adv.

他の

関: allo、else、elsewhere、otherwise

WordNet

very unusual; different in character or quality from the normal or expected; "a strange, other dimension...where his powers seemed to fail"- Lance Morrow
not the same one or ones already mentioned or implied; "today isnt any other day"- the White Queen; "the construction of highways and other public works"; "he asked for other employment"; "any other person would tell the truth"; "his other books are still in storage"; "then we looked at the other house"; "hearing was good in his other ear"; "the other sex"; "she lived on the other side of the street from me"; "went in the other direction"
recently past; "the other evening"
other than as supposed or expected; "the outcome was otherwise"
in other respects or ways; "he is otherwise normal"; "the funds are not otherwise available"; "an otherwise hopeless situation"
in or to another place; "he went elsewhere"; "look elsewhere for the answer"

PrepTutorEJDIC

《no,one,some,anyなどを伴って》『別の』,ほかの,違った / 《other thanの形で補語に用いて》…とは違った,…とは別の / 《the ~》(二者のうちの)『もう一方の』,他方の;『反対の』,向こう側の;(三者以上のうち)それ以外の,残りの / 『ほかのもの』,ほかの人[たち] / 《the ~》(二つの中で)『もう一方のもの』(『人』り,(三つ以上の中で)『これ以外のもの』(『人』),残りのもの(人) / 《『other』『than』の形で》(…と)別の方法では,(…)ではなく
『ほかの点では』,それを別にすると / 『そうでなければ』,さもないと(or else) / 『別の方法で』,違ったやり方で(in a different way) / 『別の』,異なった(different)
『どこかよそに』,ほかの所で(somewhere else)
『そのほかに』,それ以外に / 《or elseの形をとり接続詞的に》『さもないと』,そうでないと(otherwise)

Wikipedia preview

出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2013/02/11 16:53:32」(JST)

wiki en

[Wiki en表示]

For other uses, see Other (disambiguation).

The Other or Constitutive Other (also the verb othering) is a key concept in continental philosophy; it opposes the Same. The Other refers, or attempts to refer, to that which is other than the initial concept being considered. The Constitutive Other often denotes a person Other than one's self; hence, the Other is identified as "different"; thus the spelling is often capitalized.^{[citation needed]}

Concept

A person's definition of the 'Other' is part of what defines or even constitutes the self (in both a psychological and philosophical sense) and other phenomena and cultural units. It has been used in social science to understand the processes by which societies and groups exclude 'Others' whom they want to subordinate or who do not fit into their society. The concept of 'otherness' is also integral to the comprehending of a person, as people construct roles for themselves in relation to an 'other' as part of a process of reaction that is not necessarily related to stigmatization or condemnation. Othering is imperative to national identities, where practices of admittance and segregation can form and sustain boundaries and national character. Othering helps distinguish between home and away, the uncertain or certain. It often involves the demonization and dehumanization of groups, which further justifies attempts to civilize and exploit these 'inferior' others.

The idea of the other was first philosophically conceived by Emmanuel Levinas, and later made popular by Edward Said in his well-known book Orientalism.^{[citation needed]} Despite originally being a philosophical concept, othering has political, economic, social and psychological connotations and implications.

History

The concept that the self requires the Other to define itself is an old one and has been expressed by many writers:

Hegel was among the first to introduce the idea of the other as constituent in self-consciousness. He wrote of pre-selfconscious Man: "Each consciousness pursues the death of the other", meaning that in seeing a separateness between you and another, a feeling of alienation is created, which you try to resolve by synthesis. The resolution is depicted in Hegel's famous parable of the master-slave dialectic. For a direct antecedent, see Fichte.

Husserl used the idea as a basis for intersubjectivity. Sartre also made use of such a dialectic in Being and Nothingness, when describing how the world is altered at the appearance of another person, how the world now appears to orient itself around this other person. At the level Sartre presented it, however, it was without any life-threatening need for resolution, but as a feeling or phenomenon and not as a radical threat. De Beauvoir made use of otherness — in similar fashion to Sartre (though it is likely he took the idea from her) — in The Second Sex. In fact, De Beauvoir refers to Hegel's master-slave dialectic as analogous, in many respects, to the relationship of man and woman.

The French psychoanalyst Jacques Lacan and the Lithuanian-French philosopher Emmanuel Lévinas were instrumental in coining contemporary usage of "the Other," as radically other. Lacan associated the Other with the symbolic order and language. Levinas connected it with the scriptural and traditional God, in The Infinite Other.

Ethically, for Levinas, the "Other" is superior or prior to the self; the mere presence of the Other makes demands before one can respond by helping them or ignoring them^{[citation needed]}. This idea and that of the face-to-face encounter were re-written later, taking on Derrida's points made about the impossibility of a pure presence of the Other (the Other could be other than this pure alterity first encountered), and so issues of language and representation arose. This "re-write" was accomplished in part with Levinas' analysis of the distinction between "the saying and the said" but still maintaining a priority of ethics over metaphysics.

Levinas talks of the Other in terms of 'insomnia' and 'wakefulness'. It is an ecstasy, or exteriority toward the Other that forever remains beyond any attempt at full capture, this otherness is interminable (or infinite); even in murdering another, the otherness remains, it has not been negated or controlled. This "infiniteness" of the Other will allow Levinas to derive other aspects of philosophy and science as secondary to this ethic. Levinas writes:

The others that obsess me in the other do not affect me as examples of the same genus united with my neighbor by resemblance or common nature, individuations of the human race, or chips off the old block... The others concern me from the first. Here fraternity precedes the commonness of a genus. My relationship with the Other as neighbor gives meaning to my relations with all the others.^[1]

The "Other", as a general term in philosophy, can also be used to mean the unconscious, silence, insanity, the other of language (i.e., what it refers to and what is unsaid), etc.

