IV -朱紅い雫- Win版 2001 06 イースI 完全版 06 （交響曲イース -21st Century-） 09 （交響曲「ガガーブトリロジー」） 12 ツヴァイ!! 12 （イース・ヒーリング） 2002 06 VM JAPAN 06 （交響幻想曲「白き魔女」） 12 ダイナソア -リザレクション- 12 （ツヴァイ!! スーパーアレンジバージョン） 2003 09 イースVI -ナピシュテムの匣- 2004 06 英雄伝説 空の軌跡 12 ぐるみん 2005 06 RINNE 06 イース -フェルガナの誓い- プレアレンジ版 10 ザナドゥ・ネクスト 2006 03 英雄伝説 空の軌跡SC 12 イース・オリジン 2007 06 英雄伝説 空の軌跡 the 3rd 2008 12 ツヴァイ2 2009 09 イースSEVEN 2010 07 イースvs.空の軌跡 オルタナティブ・サーガ 09 英雄伝説 零の軌跡 2011 09 英雄伝説 碧の軌跡 2012 07 那由多の軌跡 09 イース -セルセタの樹海- 2013 09 英雄伝説 閃の軌跡 2014 09 英雄伝説 閃の軌跡II 2015 09 東亰ザナドゥ 12 英雄伝説 空の軌跡SC Evolution 2016 07 イースVIII -Lacrimosa of DANA- 07 英雄伝説 空の軌跡 the 3rd Evolution 08 英雄伝説 暁の軌跡 09 東亰ザナドゥ eX+ 2017 05 イースVIII -Lacrimosa of DANA- PS4版 09 英雄伝説 閃の軌跡III 2018 09 英雄伝説 閃の軌跡IV -THE END OF SAGA- 2019 09 イースIX -Monstrum NOX- 2020 08 英雄伝説 創の軌跡 2021 09 英雄伝説 黎の軌跡 2022 09 英雄伝説 黎の軌跡II -CRIMSON SiN- 2023 xx イースX -NORDICS- ↑PAGE TOP 免責 ※当wikiは非公式です。情報の妥当性や正確性について保証するものではなく一切の責任を負いかねます。 ※当wikiを利用することによって生じるいかなる損害も当サイトでは補償致しません。 ※ご利用につきましては自己責任となりますのでご注意ください。 ※また当wikiおよび当wiki管理人は日本ファルコム様とは一切関係がありません。 ※文章の著作権は当wikiにあります。内容の複写、転載はお控えください。 ※無料のウィキサービスを利用しているためこちらとは関係のない広告が表示されます。ご理解ください。 Disclaimer ※This wiki is unofficial. 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Medical write-up about normal Physical findings in English 11/07/00 Hisamatsu,M.D. カルテの記入は日本語で書くことが望ましいですが、身体所見の記載に関しては、英語のほうがより コンパクトにまとめられるのではと思います。正常所見の英語による記載方法例を作成してみました。 注）※の印は異常所見の書き方の例です。 身体所見=Physical examination 身体所見上異常認めず= Physical examination reveals(shows,discloses) no abnormalities. Physical examination are normal. Physical findings are normal. There are no abnormal findings on Physical examination VS=Vital Signs T36℃(36 degrees in Celsius or centigrade) , P88 , R14 , BP130/80(130 over 80と読む) General appearance Development（体格）,nourishment（栄養） well-developed, well-nourished, poorly developed,poorly nourished, fatty,obese,thin,lean Degree of illness be in distress, be acutely ill appear to be in no distress, appear severely ill appear to be in acute distress, appear to be in mild respiratory distress seem to be in distress Level of consciousness（意識レベル） normal, lethargy,somnolence,drowsy, stupor, coma, alert ,cooperative and oriented ×3 (oriented as to time,person,place) Emotional state（感情） look anxious, appear to be in depressed state 例） General appearance the pt is a well-developed, obese man. appears to be in no distress,but in depressed state. consciousness alert ,cooperative, and oriented×3 HEENT(Head Eyes Ears Nose Throat) Head Normocephalic and atraumatic or Normal in size and shape, No tenderness Eyes PERRLA(Pupil equal, round,reactive to light and accommodation) Visual acuity intact or Visual acuity is 1.2 on the right EOM intact bulbar (palpebral) conjunctiva not injected or congested, no icterus, no pallor Optic funds not visible（観察できず）, no abnormalities,no papilledema, exudate and bleeding Ears Hearing acuity intact or wnl (within normal limits) Tympanic membranes (Eardrums) clear with good light reflex Nose No discharge,symmetrical,septum midline,mucous membranes are not injected or congested patent (No obstruction) Sinuses No tenderness,discharge Mouth / Throat Teeth intact ,mucosa moist,gingiva normal Tongue moist,well-papillated,midline uvula midline, no injection,exudate of tonsil no tonsillar enlargement ※All teeth are absent (missing), oral hygiene is poor Neck supple (not stiff, no stiffness,no nuchal rigidity) trachea midline No thyromegaly (No enlargement of thyroid, Not increased in size), non-tender thyroid ,soft on palpation No lymphadenopathy (no enlargement of cervical lymph node,lymph node not palpable, not palpated) Carotid (artery) equal and normal upstroke and in size,no bruit Jugular vein is not distended ( Jugular venous pulsations are not visible, not distended, not elevated) ※JVP are distended (elevated) to a level of 5 cm above sternum angle at 45 degrees of elevation. Back No CVA tenderness, no deformity of the back and spine CVS(cardiovascular system) Regular rate rhythm (RRR),Non-dislocated PMI ,normal in size and intensity (PMI is visible and palpated in the 5th interspace at the LMCL (left midclavicular line) inside ... medial to ... ※outside ... ※lateral to ... ※IRIR(irregularly irregula rate rhythm) Diffuse PMI is shifted (dislocated) toward the left and felt (palpated) in the 6th interspace. S1 and S2 normal in intensity, normal split with inspiration No murmur,gallops,rubs (No GMR) ※S3 heard at the apex, Grade 2/6 pansystolic murmur at the apex with radiation to axilla or neck Lung Clear to auscultation and percussion (CTAP), No wheeze,rhonchi, rales(crackles) respiratory movement intact ,symmetrical diaphragmatic excursion 5 cm,symmetrical (diaphragm descended to 4cm) tactile (vocal) fremitus wnl ※dullness to percussion on the left side vocal fremitus decreased (increased) Abdomen the wall flat and soft, normal active bowel sound (NABS), no masses,bruits liver size normal by percussion in MCL (10 cm by percussion in MCL or percussed at 9 cm in MCL) normal liver edge spleen size normal by percussion , kidney not palpated ※the wall distended or scapohid(depressed) ー 腹部は膨満もしくは陥凹 Liver palpated 2 cm below the right costal margin Skin (integument) no clubbing ,cyanosis,edema (No CCE) Extremities No deformity Example PMH),FH) unremarkable Physical examination) VS T36℃ , P88 , R14 , BP130/80 General appearance the pt is a well-developed, obese man. appears to be in no distress,but in depressed state. Consciousness alert ,cooperative, and oriented×3 HEENT Head Normocephalic and atraumatic, no tenderness Eyes PERRLA,Visual acuity intact, EOM intact , bulbar and palpebral conjunctiva not injected or congested, no icterus, no pallor fundi no papilledema, exudate and bleeding Ears Hearing acuity wnl ,Tympanic membranes clear with good light reflex Nose No discharge,symmetrical,septum midline,mucous membranes are not injected ,patent Sinuses No tenderness,discharge Mouth / Throat Teeth intact ,mucosa moist,gingiva normal, Tongue moist,well-papillated,midline uvula midline, no injection,exudate of tonsil Neck supple ,trachea midline, No thyromegaly,No lymphadenopathy Carotid equal and normal upstroke and in size,no bruit, jugular venous pulsations are not elevated) Back No CVA tenderness, no deformity of the back and spine CVS RRR,Non-dislocated PMI ,normal in size and intensity S1 and S2 normal in intensity, normal split with inspiration, No murmur,gallops,rubs Lung Clear to auscultation and percussion , No wheeze,rhonchi, rales respiratory movement intact ,symmetrical, diaphragmatic excursion 5 cm,symmetrical , tactile and vocal fremitus wnl Abdomen the wall flat and soft, normal active bowel sound ,no masses,bruits liver size normal by percussion in MCL ,normal liver edge spleen size normal by percussion , kidney not palpated Skin (integument) no clubbing ,cyanosis,edema (No CCE) Extremities No deformity Pulse carotid brachial radial femoral popliteal post tibial dosalis pedis Rt + + + + + + + Lt + + + + + + +
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Wound Management nishitarumizu 2000.9.19 I. General Principles The goal of wound management is primarily restoration of function, which requires minimizing risk of infection and repair of injured tissue with a minimum of cosmetic deformity. Be sure to maintain universal precautions. II. Significant History A. Mechanism of injury. 1.Blunt trauma. Split or crush type of injuries will swell more and tend to have more devitalized tissue and a higher risk of infection. 2.Sharp trauma. Clean edges, low cellular injury, and risk of infection. 3.Puncture wounds. 4.Bite injury. B.Contaminants. Wound contact with manure, rust, dirt, etc., will increase risk of infection. Wounds sustained in barnyards or stables are considered contaminated. Clostridium tetani is indigenous in manure. C.Time of injury. After 3 hours, the bacterial count in a wound increases dramatically.Wounds may be closed primarily up to 12-18 hours out; clean well and use clinical judgment when choosing which wounds to close. Wounds up to 24 hours old on the face may be closed after good cleaning. The blood supply in this area is much better and the risk of infection therefore much less. The risk of infection may be reduced in wounds by use of tape closures (such as Steri-Strip tape). D.Tetanus status(http //homepages.go.com/homepages/a/n/e/anealkhan/tetanus_prophylaxis.htm) E.Other medical illnesses. Diabetes, chemotherapy, steroids, peripheral vascular disease, and malnutrition may delay wound healing and increase the risk of infection. III.Physical Exam A.Vascular injury. Direct pressure is the first choice for controlling bleeding. If a fracture is involved, immobilization will help control bleeding. Do not clamp vascular structures until it is determined if it is a significant vessel needing repair. If the anatomy is suspicious for injury to major vascular structures, obtain angiogram and consider surgical consult. Capillary refill should be checked distally. Bleeding on the scalp is best controlled by suturing of the wound. For extremities, inflating a blood pressure cuff above systolic pressure assists in wound inspection and repair. However, be careful not to cause