There may also arise a tendency towards relativism if the Other, as pure alterity, leads to a notion that ignores the commonality of truth. Likewise, issues may arise around non-ethical uses of the term, and related terms, that reinforce divisions.

Imperialism

Before the modern world system where the politics and economy of nation-states are relatively interdependent, there existed what is classified as the "system of world empires" up until the 1500s. In this world system political and economic affairs of different empires were fragmented and empires "provided for most of their own needs... [spreading] their influence solely through conquest or the threat of conquest..."^[2] The Dictionary of Human Geography defines imperialism as "The creation and maintenance of an unequal economic, cultural and territorial relationship, usually between states and often in the form of an empire, based on domination and subordination."^[3] The maintenance of this unequal relationship wholly depends on the subordination of an "other" group or peoples, from which resources can be taken and land can be exploited. Other, then, describes the process of justifying the domination of individuals or groups in the periphery to facilitate subordination. The creation of the other is done by highlighting their weakness, thus extenuating the moral responsibility of the stronger self to educate, convert, or civilize depending on the identity of the other. Indeed, as defined by Martin Jones et al., othering is "A term, advocated by Edward Said, which refers to the act of emphasizing the perceived weaknesses of marginalized groups as a way of stressing the alleged strength of those in positions of power."^{[citation needed]} Othering can be done with any racial, ethnic, religious, or geographically-defined category of people.

In keeping with the example of imperial Britain, the discussion of empire building through othering unfolds in a global context. Empire building stands in fundamental opposition to global community; instead of understanding groups of people, and consequentially their intellectual, economic, and political capability as vital and contributory to the global community, othering renders all but one culture's ideology and systems worthless. Emmanuel Wallerstein's world systems theory is a more modern criticism of othering and the doctrine of discrimination and racism in society, economics, and all other fronts. Imperial Britain saw the values or good qualities of other cultures or powers as a threat to its own power—this was the case even with other economic and industrial powers such as Germany.^{[citation needed]}

Knowledge

Scholars such as Michel Foucault, the Frankfurt School and other postmodernists have argued that the process of othering has everything to do with knowledge, and power acting through knowledge to achieve a particular political agenda in its goal of domination.^[4] Edward Said quotes the following from Nietzsche,^[5] saying what is the truth of language but

...a mobile army of metaphors, metonyms, and anthropomorphisms—in short, a sum of human relations, which have been enhanced, transposed, and embellished poetically and rhetorically, and which after long use seem firm, canonical, and obligatory to a people: truths are illusions about which one has forgotten that this is what they are.^[6]

The knowledge of this sheds much light on historiographies of other cultures created by the dominant culture, and by the discourses, whether academic or otherwise, that surround these written and oral histories. The cultures that a supposed superior ethnic group deems important to study, and the different aspects of that culture that are either ignored or considered valuable knowledge, relies on the judgment of the ethnic group in power. In the case of historiographies of the Middle East, and the Oriental discipline, another dynamic adds depth to this issue. Prior to the late nineteenth century, western (specifically European) empires studied what was said to be high culture of the Middle East, being literature, language, and philology; however, a reciprocal program and curriculum of study did not exist in the Orient which looked at European lands.^[7] Distortions in the writing of history have carried over to the post-modern era in the writing of news. As mentioned before under examples of intranational othering, political parties in developing countries sometimes create facts on the ground, report threats that are nonexistent, and extenuate the faults of opposing political parties which are made up of opposing ethnic groups in the majority of cases.^[8] Othering via ideas of ethnocentricity—the belief that one's own ethnic group is superior to all others and the tendency to evaluate and assign meaning to other ethnicities using yours as a standard^[9] —is additionally achieved through processes as mundane as cartography. The drawing of maps has historically emphasized and bolstered specific lands and their associated national identities. Cartographers in early centuries commonly distorted actual locations and distances when depicting them on maps; British cartographers for example centered Britain on their maps, and drew it proportionally larger than it should be. Polar perspectives of the Northern Hemisphere drawn by recent American cartographers uses spatial relations between the United States and Russia to emphasize superiority.^[10] Thus we see that agendas of domination and subordination are not only supported by the soft sciences like language, popular culture, and literature, but also through the hard and exact sciences like mathematics and geography.

Gender studies

Simone De Beauvoir changed the Hegelian notion of the Other, for use in her description of male-dominated culture. This treats woman as the Other in relation to man. The Other has thus become an important concept for studies of the sex-gender system. Michael Warner argues that:

the modern system of sex and gender would not be possible without a disposition to interpret the difference between genders as the difference between self and Other ... having a sexual object of the opposite gender is taken to be the normal and paradigmatic form of an interest in the Other or, more generally, others.

Thus, according to Warner, Freudian and Lacanian psychoanalysis hold the heterosexist view that if one is attracted to people of the same gender as one's self, one fails to distinguish self and other, identification and desire. This is a "regressive" or an "arrested" function.^{[clarification needed]} He further argues that heteronormativity covers its own narcissistic investments by projecting or displacing them on queerness.