ischemic injury to the extremity. B.Neurologic injury. Check distal muscle strength and sensation. Always check sensation before administering anesthesia. For hand and finger lacerations check 2-point discrimination, which should be less than 1 cm at the fingertips. A crush injury may also decrease 2-point discrimination. This may take several months to recover. A lacerated nerve may be repaired immediately or have repair delayed. Loss of sensation may be the first sign of a developing compartment syndrome. C.Tendons. Can be evaluated by inspection, but individual muscles must also be tested for full range of motion and full strength. D.Bones. Check for open fracture or associated fractures. X-ray if any question. An open fracture is an indication for surgical debridement and repair except in the case of a distal phalanx fracture where copious irrigation and oral antibiotics are acceptable treatment if the injury can be watched carefully for infection. E.Foreign bodies. Inspect and x-ray the area. Remember that wood or low-lead glass may not show on radiograph. Wound markers can be used during radiographing, and views obtained in two planes can help localize the object for recovery. Glass may penetrate at an angle and be buried deeper than it appears to be. Ultrasonography is very sensitive at picking up foreign bodies if radiograph is questionable or there is strong clinical suspicion. IV.Repair A.Wound healing. 1.Ephithelialization occurs in 24-48 hours under optimal conditions. 2.Collagen formation. Peaks at day 7. Wound has 15% to 20% of full strength at 3 weeks, 60% full strength at 4 months. The wound is then completely sealed. 3.Scar formation. Requires 6 to 12 months for a mature scar. The smallest scar will be formed when the wound is not under tension. Scars should not be revised until 12 months have passed. Contractures can develop when a scar intersects perpendicularly to a joint crease. B.Wound preparation. Hand washing, face masks are recommended. C.ANESTHESIA 1.In general, pain control should be provided before extensive wound preparation. 2.Local. Use 27- or 30-gauge needle and infiltrate slowly and through the open wound edge avoiding the intact skin. This decreases the pain of infiltration. The addition of bicarbonate to lidocaine before infiltration has been shown to significantly decrease the pain of injection (9 ml of lidocaine and 1 ml of bicarbonate) and warming lidocaine to body temperature may help as well. a.Lidocaine (0.5% to 2%) most frequently used with onset 2 to 5 minutes, duration 60 minutes. Can use 3 to 5 mg/kg with not more than 300 mg total (in adults). Avoid using lidocaine with epinephrine on distal extremities such as the ears, fingers, toes, and penis. b.Mepivacaine (Carbocaine) has onset 3 to 5 minutes, duration of 90 to 120 minutes. c.Bupivacaine (Marcaine) has onset 5 to 10 minutes, duration of hours; longest lasting of the local anesthetics. Intravenous administration may cause serious arrhythmias. d.For "caine" allergies, use diphenhydramine diluted to 1%. Mix 5% diphenhydramine 1 4 ml with normal saline to make a 1% solution. Onset of anesthesia takes longer and does not last so long as with lidocaine. Stronger solutions may cause tissue necrosis. 3. Regional anesthesia. Especially good for fingers, hands, feet, toes, mouth, and face. See Chapter 17 for common blocks. HEMOSTASIS Control of bleeding is necessary for both hemodynamic stability and for proper evaluation of a wound. Direct pressure, epinephrine, bipolar electrocautery, tourniquet. FOREIGN -BODY REMOVAL Avoid the temptation to initially explore wounds with a finger in search of foreign body. Plain radiography , US, CT HAIR REMOVAL Shaving the area with a razor damage the hair follicle, allowing bacterial invasion, and is associated with a ten fold increase in infection rate when compared with clipping. Hair should be as completely as possible with clipping 1to 2 mm above the skin with scissors. Never shave eyebrows because they are needed for alignment of the wound and may not grow back. IRRIGATION Irrigation pressures of 5 to 8 psi are recommended, which is achieved using a 19-guage needle with either 35-ml or 65-ml syringe. Fluid (saline) volume 60ml /cm of wound length. 200ml- 1000ml. There is no added benefit to the addition of an antiseptic ( such as povidone-iodine or hydrogen peroxide) . All detergents cause tissue and fibroblast toxicity. DEBRIDEMENT Not only removes foreign matters, bacteria, and devitalized tissue,but also creates a sharp wound edge that is easier to repair. Using aseptic technique, devitalized tissue should be removed; avoid taking healthy tissue. High-pressure irrigation is the most effective means of cleansing a wound. Scrubbing does not cleanse the wound as well and using any disinfectant in the wound damages healthy cells needed for healing. SKIN DISINFECTION Can be performed with povidone-iodine solution or chlorhexidine. Avoid getting these solutions in the wound because they impede wound healing. D.Wound closure. 1.Avoid primary closure of infected and inflamed wounds, dirty wounds, human and animal bites, neglected and severe crush wounds,and puncture wounds. 2.Tape closure (with Steri-Strips or others). Strips carry a lower risk of infection than suturing does and may be a consideration for higher-risk wounds. 3.Open wound care. Saline wet to dry dressings with gauze will keep the tissue moist and help debride, Gentle washing of the wound 2 to 3 times per day will remove bacterially contaminated secretions (showers are appropriate for this). Avoid iodine dressings because they damage healthy tissue and will slow granulation. When clean granulation tissue is apparent, secondary closure may be considered or can change to dry, sterile, packing material. 4.Suturing. Sutures are of two types (1)absorbable and (2)nonabsorbable. Precision-point cutting needles, and small-sized suture (5-0 or 6-0) should be chosen for skin when a cosmetic closure is important as on the face. Conventional cutting needle is used for routine skin closure. 4-0 or 3-0 nylon may be used on extremities. Noncutting needle should be used for subcutaneous tissue. Extensor tendons are slow healing and should have permanent suture of small size chosen (such as polypropylene). Depending on your practice situation, a surgical consultation should be considered. The majority of subcutaneous or dermal suturing may be performed with an intermediate-duration absorbable suture. However, some wounds require permanent sutures (such as stainless steel wires in sternotomy). 5.Staples. Can be used on the scalp and abdomen with good result. However, avoid use on face, hand, or other areas where structures such as tendons and nerves may become incorporated into the staples. 6.Dressings. Maintaining a moist environment for the first 24h-48 h facilitate healing. Dressing absorbs exudate, protect contamination, and prevention of premature removal. Consider antibiotic petroratum-based ointment on face and torso. Antibiotic ointment should be avoided on distal extremities for more than 24 to 48 hours because it may lead to maceration and delayed wound healing. Immobilize if motion of a joint is going to increase skin tension. Keep the wound for 24 hours, after which time most wounds do not require a dressing. 7.Antibiotics. There is no medical indication for using prophylactic antibiotics in routine, noncontaminated, skin wounds. a.Consider antibiotic use for patients prone to endocarditis, patients with hip prostheses, lymphedema, contaminated foot wound in diabetics, or others with peripheral vascular disease. b.See Chapter 1 for antibiotic choices for bite wounds. V.Follow-Up Care A.Risk of infection highest 24 to 48 hours, and so all wounds should be rechecked at 48h. B.Washing and Grooming Within 8 to 24h after closure, wounds in highly vascular areas can be washed. Other areas can be washed after 12- 24h without increased an adverse outcome. However, immersion or soaking should be avoided. C.General guidelines for suture removal. Face, 3 to 5 days with tape reinforcement after suture removal. Scalp, 7 to 10 days; trunk, 7 to 10 days; arms, 7 to 10 days; legs, 10 to 14 days; joints, dorsal surface, 14 days. Increase length for diabetics or steroid-dependent patients who may require several weeks to heal.
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INTERNATIONAL=国代表(A~E) RAT=評価 POS1=1stポジション POS2=2ndポジション POS3=代替ポジション HEI=身長 WEI=体重 CLUB=所属クラブ AB1~3 SP~AG ※IRBランキングは2007年9月度 ※★＝インパクトプレイヤー ARGENTINA（アルゼンチン：ロス・プーマス） IRBランキング4位公式 NO NAME AGE RAT POS1 POS2 POS3 HEI WEI CLUB AB1 AB2 AB3 SP AC AL HD PS KC KP GO TL ST RC SM HK LO AG 1 O.HASAN 36 82 PR 185 114 TOULOUSE SM 46 46 52 57 53 30 59 20 77 91 67 90 72 59 95 2 M.LEDESMA 34 85 HK 183 110 SM TB BW 63 57 41 66 74 38 50 5 77 89 69 86 93 67 78 3 R.RONCERO 30 82 PR 178 113 SM 41 41 38 71 66 38 62 8 77 87 70 91 29 40 77 4 P.ALBACETE 26 80 SR 201 115 SM JP 64 57 38 28 46 23 61 4 85 71 61 86 8 90 74 5 R.ALVAREZ 33 84 SR FL N8 196 107 SM JP 59 62 44 53 42 18 64 10 78 87 76 86 45 87 87 6 M.DURAND 31 77 FL N8 183 96 TL 67 62 44 59 48 25 64 9 81 75 73 70 58 72 77 7 J.LOBBE 26 74 FL N8 