De Beauvoir calls the Other the minority, the least favored one and often a woman, when compared to a man, "for a man represents both the positive and the neutral, as indicated by the common use of man to designate human beings in general; whereas woman represents only the negative, defined by limiting criteria, without reciprocity" (McCann, 33). Betty Friedan supported this thought when she interviewed women and the majority of them identified themselves in their role in the private sphere, rather than addressing their own personal achievements. They automatically identified as the Other without knowing. Although the Other may be influenced by a socially constructed society, one can argue that society has the power to change this creation (Haslanger).

In an effort to dismantle the notion of the Other, Cheshire Calhoun proposed a deconstruction of the word "woman" from a subordinate association and to reconstruct it by proving women do not need to be rationalized by male dominance.^[11] This would contribute to the idea of the Other and minimize the hierarchal connotation this word implies.

Sarojini Sahoo, an Indian feminist writer, agrees with De Beauvoir that women can only free themselves by "thinking, taking action, working, creating, on the same terms as men; instead of seeking to disparage them, she declares herself their equal." She disagrees, however, that though women have the same status to men as human beings, they have their own identity and they are different from men. They are "others" in real definition, but this is not in context with Hegelian definition of "others". It is not always due to man's "active" and "subjective" demands. They are the others, unknowingly accepting the subjugation as a part of "subjectivity".^[12] Sahoo, however contends that whilst the woman identity is certainly constitutionally different from that of man, men and women still share a basic human equality. Thus the harmful asymmetric sex/gender "Othering" arises accidentally and ‘passively' from natural, unavoidable intersubjectivity.^[13]

Quotations

The poet Arthur Rimbaud may be the earliest to express the idea: "Je est un autre" (I is another).
Friedrich Nietzsche, in The Gay Science, phrased it thus: "You are always a different person."
Ferdinand de Saussure described language as, in Calvin Thomas' words, a "differential system without positive terms".
Jacques Lacan argued that ego-formation occurs through mirror-stage misrecognition, and his theories were applied to politics by Althusser. As the later Lacan said: "The I is always in the field of the Other."
Jean-Paul Sartre's character Garcin, in the play Huis clos (No Exit), states that "Hell is others," or, alternatively, "Hell is other people." ("L'enfer, c'est les Autres.")

Sexual difference

Sarojini Sahoo
Julia Kristeva
Judith Butler
Luce Irigaray

Bibliography

Levinas, Emmanuel (1974). Autrement qu'être ou au-delà de l'essence. (Otherwise than Being or Beyond Essence).
Levinas, Emmanuel (1972). Humanism de l'autre homme. Fata Morgana.
Lacan, Jacques (1966). Ecrits. London: Tavistock, 1977.
Lacan, Jacques (1964). The Four Fondamental Concepts of Psycho-analysis. London: Hogarth Press, 1977.
Foucault, Michel (1990). The History of Sexuality vol. 1: An Introduction. Trans. Robert Hurley. New York: Vintage.
Derrida, Jacques (1973). Speech and Phenomena and Other Essays on Husserl's Theory of Signs. Trans. David B. Allison. Evanston: Ill.: Northwestern University Press.
Kristeva, Julia (1982). Powers of Horror: An Essay on Abjection. Trans. Leon S. Roudiez. New York: Columbia University Press.
Butler, Judith (1990). Gender Trouble: Feminism and the Subversion of Identity. New York: Routledge.
Butler, Judith (1993). Bodies That Matter: On the Discursive Limits of "Sex". New York: Routledge.
Zuckermann, Ghil‘ad (2006), "'Etymythological Othering' and the Power of 'Lexical Engineering' in Judaism, Islam and Christianity. A Socio-Philo(sopho)logical Perspective", Explorations in the Sociology of Language and Religion, edited by Tope Omoniyi and Joshua A. Fishman, Amsterdam: John Benjamins, pp. 237–258.

Sources

Thomas, Calvin, ed. (2000). "Introduction: Identification, Appropriation, Proliferation", Straight with a Twist: Queer Theory and the Subject of Heterosexuality. University of Illinois Press. ISBN 0-252-06813-0.
Cahoone, Lawrence (1996). From Modernism to Postmodernism: An Anthology. Cambridge, Mass.: Blackwell.
Colwill, Elizabeth. (2005). Reader—Wmnst 590: Feminist Thought. KB Books.
Haslanger, Sally. Feminism and Metaphysics: Unmasking Hidden Ontologies. [1]. 28 November 2005.
McCann, Carole. Kim, Seung-Kyung. (2003). Feminist Theory Reader: Local and Global Perspectives. Routledge. New York, NY.
Rimbaud, Arthur (1966). "Letter to Georges Izambard", Complete Works and Selected Letters. Trans. Wallace Fowlie. Chicago: University of Chicago Press.
Nietzsche, Friedrich (1974). The Gay Science. Trans. Walter Kaufmann. New York: Vintage.
Saussure, Ferdinand de (1986). Course in General Linguistics. Eds. Charles Bally and Albert Sechehaye. Trans. Roy Harris. La Salle, Ill.: Open Court.
Lacan, Jacques (1977). Écrits: A Selection. Trans. Alan Sheridan. New York: Norton.
Althusser, Louis (1973). Lenin and Philosophy and Other Essays. Trans. Ben Brewster. New York: Monthly Review Press.
Warner, Michael (1990). "Homo-Narcissism; or, Heterosexuality", Engendering Men, p. 191. Eds. Boone and Cadden, London UK: Routledge.
Tuttle, Howard (1996). The Crowd is Untruth, Peter Lang Publishing, ISBN 0-8204-2866-3

References

^ Otherwise than Being or Beyond Essence, p.159
^ Gelvin, James L. The Modern Middle East: A History. 2nd ed. Oxford; New York: Oxford University Press, 2008. 39-40. Print.
^ Johnston, R.J., et al. The Dictionary of Human Geography. 4th Ed. Malden: Blackwell Publishing, 2000. 375.
^ Said, Edward W. Orientalism. 25th Anniversary Edition. New York: Pantheon Books, 1978. xviii. Print.
^ Nietzsche, Friedrich. "On Truth and lie in an extra-moral sense." The Portable Nietzsche. Ed. Walter Kaufmann. New York: Viking Press, 1954. 46-7.
^ Said, Edward W. Orientalism. 25th Anniversary Edition. New York: Pantheon Books, 1978. 202. Print.
^ Humphreys, Steven R. "The Historiography of the Modern Middle East: Transforming a Field of Study." Middle East Historiographies: Narrating the Twentieth Century. Ed. Israel Gershoni, Amy Singer, and Y. Hakam Erdem. Seattle: University of Washington Press, 2006. 19-21. Print.
^ Sehgal, Meera. "Manufacturing a Feminized Siege Mentality." Journal of Contemporary Ethnography 36.2 (2007): 173. Print.
^ Fellmann, Jerome D., et al. Human Geography: Landscapes of Human Activities. 10th Ed. New York: McGraw-Hill, 2008. 179.
^ Fellmann, Jerome D., et al. Human Geography: Landscapes of Human Activities. 10th Ed. New York: McGraw-Hill, 2008. 10.
^ McCann, 339
^ "http://sarojinisahoo.blogspot.com"
^ Jemmer, Patrick: The O(the)r (O)the(r), Engage Newcastle Volume 1 (ISSN: 2045-0567; ISBN 978-1-907926-00-6) August 2010, published Newcastle UK: NewPhilSoc Publishing, Page 7, also see at "http://books.google.co.in/books?hl=en&lr=&id=YlN_kz8th4cC&oi=fnd&pg=PA5&dq=Sarojini+Sahoo&ots=EFtjSxyA3q&sig=qa7R"

External links

Look up other in Wiktionary, the free dictionary.

Definitions of Other/Othering
The Centre for Studies in Otherness

UpToDate Contents

全文を閲覧するには購読必要です。 To read the full text you will need to subscribe.

1. 他の病状に影響を与える心理的要因：臨床的特徴、評価、および診断 psychological factors affecting other medical conditions clinical features assessment and diagnosis
2. 他の病状に影響を与える心理的要因：マネージメント psychological factors affecting other medical conditions management
3. 幼児血管腫の疫学、病因、臨床的特徴、および合併症 epidemiology pathogenesis clinical features and complications of infantile hemangiomas
4. TTウイルスおよびその他のアネロウイルス tt virus and other anelloviruses
5. LSDおよび他の一般的な幻覚剤による中毒 intoxication from lsd and other common hallucinogens

English Journal

The National Ambulatory Medical Care Survey: a resource for understanding the outpatient dermatology treatment.

Ahn CS1, Allen MM, Davis SA, Huang KE, Fleischer AB Jr, Feldman SR.Author information 1Department of Dermatology and.AbstractBACKGROUND: The National Ambulatory Care Survey (NAMCS) collects information on outpatient medical care in the United States. Key characteristics of the NAMCS methodology are not well recognized. We describe the NAMCS survey design and patient visits to dermatologists and to present information on the validity of the NAMCS data by comparing key features of the dermatologist sample to other surveys of dermatologists.
The Journal of dermatological treatment.J Dermatolog Treat.2014 Dec;25(6):453-8. doi: 10.3109/09546634.2014.858409. Epub 2013 Nov 21.
BACKGROUND: The National Ambulatory Care Survey (NAMCS) collects information on outpatient medical care in the United States. Key characteristics of the NAMCS methodology are not well recognized. We describe the NAMCS survey design and patient visits to dermatologists and to present information on t
PMID 24256113

Phototherapy trends in dermatology.

Luersen K1, Dabade TS, West CE, Davis SA, Feldman SR.Author information 1Departments of Dermatology, Center for Dermatology Research, Wake Forest School of Medicine , Winston-Salem, NC , USA.AbstractBACKGROUND: Use of phototherapy in the United States declined during the 1990s, largely due to unfavorable economic incentives. The trends in phototherapy since then are not well characterized.
The Journal of dermatological treatment.J Dermatolog Treat.2014 Dec;25(6):487-8. doi: 10.3109/09546634.2013.806767. Epub 2013 Jun 2.
BACKGROUND: Use of phototherapy in the United States declined during the 1990s, largely due to unfavorable economic incentives. The trends in phototherapy since then are not well characterized.METHODS: We analyzed the National Ambulatory Medical Care Survey (NAMCS) data on quantity of phototherapy v
PMID 23688185

Three cases of perioral dermatitis related to fusobacteria treated with β-lactam antibiotics.

Ishiguro N1, Maeda A, Suzuki K, Yamana Y, Fukuya Y, Kawashima M.Author information 1Department of Dermatology, Tokyo Women's Medical University , Tokyo , Japan.AbstractBACKGROUND: The oral tetracyclines, especially minocycline hydrochloride, are often used as an effective treatment for perioral dermatitis; however, they are sometimes difficult to use, especially in children, because of the side effects.
The Journal of dermatological treatment.J Dermatolog Treat.2014 Dec;25(6):507-9. doi: 10.3109/09546634.2012.757284. Epub 2013 Feb 24.
BACKGROUND: The oral tetracyclines, especially minocycline hydrochloride, are often used as an effective treatment for perioral dermatitis; however, they are sometimes difficult to use, especially in children, because of the side effects.OBJECTIVE: The effectiveness of β-lactam antibiotics was eval
PMID 23240905

Recognition and treatment of non-infectious hyaluronic acid reactions.