201 115 SALE SM JP 64 57 38 28 46 23 50 4 85 71 61 86 8 90 74 8 G.LONGO 33 75 N8 193 102 CLERMONT TL 64 67 61 75 78 65 60 25 76 73 75 69 4 3 69 9 A.PICHOT★ 33 94 SH 175 77 PS PM DO 79 87 89 93 94 75 82 53 68 64 60 31 13 3 77 10 F.CONTEPOMI 30 92 FH CT 183 93 PS PM GK 77 81 84 93 89 85 90 83 71 74 66 21 3 10 79 11 I.CORLETO 29 79 FB WG 185 90 SC 89 89 78 59 61 76 83 47 64 71 30 15 5 27 66 12 G.TIESSI 22 82 CT FH 175 78 LONDON IRISH CB 82 84 84 87 76 78 50 75 72 61 54 28 22 35 67 13 M.CONTEPOMI 30 70 CT 188 90 SC CB 70 77 42 62 74 66 70 22 71 80 31 4 2 10 62 14 L.BORGES 27 81 WG 178 81 86 83 76 58 64 70 75 28 78 72 48 0 2 0 77 15 J.HERNANDEZ 25 77 FB CT WG 185 85 CB 73 80 65 69 53 82 80 48 62 69 52 8 3 35 79 16 G.SANTIAGO 23 64 FH FB 178 84 77 58 69 73 53 67 50 61 34 43 27 10 3 11 55 17 G.PABEL 24 82 PR 178 113 SM 41 41 38 71 66 38 50 8 77 87 70 91 29 40 77 18 I.LOBBE 32 74 FL FL 196 110 SALE SM JP 63 52 47 45 52 41 57 7 68 82 66 87 50 83 86 19 J.LEGUIZAMON 24 81 FL 191 100 LONDON IRISH TL BW 58 66 51 69 60 34 56 11 84 81 72 77 29 66 58 20 N.MIRANDA 34 58 SH 178 85 79 89 73 70 63 73 82 45 41 46 39 12 7 13 58 21 F.TODESCHINI 32 78 FH FB 183 93 PM GK 78 72 65 70 79 81 88 83 71 74 58 21 3 10 71 22 H.SENILLOSA 29 64 CT WG 180 90 CLERMONT SC 84 84 87 66 60 53 76 30 67 72 54 20 7 25 65 R H.AGULLA 29 74 FB WG 185 90 SC 86 80 72 57 56 69 74 46 64 66 30 15 5 27 79 R J.GOMEZ 31 74 FL N8 191 101 70 74 66 68 69 41 52 21 75 79 68 72 1 1 69 R J.PIOSSEK 30 73 WG CT 185 90 CASTRES TB 83 69 66 64 41 58 89 35 69 78 62 13 6 16 73 R M.GAITAN 29 82 CT 180 83 SC CB 74 87 65 92 69 59 75 44 77 67 30 6 0 0 82 R F.ARAMBURU 27 59 CT WG 183 87 BIARRITZ 84 67 54 46 72 62 74 37 69 72 42 16 8 28 63 R E.LOZADA 22 79 SR 201 115 SM 64 57 38 28 46 23 50 4 85 71 61 86 8 90 74 R P.LEDESMA 25 74 PR 183 115 SM 56 44 49 62 54 32 50 13 70 82 67 75 79 52 71 R N.VERGALLO 20 51 SH 175 77 71 75 69 54 57 52 50 46 42 33 12 7 5 9 55 AUSTRALIA（オーストラリア：ワラビーズ） IRBランキング2位公式 NO NAME AGE RAT POS1 POS2 POS3 HEI WEI CLUB AB1 AB2 AB3 SP AC AL HD PS KC KP GO TL ST RC SM HK LO AG 1 B.ROBINSON 23 63 PR 183 110 WARATAHS 50 54 40 54 57 18 57 13 70 56 61 66 11 25 67 2 J.PAUL 30 87 HK PR 185 104 BRUMBIES PM CB SM 71 64 69 87 68 30 72 66 85 79 84 83 92 80 81 3 R.BLAKE 24 78 PR 191 126 REDS 66 70 61 76 64 34 54 20 82 85 75 70 36 3 84 4 N.SHARPE 29 84 SR N8 201 115 WESTERN FORCE CB TL JP 66 49 69 74 58 11 59 2 83 85 77 75 0 89 84 5 D.VICKERMAN 28 86 SR 203 117 WARATAHS TL JP 41 49 56 72 67 31 56 3 89 82 79 82 2 89 72 6 R.ELSOM 24 82 FL 196 106 WARATAHS TB BW 66 72 54 63 40 36 63 4 82 88 72 57 5 16 66 7 P.WAUGH 27 81 FL N8 175 100 WARATAHS DO 64 72 70 83 70 36 64 30 79 80 81 83 50 79 79 8 W.PALU 25 78 FL N8 FL 183 118 WARATAHS 62 65 54 68 63 43 63 22 78 85 73 70 3 44 81 9 G.GREGAN★ 34 99 SH 173 80 BRUMBIES CM TL DO 72 88 90 89 93 87 82 60 89 67 66 3 1 13 92 10 S.LARKHAM★ 33 99 CT FH FB 188 88 BRUMBIES CM PS PM 73 84 81 95 96 75 84 52 81 66 49 2 3 14 60 11 L.TUQIRI★ 27 93 WG CT FB 191 102 WARATAHS SC 93 83 82 83 80 79 76 60 82 75 55 30 30 30 71 12 M.GITEAU★ 24 93 SH FH CT 178 85 WESTERN FORCE PS PM GK 78 90 89 92 86 85 86 84 75 56 54 19 3 19 70 13 S.MORTLOCK 30 81 CT WG FB 191 100 BRUMBIES SC CB TL 85 82 76 85 71 76 76 77 82 87 47 6 1 25 80 14 D.MITCHELL 23 84 FB WG CT 180 85 WESTERN FORCE SC CB 88 86 65 74 67 81 83 32 64 77 36 6 3 13 60 15 C.LATHAM★ 31 95 FB WG 191 100 REDS TK CB TL 84 83 80 94 81 83 95 52 82 86 52 4 1 4 90 16 S.MOORE 24 69 HK 191 110 REDS TL 62 50 29 70 61 34 60 5 69 78 54 60 82 70 59 17 G.HOLMES 24 75 PR 183 112 REDS 38 44 48 62 46 29 56 13 77 83 68 74 34 7 62 18 M.CHISHOLM 25 71 SR 198 112 BRUMBIES JP 59 46 38 45 36 32 57 4 64 74 71 67 44 76 72 19 G.SMITH★ 27 93 SR N8 FL 180 98 BRUMBIES TB TL BW 75 83 82 84 69 61 66 38 92 87 95 79 2 71 95 20 S.CORDINGLEY 31 60 SH 180 86 REDS PS 72 81 72 61 67 77 75 36 49 55 43 15 4 25 39 21 B.BARNES 21 71 FH 183 86 REDS 81 72 51 62 75 78 77 36 70 57 42 2 0 3 69 22 M.GERRARD 25 83 FB WG 191 99 BRUMBIES PM SC 86 85 82 81 59 72 78 25 54 76 42 10 5 17 48 R C.RATHBONE 26 80 CT FB WG 180 93 BRUMBIES SC CB 84 82 78 75 81 77 78 36 85 87 75 0 0 0 90 R C.SHEPHERD 23 66 WG FB 188 100 WESTERN FORCE SC 69 66 60 54 57 81 86 72 47 50 35 8 4 12 47 R G.SHEPHERDSON 25 63 PR 188 116 BRUMBIES 55 57 46 59 62 30 53 10 61 66 60 68 8 3 66 R H.MCMENIMAN 23 73 SR 201 110 REDS JP 54 46 35 45 59 32 60 9 69 77 72 62 36 84 67 R A.CAMPBELL 28 71 SR 201 112 BRUMBIES BW JP 53 61 46 62 57 27 62 9 74 69 66 68 12 72 64 R S.STANIFORTH 29 79 WG CT FB 188 100 WESTERN FORCE SC 89 76 70 64 72 74 75 36 77 60 70 0 0 0 90 R B.CANNON 30 85 HK 188 108 WESTERN FORCE BW SM 41 43 61 69 59 21 59 10 79 83 80 86 90 71 75 R D.LYONS 27 81 N8 FL 191 117 WARATAHS TB BW 59 71 72 83 63 32 65 30 75 77 87 80 50 77 78 CANADA（カナダ：メイプルリーフス） IRBランキング14位公式 NO NAME AGE RAT POS1 POS2 POS3 HEI WEI CLUB AB1 AB2 AB3 SP AC AL HD PS KC KP GO TL ST RC SM HK LO AG 1 K.TKACHUK 30 56 PR 180 115 40 50 46 56 53 15 52 8 60 62 54 40 40 35 71 2 A.ABRAMS 28 70 HK 183 109 LLANELLI TB SM 51 36 37 61 57 21 54 18 68 67 64 70 72 68 53 3 D.PLETCH 24 75 PR HK 180 110 SM 50 50 46 44 39 10 61 9 66 82 67 81 50 59 68 4 C.YUKES 27 68 SR 193 106 JP 46 46 48 44 34 5 57 2 55 73 64 70 24 73 77 5 J.CUDMORE 27 74 SR FL 198 112 BW 51 51 51 59 51 34 50 11 69 74 81 72 34 72 73 6 M.WEBB 28 75 FL SR 185 100 67 72 53 67 66 63 66 43 82 76 67 68 4 87 73 7 S.MCKEEN 25 69 N8 FL 191 103 60 52 26 66 46 28 61 7 72 77 59 56 8 26 74 8 SM.STEPHEN 24 71 SR N8 196 108 JP 52 46 48 52 41 21 50 8 60 75 71 67 34 77 74 9 M.WILLIAMS 31 68 SH 183 82 PARIS PS TB 70 79 56 62 71 64 68 34 67 62 55 14 3 15 84 10 A.MONRO 26 67 FH SH 178 88 PM 70 68 59 60 66 74 83 76 44 35 27 10 26 12 70 11 B.HENDERSON 23 68 WG FB 185 100 82 72 50 63 49 60 65 5 70 59 41 5 10 0 81 12 J.MENSAH-COKER 23 49 CT 185 96 84 75 63 46 52 60 70 25 56 64 41 10 10 10 71 13 D.SPICER 22 64 CT FH 183 91 64 69 42 53 76 69 74 21 64 56 24 2 0 3 66 14 M.PYKE 23 68 WG FB 196 104 82 72 50 63 49 68 70 29 70 59 41 5 10 0 81 15 J.PRITCHARD 28 68 WG FB 175 85 82 72 50 63 49 70 72 5 70 59 41 5 10 0 81 16 M.JAMES 34 71 SR 198 112 JP 52 46 48 52 41 21 74 8 60 75 71 67 34 77 74 17 M.BURAK 26 55 SR 201 107 60 66 46 57 69 39 56 10 66 72 57 82 13 2 80 18 D.DAYPUCK 29 63 FB CT WG 183 93 64 69 57 59 63 62 74 22 46 43 37 4 0 5 41 19 M.LAWSON 27 69 HK 183 100 65 65 59 59 58 40 55 18 67 69 68 61 82 65 78 20 E.FAIRHURST 28 67 FH SH 183 86 PM 70 68 59 60 66 74 85 75 44 35 27 10 26 12 70 21 P.RIORDAN 27 70 HK 185 106 TB SM 51 36 37 61 57 21 50 18 68 67 64 70 72 68 53 22 A.CARPENTER 24 75 FL SR 185 100 67 72 53 67 66 63 50 43 82 76 67 68 4 87 73 R A.KLEEBERGER 23 64 CT FH 196 95 64 69 42 53 76 69 61 21 64 56 24 2 0 3 66 R R.SMITH 23 49 CT 191 93 84 75 63 46 52 62 61 25 56 64 41 10 10 10 71 R M.BARBIERI 28 70 HK FL 183 109 TB SM 61 36 37 61 57 21 50 18 68 67 64 70 72 68 53 R DTH.YAN DER MER 21 64 FB WG 183 89 64 69 57 59 63 67 72 22 46 43 37 4 0 5 41 R L.TAIT 25 74 SR FL 198 112 BW 51 51 51 59 51 34 50 11 69 74 81 72 34 72 73 R I.EXNER 28 75 PR HK 183 115 SM 50 50 46 44 39 10 50 9 66 82 67 81 50 59 68 R J.JACKSON 26 71 SR FL N8 198 112 TL 57 55 56 53 51 31 59 8 69 70 69 75 31 70 70 R O.ATKINSON 26 74 SR FL 198 109 BW 51 51 51 59 51 34 50 11 69 74 81 72 34 72 73 ENGLAND（イングランド） IRBランキング7位公式 NO NAME AGE RAT POS1 POS2 POS3 HEI WEI CLUB AB1 AB2 AB3 SP AC AL HD PS KC KP GO TL ST RC SM HK LO AG 1 P.VICKERY 31 92 PR 191 116 LONDON WASPS TB TL SM 63 63 56 79 64 53 52 20 90 91 88 87 40 28 89 2 G.CHUTER 31 82 HK PR 178 101 LEICESTER TIGERS SM 53 32 54 61 61 20 53 14 74 83 80 86 85 69 70 3 J.WHITE 34 82 PR 185 115 LEICESTER TIGERS SM 46 47 37 66 61 47 53 10 74 90 67 95 31 34 88 4 S.BORTHWICK 27 87 SR FH 198 110 BATH TB SM JP 57 60 47 76 65 40 58 14 85 89 73 83 5 90 66 5 L.DEACON 26 62 SR 196 113 LEICESTER TIGERS 62 57 53 61 56 42 56 10 58 63 64 62 23 66 55 6 T.REES 22 81 FL 180 100 LONDON WASPS TL BW 68 62 53 64 51 41 50 7 85 82 72 77 42 70 78 7 M.LUND 24 75 FL N8 191 106 SALE TL 67 51 41 64 52 26 57 3 82 74 66 72 10 59 87 8 M.CORRY 33 88 N8 FL SR 196 112 LEICESTER TIGERS TB TL BW 61 58 56 63 79 41 59 9 85 87 84 85 8 82 64 9 H.ELLIS 25 75 SH 178 85 LEICESTER TIGERS PS 78 86 81 90 86 80 82 60 46 51 39 14 19 18 54 10 T.FLOOD 22 80 FH FB 188 95 NEWCASTLE CO PM TK 73 65 59 77 72 82 86 82 58 59 29 8 4 6 69 11 J.ROBINSON★ 33 95 FB WG CT 173 85 SALE SC 92 99 95 87 75 76 78 52 77 70 41 13 10 25 57 12 M.CATT 35 90 FH CT FB 178 86 LONDON IRISH PS PM TK 75 72 77 84 91 87 84 84 62 60 30 13 18 40 33 13 M.TAIT 21 90 CT WG 180 85 NEWCASTLE PS PM SC 84 83 85 92 83 69 75 52 64 60 47 12 15 27 59 14 J.LEWSEY★ 30 91 WG FB CT 180 87 LONDON WASPS SC TB TL 87 77 84 83 61 81 82 49 81 89 67 12 6 14 94 15 M.CUETO 27 88 WG FB 183 93 SALE SC TB 85 87 88 84 77 82 81 45 80 85 41 17 13 38 62 16 D.WARD SMITH 33 73 CT 183 102 79 81 74 71 75 74 76 42 66 73 54 29 13 34 61 17 A.FARRELL 32 84 FL N8 CT 191 102 SARACENS GK TB TL 74 77 69 96 79 66 84 85 88 86 69 68 3 76 73 18 M.STEVENS 24 75 PR SR 183 121 BATH SM 64 60 62 65 59 37 52 28 74 78 72 75 10 53 59 19 P.RICHARDS 29 78 SH 175 94 LONDON IRISH PS PM 79 82 80 91 84 76 72 63 55 71 41 13 7 17 36 20 S.PERRY 29 72 SH 178 96 BRISTOL 82 76 64 70 78 70 79 33 69 62 53 38 8 25 75 21 J.WILKINSON★ 28 99 FH CT 178 85 NEWCASTLE PM GK