Hatcher JL1, Goldman ND.Author information 1Department of Otolaryngology, Wake Forest School of Medicine , Winston-Salem , USA.AbstractOBJECTIVE: To differentiate a non-infectious inflammatory reaction following hyaluronic acid injection for facial rejuvenation from other reported complications, and describe appropriate treatment.
The Journal of dermatological treatment.J Dermatolog Treat.2014 Dec;25(6):513-5. doi: 10.3109/09546634.2012.703307. Epub 2012 Jul 25.
OBJECTIVE: To differentiate a non-infectious inflammatory reaction following hyaluronic acid injection for facial rejuvenation from other reported complications, and describe appropriate treatment.METHODS: Using a review of the literature and information available from the manufacturer, recommendati
PMID 22702401

Japanese Journal

Synthesis of pH-responsive polysilane with polyelectrolyte side chains through γ-ray-induced graft polymerization

Tanaka Hidenori,Kawade Yasushi,Sato Nobuhiro,Matsuyama Tomochika
Radiation Physics and Chemistry 81(2), 185-189, 2012-02
… The other method is the direct grafting of electrolyte monomers. …
NAID 120003573894

Chemokines in tumor development and progression

Mukaida Naofumi,Baba Tomohisa
Experimental Cell Research 318(2), 95-102, 2012-01-15
… Moreover, chemokines have profound effects on other types of cells associated with the inflammatory response, such as endothelial cells and fibroblasts. …
NAID 120003534663

住宅におけるエネルギーマネジメントの効果を検証する実証的ホームシミュレータの提案と実装

岡田崇,牧野義樹,キムジュンスー,中田潤也,丹康雄
情報処理学会論文誌 53(1), 365-378, 2012-01-15
温室効果ガス排出量の削減や非常時,災害時におけるエネルギー確保を実現するため,エネルギーマネジメントはわが国の重要な課題である.近年,情報家電の普及にともない宅内にホームネットワーク(HN)が構築され,スマートハウス構想の実現に向け,HEMS(Home Energy Management System)やDSM(Demand Side Management)に対する期待が高まっている.新しいHEM …
NAID 110008736792

アドホックネットワークにおけるゾーン重複のない複数経路構築手法の提案と評価

江藤大,油田健太郎 ,岡崎直宣,朴美娘
情報処理学会論文誌 53(1), 336-341, 2012-01-15
アドホックネットワークでは,バッテリ容量の制限やノードの移動により,接続が安定しない場合が多いが,提案されているプロトコルは単一の経路のみを構築するプロトコルが多い.ロバストな通信手段を実現するためには,複数の経路を構築するプロトコルが求められる.さらに,一定の範囲で通信障害が起こった場合でも他の経路に影響を与えないことが望ましい.そこで本論文では,ゾーンの概念を導入し,ゾーンレベルで重複しない複 …
NAID 110008736789

Related Pictures

★リンクテーブル★

リンク元	「100Cases 33」「子宮頚癌」「他」「elsewhere」「else」
拡張検索	「induced hypertension chemotherapy」「neoadjuvant chemotherapy」

「100Cases 33」

　　[★]

☆case33　頭痛と混乱

■glossary

accompany

vt.

(人)と同行する、(人)に随行する。(もの)に付随する。～と同時に起こる。～に加える(添える、同封する)(with)

slurred n. 不明瞭

強直間代痙攣 tonic-clonic convulsion

　意識消失とともに全身の随意筋に強直痙攣が生じ(強直痙攣期tonic convulsion)、次いで全身の筋の強直と弛緩とが律動的に繰り返される時期(間代痙攣期clonic convulsion)を経て、発作後もうろう状態を呈する一連の発作。

■症例

28歳、女性　黒人　南アフリカ　手術室看護師　ロンドン住在

主訴：頭痛と混乱

現病歴：過去3週間で頭痛が続いており、ひどくなってきた。現在も頭痛が持続しており、頭全体が痛い。友人曰く「過去六ヶ月で体重が10kg減っていて、最近、混乱してきたようだ」。発話は不明瞭。救急室にいる間に強直間代痙攣を起こした。

・診察 examination

やせている。55kg。38.5℃。口腔カンジダ症(oral candidiasis)。リンパ節腫脹無し。心血管、呼吸器系、消化器系正常。痙攣前における神経検査では時間、場所、人の見当識無し。神経局所症状無し(no focal neurological sign)。眼底両側に乳頭浮腫有り。

・検査 investigation

血算：白血球増多

血液生化学：ナトリウム低下

CT：供覧

■キーワード＆着目するポイント

・口腔カンジダ症(oral candidiasis)

・頭痛、精神症状、強直間代痙攣

・眼底両側に乳頭浮腫

・CT 所見

・低ナトリウム血症は二次的なもの

■アプローチ

・口腔カンジダ症(oral candidiasis)　→　細胞免疫低下状態(DM、免疫抑制、AIDSなど) or 常在細菌叢の攪乱(長期の抗菌薬の使用)

　・The occurrence of thrush in a young, otherwise healthy-appearing person should prompt an investigation for underlying HIV infection.(HIM.1254)

　・More commonly, thrush is seen as a nonspecific manifestation of severe debilitating illness.(HIM.1254)