TL 77 87 85 95 89 93 95 96 90 82 43 20 15 29 84 22 J.WORSLEY 30 92 FL N8 196 110 LONDON WASPS TB TL BW 68 72 53 67 60 41 66 7 91 90 86 80 42 77 86 R M.TINDALL 28 82 CT 188 105 GLOUCESTER CB TL 79 79 64 81 79 82 85 81 85 86 45 29 21 37 40 R P.FRESHWATER 34 83 PR HK 185 110 SM 46 31 26 64 54 41 56 19 68 96 77 89 44 69 82 R L.MOODY 29 78 CT FL 191 105 LEICESTER TIGERS TL BW 64 56 67 78 75 70 68 39 85 86 81 78 19 78 62 R L.MEARS 28 81 HK 175 98 BATH SM 56 65 47 72 60 49 54 15 74 88 70 87 81 69 80 R D.GREWCOCK 34 83 SR 198 119 BATH BW JP 64 56 43 75 70 22 56 18 77 81 86 76 44 89 92 R T.PALMER 28 60 SH SR 198 105 LONDON WASPS JP 56 39 28 48 60 67 68 47 70 79 58 73 7 81 88 R A.SHERIDAN 27 91 PR SR N8 196 120 SALE TL SM 57 54 39 76 64 24 51 62 85 98 82 92 7 31 65 R I.BALSHAW 28 85 WG FB 185 88 SC 86 84 82 82 77 79 80 55 77 78 38 15 18 27 38
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Depression nishitarumizu 2000.9.1 Overview Lifetime risk 7% to 12% for men, 20% to 25% for women. As many as two-thirds of the people suffering from depression do not realize that they have a treatable illness and do not seek treatment. Clinical depression commonly occurs concurrently with other medical illnesses and worsens the prognosis for these illnesses. Tip-offs for depression in a primary care setting May include fatigue, somatic complaints (such as headache, backache, chest pain, dyspepsia, and limb pain), anxiety symptoms, depressed mood, or insomnia. Risk factors female (especially post partum), history of depressive illness in first-degree relatives, prior episodes of major depression, prior suicide attempts, age 40 years, medical comorbidity, decreased social support, stressful life events, and current substance or alcohol abuse. Symptoms can be divided into 1. Emotional. Dysphoria, irritability, anhedonia, withdrawal. 2. Cognitive. Self-criticism, sense of worthlessness or guilt, hopelessness, poor concentration, memory impairment, delusions or hallucinations. 3. Vegetative. Fatigue, decreased energy, insomnia, hypersomnia, anorexia, psychomotor retardation or agitation, impaired libido. Diagnosis Depression is often difficult to diagnose because it can manifest in many different forms. Depression is a holistic disorder, affecting body, feelings, thoughts and behaviors. In addition to Depressed mood or Anhedonia ( loss of interest or pleasure ), five or more of the following symptoms have been present during the same two week period ESCAP-GS E nergy decreased S leep disturbance (classically , early awakening ; or may sleep longer than usually) C oncentration disturbance A ppetite disturbance (increased or decreased; with or without weight loss) P sychomotor changes G uilt (self-deplication, feelings of worthlessness) S uicidal thinking Depressed mood is neither necessary nor sufficient for a diagnosis of depression. Barriers to diagnosis Patient Barriers Somatic Presentations Stigma Clinician barriers Pandora’s Box Normal feature At least 50% of depressed patients are either undetected or are not adequately treated by primary care providers. Evaluation History May use Beck Depression Scale , Zung Depression Scale, or Geriatric Depression Scale to screen for high-risk patients. If depressive symptoms are present, determine a. Time course and severity. b. Any prior episodes and level of recovery. c. Any history of manic or hypomanic episodes. d. If other major psychiatric disorders are present. e. Any suicidal ideation, plan, or intent. Examination Evaluate for possible related medical conditions anemia, hypothyroidism, chronic infection, substance abuse, or medication side effects (oral contraceptives,antihypertensives, etc.). Causes of organic depressions Type Specific Cause Drugs corticosteroids,contraceptives,reserpine, antibiotics alpha-methyldopa,anticholinestherase, cimetidine ranitidine, indomethacin, phenothiazines, thallium mercury, cyclosporine, vincristine, vinblastine Drug withdrawal amphetamine, cocaine Infection Tertiary syphillis, influenza, AIDS, viral pneumoniae Viral hepatitis, infectious mononucleosis, Tb Endocrine Hypothyroidism, apathetic hyperthyroidism, Hyperparathyroidism, postpartum and menses-related, Cushing’s disease, adrenal insufficiency Collagen SLE, RA, vasculitis Neurologic MS, Parkinson’s disease, head trauma Complex partial seizures, CNS tumors, stroke, Early dementia, sleep apnea Nutritional Vitamine deficiencies (B12, C, folate, niacin, thiamine) Neoplastic Pancreatic cancer, disseminated carccinomatosis Others Renal Failure,Liver Failure, Alcohol/Substance Abuse Lab tests Screen for medical causes of depression (if suspected by Hx or Pex) Complete blood count (CBC) Electrolytes, including calcium, phosphate, magnesium BUN and Creatinine Calcium Serum toxicology screen TSH level CT or MRI of brain Electrocardiogram (ECG), Electroencephalogram (EEG) Physical Psychomotor retardation or agitation, such as slowed speech, sighs, and long pauses Slowed body movements, even to the extent of motionlessness or catatonia Pacing, handwringing and pulling on hair Preoccupation Lack of eye contact Tearfulness Self-deprecatory manner Memory loss, poor concentration and poor abstract reasoning Consultations Psychiatry should be consulted after a screening evaluation is complete and all acute medical complications are addressed. Treatment Treatment is effective in at least 70% of cases. Communicating with depressed patients Empathy Presenting the diagnosis “These symptoms indicate to me that you are suffering from depression.” It can be helpful to then add a couple of additional symptoms not mentioned by the patient. It is helpful to explain depression as a common biological disorder. Drawing a picture of a synapse and neurotransmitters may be helpful. Depression is a curable illness. Counseling by the physician SPEAK approach Schedule Pleasurable activities Exercise Assertiveness Kind thoughts about onself Psychotherapy cognitive therapy behavioral therapy Medication Most antidepressants believed to be equally effective in equivalent therapeutic doses. Expect a 2- to 6- week latent period before the full effect is seen at therapeutic doses. To prevent relapse, continue medication for at least 4 to 9 months after patient becomes asymptomatic. For recurrent depression, consider chronic prophylactic therapy. If at 6 weeks a patient shows no response or a poor response to an adequate dose of antidepressant medication , treatment should be changed. Tricyclic antidepressants (TCAs). Choose between them based on patient s sedation requirements and ability to tolerate orthostatic hypotension, weight gain, and anticholinergic adverse effects TCAs are usually given QHS to take advantage of sedating effects. All TCAs may cause slowing of cardiac conduction. May be fatal in overdoses around 2000 mg or more in adults. A therapeutic trial usually is considered 100 mg/day of amitriptyline or its equivalent for at least 3 weeks. Note Nortriptyline (Pamelor) has a "therapeutic window" plasma level of 50 to 150 ng/ml for optimal efficacy. It has the lowest risk for orthostatic hypotension of all TCAs making it a safe choice in the geriatric patient. Selective serotonin reuptake inhibitors (SSRIs) Much safer in overdose than TCAs. Expensive in contrast to generic TCAs. Initial dose often an effective dose. May need to start at lower doses in the elderly of others sensitive to side effects. Side effects vary and may include nausea, anorexia, insomnia or mild sedation, sweating, headache, tremor, sexual dysfunction, and nervousness. Fluvoxamine is contraindicated with astemizole and terfenadine. All SSRIs contraindicated with MAOIs. If switching from a SSRI to a MAOI, need a drug-free period of 14 days for paroxetine, sertraline or fluvoxamine or 5 weeks for fluoxetine. Monoamine oxidase inhibitors (MAOIs) Sometimes used in depression refractory to the other treatments. Consider consulting psychiatrist before starting because of the serious adverse effect potential. St. John’s wort For short-term treatment of mild acute depression. Equally effective. Induction of the cytochrome P450 system. Psychostimulants Methylphenidate(Ritalin) They take effect very quickly( 24h) Provide a relatively quick test of whether antidepressants are likely to be effective. Electroconvulsive therapy. ECT is the most effective, rapid method of treating severe major depressive disorder (MDD). Indicated for patients with poor response to medications, poor tolerance of usual antidepressants, severe vegetative symptoms, or psychotic features. The decision to administer ECT should be made by a psychiatrist. Figure. Adverse effects of selective serotonin reuptake inhibitors (striped bars) and tricyclic antidepressants (white bars). REFERENCE Pharmacologic Treatment of Acute Major Depression and Dysthymia Ann Intern Med. 2000; 132 738-742 Behavioral Medicine in Primary Care A Practical Guide 1st.ed. Assessing and Managing Depression in the Terminally ill Patients. Ann Intern Med. 2000; 132 209-218 http //www.wellbutrin-sr.com/eval/zung.htm http //www.vh.org/Providers/ClinRef/FPHandbook/Chapter15/01-15.html#Box%2015-1 http //www.emedicine.com/emerg/index.shtml