・精神症状、強直間代痙攣　→　一次的、あるいは二次的な脳の疾患がありそう

・頭痛　→　漠然としていて絞れないが、他の症状からして機能性頭痛ではなく症候性頭痛っぽい。

・眼底両側に乳頭浮腫　→　脳圧亢進の徴候　→　原因は・・・脳腫瘍、ことにテント下腫瘍と側頭葉の腫瘍、クモ膜下出血、脳水腫など、そのほか、眼窩内病変、低眼圧などの局所的要因、悪性高血圧、血液疾患、大量出血、肺気腫などの全身的要因 (vindicate本のp342も参考になる)

　・頭痛と脳圧亢進　→　頭蓋内圧占拠性病変、脳炎(IMD.274)

・CT 所見　→　ringformの病変、脳浮腫、脳圧亢進

・低ナトリウム血症　→　脳ヘルニアに続発して起こることがあるらしい。実際には下垂体にトキソプラズマによる病変が形成されることにより起こりうる。

・そのほか出身地、体重減少もHIVを疑わせる点

パターン認識でHIV + 精神症状 + てんかん発作(強直間代痙攣) + 脳圧亢進 + CT 所見 = 一番ありそうなのはToxoplasma gondiiによるトキソプラズマ脳症 cerebral toxoplasosis (トキソプラズマ脳炎 toxoplasmic encephalitis)

■Toxoplasma gondii

　原虫　胞子原虫類

(感染予防学 080521のプリント、CASES p,92、HIM p.1305-)

・疫学：西洋では30-80%の成人がトキソプラズマの感染の既往がある・・・うぇ(CASES)。日本では10%前後(Wikipedia)。

・生活環

　・終宿主：ネコ：ネコの小腸上皮細胞で有性・無性生殖　糞便にオーシストの排泄

　・中間宿主：ヒト.ブタを含むほ乳類と鳥類：無性生殖で増殖、シストの形成

　　　急性期の増殖盛んな急増虫体 tachyzoiteとシスト内の緩増虫体 bradyzoite

・病原、病因 phathogenesis

　・緩増虫体(bradyzoite)、接合子嚢(oocyst)

・感染経路

　1. オーシストの経口摂取

　2. 中間宿主の生肉中のシストの経口摂取

　3. 初感染妊婦からの経胎盤感染。既感染なら胎盤感染しないらしい(HIM.1306)

　(4)移植臓器、輸血。確率は低い(at low rate)(HIM.1306)

・病態

　1. 先天性トキソプラズマ症　congenital toxoplasmosis

　　　①網脈絡膜炎、 ②水頭症、 ③脳内石灰化、 ④精神・運動障害

　2. 後天性トキソプラズマ症　acquired toxoplasmosis

　　(1) 健常者

　　　・多くは不顕性感染。発熱、リンパ節腫脹、皮疹(rash)

　　　・(少数例)筋肉痛、暈疼痛、腹痛、斑状丘疹状皮疹(maculopapular rash)、脳脊髄炎、混乱(HIM.1308)

　　　・(まれ)肺炎、心筋炎、脳症、心膜炎、多発筋炎

　　　・網膜、脈絡叢に瘢痕や、脳に小さい炎症性の病変を残すことあり(CASES)。

　　　・急性感染の症状は数週間で消失　筋肉や中枢神経系に緩増虫体が残存

　　(2)HIV 感染者、臓器移植例、がん化学療法例

　　　シスト内緩増虫体→急増虫体→播種性の多臓器感染

　　　AIDSでは、トキソプラズマ性脳炎が指標疾患 AIDS-defineing illness(CASES)

・治療

　(日本)アセチルスピラマイシン、ファンシダール(感染予防学 080521)

■トキソプラズマ脳炎 toxoplasmic encephalitis、トキソプラズマ脳症 cerebral toxoplasosis

・症状

　発熱、頭痛、混乱ｍ、痙攣、認知の障害、局所神経徴候(不全片麻痺、歯垢、脳神経損傷、視野欠損、感覚喪失)(CASES)

・画像検査

　(CT,MRI)多発性、両側性、ring-enhancing lesion、特に灰白質-白質境界、大脳基底核、脳幹、小脳が冒されやすい(CASES)

・鑑別診断(臨床症状・画像診断の所見で)

　リンパ腫、結核、転移性脳腫瘍(CASES)

・病歴と画像所見からの鑑別診断

　リンパ腫、結核、転移性腫瘍

？

このCTがcerebral toxoplasmosisに特徴的かは不明

□最後に残る疑問

　AIDSでWBC(leukocyte)の数はどうなるんだろう？？？AIDSの初診患者ではWBCが低い人が多いらしいし()、HIVはCD4+ T cellとmacrophageに感染して殺すから、これによってB cellは減るだろうし、CD8+ T cellも若干減少するだろうからWBCは減るんじゃないか？！好中球はAIDSとは関係ない？好中球は他の感染症に反応性に増加している？ちなみに、好酸球は寄生虫(原虫)の感染のために増える傾向にあるらしい(HIMのどこか)。

葉酸拮抗剤である。

サルファ剤と併用され、抗トキソプラズマ薬、抗ニューモシチス・カリニ薬として相乗的に働く。

ST 合剤

SMX-TMP

スルファメトキサゾール・トリメトプリム合剤 sulfamethoxazole and trimethoprim mixture

□AIDSの定義(http://en.wikipedia.org/wiki/CDC_Classification_System_for_HIV_Infection_in_Adults_and_Adolescents)

According to the US CDC definition, one has AIDS if he/she is infected with HIV and present with one of the following:

A CD4+ T-cell count below 200 cells/μl (or a CD4+ T-cell percentage of total lymphocytes of less than 14%).

or he/she has one of the following defining illnesses:

01. Candidiasis of bronchi, trachea, or lungs
02. Candidiasis esophageal
03. Cervical cancer (invasive)
04. Coccidioidomycosis, disseminated or extrapulmonary
05. Cryptococcosis, extrapulmonary
06. Cryptosporidiosis, chronic intestinal for longer than 1 month
07. Cytomegalovirus disease (other than liver, spleen or lymph nodes)
08. Encephalopathy (HIV-related)
09. Herpes simplex: chronic ulcer(s) (for more than 1 month); or bronchitis, pneumonitis, or esophagitis
10. Histoplasmosis, disseminated or extrapulmonary
11. Isosporiasis, chronic intestinal (for more than 1 month)
12. Kaposi's sarcoma
13. Lymphoma Burkitt's, immunoblastic or primary brain
14. Mycobacterium avium complex
15. Mycobacterium, other species, disseminated or extrapulmonary
16. Pneumocystis carinii pneumonia
17. Pneumonia (recurrent)
18. Progressive multifocal leukoencephalopathy
19. Salmonella septicemia (recurrent)
20. Toxoplasmosis of the brain
21. Tuberculosis
22. Wasting syndrome due to HIV

People who are not infected with HIV may also develop these conditions; this does not mean they have AIDS. However, when an individual presents laboratory evidence against HIV infection, a diagnosis of AIDS is ruled out unless the patient has not:

undergone high-dose corticoid therapy or other immunosuppressive/cytotoxic therapy in the three months before the onset of the indicator disease
OR been diagnosed with Hodgkin's disease, non-Hodgkin's lymphoma, lymphocytic leukemia, multiple myeloma, or any cancer of lymphoreticular or histiocytic tissue, or angioimmunoblastic lymphoadenopathy
OR a genetic immunodeficiency syndrome atypical of HIV infection, such as one involving hypogamma globulinemia

AND

the individual has had Pneumocystis carinii pneumonia
OR one of the above defining illnesses AND a CD4+ T-cell count below 200 cells/μl (or a CD4+ T-cell percentage of total lymphocytes of less than 14%).

□AIDSのステージング

Revised World Health Organization (WHO) Clinical Staging of HIV/AIDS For Adults and Adolescents (2005)

http://en.wikipedia.org/wiki/WHO_Disease_Staging_System_for_HIV_Infection_and_Disease_in_Adults_and_Adolescents

■参考文献

HIM = Harrison's Principles of Internal Medicine 17th Edition

CASES = 100 Cases in Clinical Medicine Second edition

IMD = 内科診断学第2版

「子宮頚癌」

　　[★]

英: cervical cancer, cancer of the cervix, cancer of the uterine cervix, uterine cervical cancer, endocervical carcinoma
ラ: carcinoma colli uteri
同: 子宮頸癌
関: 子宮頚部、子宮、腫瘍

概念

子宮頚部に発生した癌

疫学

95%扁平上皮癌、5%腺癌。腺癌の割合は年々増えてきている。

腺癌は若年者で多く、高分化型腺癌である。原因は不明

子宮頚癌：子宮体癌＝90：10　←　とにかく子宮頚癌が多い
50歳前後

病因

子宮頚癌の99%にヒトパピローマウイルス(HPV)が認められ、HPVの関与が大きい。

HPV遺伝子型の16,18型で7割を占める。他のハイリスク型は31,33,35,45,52,58である。

感染者の90%が治癒するが、10%は持続感染する。
持続感染者の一部が5-10年を経て異形成から子宮頚癌に進展する。

病理

扁平上皮癌

扁平-円柱上皮接合部 squamocolumnar junction SCJの円柱上皮下より発生する。この部位に予備細胞があり、この細胞が扁平上皮化生することにより生じる。
HIV感染により異型細胞(コイロサイトーシス)を生じる。基底細胞に異型細胞が認められればCIN1(下層1/3),CIN2(下層2/3),CIN3(表層以外),CIS(CIN3,全層),微小浸潤癌と進展していく。

腺癌

腺上皮類似の細胞より構成され、腺管形成傾向を示す。表層では乳頭状に、深部では腺管形成を示して増殖する。粘液を産生している細胞が認められる。
腺癌は手術で根治治療できない場合、放射線や化学療法が奏効しづらく予後不良である。

リスクファクター

発展途上国在住、活発な性行動、低所得階級、多産婦、喫煙、ピル、ステロイド、HIV、眼瞼親身受診、他のSTD

症状

初期：上皮内癌(臨床進行期では0期)および微小浸潤癌(Ia期)のほとんどが無症状(⇔子宮体癌では不正出血)　←　検診が重要となる　
浸潤癌：不正性器出血、接触出血あるいは帯下など
周辺臓器浸潤：骨盤痛、血尿、下血

検査

細胞診

スクリーニング検査として行われる

ベセスダシステム	推定病変	用語説明	日母分類
NILM	非腫瘍性病変, 炎症	陰性	I/II
ASC-US	軽度扁平上皮内病変(LSIL)疑い	意義不明異型扁平上皮	II/IIIa
ASC-H	高度扁平上皮内病変(HSIL)疑い	高度病変を除外できない異型扁平上皮	III/IIIb
LSIL	HPV感染, 軽度異形成	軽度扁平上皮内病変	IIIa
HSIL	中等度異形成, 高度異形成, 上皮内癌	高度扁平上皮内病変	IIIa, IIIb, IV
SCC	扁平上皮癌（微小浸潤含む）	扁平上皮癌	V
AGC	腺異形成, 腺系病変疑い	異型腺細胞	III
AIS	上皮内腺癌	上皮内腺癌	IV
adenocarcinoma	腺癌	腺癌	V
other	その他のがん	その他の悪性腫瘍	V

HPV検査

スクリーニング検査押して行われる
癌または前癌病変の発見率95%。細胞診と組み合わせると発見率は100%。

コルポ診

コルポスコープと呼ばれる拡大鏡を用いて子宮頚部粘膜表面を拡大し、観察。
3-5%の酢酸を子宮頚部に接触させ、それによる変化も所見とする。

画像検査

MRI

T2：淡い高信号(中～高信号)。子宮頚部間質は低信号。このコントラスト差を利用して浸潤の程度を把握する。水平断ではstromal ring(子宮内腔を取り囲む低信号)の消失がみられる
T1Gd造影：腫瘍は低信号となる。周囲組織浸潤を見積もるために使用される

臨床進行期

治療前に決定される

出典不明

子宮頸癌	0期(上皮内癌)			上皮内癌	・円錐切除(挙児希望) ・円錐切除or単純子宮全摘術(挙児希望なし)
	I期子宮頚部に限局	Ia期微小浸潤癌	Ia1期	(微小浸潤癌) 病理組織間質浸潤深さ3mm以内幅7mmを超えない	・円錐切除(挙児希望) ・単純子宮全摘術(挙児希望なし)
			Ia2期	(微小浸潤癌) 病理組織間質浸潤深さ3-5mm以内幅7mmを超えない	・(準)広汎子宮全摘術+骨盤リンパ節郭清術・広汎子宮全摘術
		Ib期	Ib1期	4cm以下	・広汎子宮全摘術
			Ib2期	4cmを超える	・広汎子宮全摘術・放射線療法・同時科学放射線療法
	II期頸部を超えて進展かつ骨盤壁or膣壁下1/3に達しない	IIa期		膣壁浸潤のみ	・広汎子宮全摘術・放射線療法・同時科学放射線療法
		IIb期		子宮傍組織浸潤のみ	・広汎子宮全摘術・放射線療法・同時科学放射線療法
	III期骨盤壁に達するor 膣壁浸潤下1/3	IIIa期		膣壁浸潤下1/3	・放射線療法・同時科学放射線療法
		IIIb期		骨盤壁に達する	・放射線療法・同時科学放射線療法
	IV期膀胱,直腸の粘膜へ浸潤or 小骨盤を超えて進展	IVa期		膀胱,直腸の粘膜へ浸潤	・放射線療法・同時科学放射線療法
		IVb期		小骨盤を超えて進展	・放射線療法・化学療法

妊娠と治療

0期(CIN), Ia期：分娩まで経過観察し、分娩後治療(円錐切除もしくは単純子宮全摘術)
Ib期：原則的に広汎子宮全摘出術　　←　　妊娠継続は母体へのリスクが大きすぎるため(周辺臓器浸潤、転移など？)。

診断

診察＋検査で診断する。

視診、内診、直腸診、細胞診、コルポスコピー、組織診、尿路系検査、単純X線撮影、超音波検査、CT、MRI、腫瘍マーカー、リンパ管造影、ガリウムシンチグラム。

新臨床進行期分類(日産婦1997, FIGO 1994)(参考4)により治療前に病期を決定する。決定の根拠とできる診察＆検査は以下の通りである。触診、視診、コルポスコピー、診査切除、頸管内掻爬、子宮鏡、膀胱鏡、直腸鏡、排泄性尿路造影、肺及び骨のＸ線検査。なお、子宮頸部円錐切除術は臨床検査とみなす。

治療

手術療法

化学療法

放射線療法

適応：(1)腫瘍切除後に顕微鏡的に癌の残存が疑われる、(2)リンパ節転移あり、(3)骨盤近くまで浸潤、(4)脈管内浸潤有り、(5)膣摘出不十分 (NGY.223)

QB Q-288

外部照射：(Ib1？～II)広汎子宮全摘術後に膣断端陰性
外部照射＋腔内照射(遠隔操作式後装填法 RALS)：(Ib1？～II)広汎子宮全摘術後に膣断端陰性、あるいはIII,IV期

ガイドライン2

進行期		外部照射（Gy）		腔内照射（Gy／回，A点線量）
進行期		全骨盤	中央遮蔽	腔内照射（Gy／回，A点線量）
Ⅰ		0	45～50	'29／5
Ⅱ	小	0	45～50	'29／5
Ⅱ	大	20	30	'23／4
Ⅲ	小～中	20～30	20～30	'23／4
Ⅲ	大	30～40	20～25	'15／3～20／4
ⅣA		30～50	10～20	'15／3～20／4

総照射線量は進行期によって変わる。ガイドライン2によれば、外部照射は45-70Gyまでありうる。施設ごとに放射線治療のプロトコールは異なる。例えば、参考7を参照すると、外部照射は最大54Gyである。

合併症

ガイドライン2

急性期：悪心(放射線宿酔)、下痢、膀胱炎、皮膚炎(特に下方へ延長した照射野を設定した場合の会陰部)、白血球減少症
晩発性(grade3以上の頻度)：直腸炎(出血)(5?10%)、膀胱炎(出血)(5%以下)、小腸障害(腸閉塞)(5%以下)皮下組織繊維化・浮腫(下腹部)、腟粘膜の癒着・潰瘍、膀胱腟瘻、直腸腟瘻、骨折、下肢浮腫