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• A total 21 quality indicators of palliative care were settled. • Symptom palliation and supporting decision-making process are two major domains. • Outcome measure could only be evaluated by bereaved family survey. Although recent attention to palliative care for patients with cardiovascular diseases has been increasing, there are no specific recommendations on detailed palliative care practices. We proceed on a discussion of the appropriateness and applicability of potential quality indicators for acute cardiovascular diseases according to our previous systematic review. We created a multidisciplinary panel of 20 team members and 7 external validation clinicians composed of clinical cardiologists, a nutritionist, a physiotherapist, a clinical psychologist, a critical and emergent care specialist, a catheterization specialist, a primary care specialist, a palliative care specialist, and nurses. After crafting potential indicators, we performed a Delphi rating, ranging from "1 = minimum" to "9 = maximum". The criterion for the adoption of candidate indicators was set at a total mean score of seven or more. Finally, we subcategorized these indicators into several domains by using exploratory factor analysis. Sixteen of the panel members (80%) were men (age, 49.5 ± 13.7 years old). Among the initial 32 indicators, consensus was initially reached on total 23 indicators (71.8%), which were then summarized into 21 measures by selecting relatively feasible time variations. The major domains were "symptom palliation" and "supporting the decision-making process". Factor analysis could not find optimal model. Narratively-developed seven sub-categories included "presence of palliative care team", "patient-family relationship", "multidisciplinary team approach", "policy of approaching patients", "symptom screening and management", "presence of ethical review board", "collecting and providing information for decision-maker", and "determination of treatment strategy and the sharing of the care team's decision". In this study we developed 21 quality indicators, which were categorized into 2 major domains and 7 sub-categories. These indicators might be useful for many healthcare providers in the initiation and enhancement of palliative care practices for acute cardiovascular diseases in Japan. [ABSTRACT FROM AUTHOR]

Background: The prevalence of anisakiasis is rare in the United States and Europe compared with that in Japan, with few reports of its presentation in the emergency department (ED). This study describes the clinical, hematologic, computed tomographic (CT) characteristics, and treatment in gastric and small intestinal anisakiasis patients in the ED. Methods: We retrospectively reviewed the data of 83 consecutive anisakiasis presentations in our ED between 2003 and 2012. Gastric anisakiasis was endoscopically diagnosed with the Anisakis polypide. Small intestinal anisakiasis was diagnosed based on both hematologic (Anisakis antibody) and CT findings. Results: Of the 83 cases, 39 had gastric anisakiasis and 44 had small intestinal anisakiasis based on our diagnostic criteria. Although all patients had abdominal pain, the gastric anisakiasis group developed symptoms significantly earlier (peaking within 6 hours) than the small intestinal anisakiasis group (peaking within 48 hours), and fewer patients with gastric anisakiasis needed admission therapy (5% vs 57%, P<.01). All patients in the gastric and 40 (91%) in the small intestinal anisakiasis group had a history of raw seafood ingestion. Computed tomographic findings revealed edematous wall thickening in all patients, and ascites and phlegmon of the mesenteric fat were more frequently observed in the small intestinal anisakiasis group. Conclusions: In the ED, early and accurate diagnosis of anisakiasis is important to treat and explain to the patient, and diagnosis can be facilitated by a history of raw seafood ingestion, evaluation of the time-to-symptom development, and classic CT findings. [ABSTRACT FROM AUTHOR]

Abstract: Background: Anion gap (AG) is a useful index for assessing the clinical condition of critically ill patients especially in intoxication. Recently, AG can be obtained easily using a blood gas analyzer (BGA); however, its reliability requires validation. Methods: We enrolled patients who simultaneously underwent blood gas analysis and blood test in the central hospital laboratory and patients who visited the emergency department of our hospital from January 1, 2004, to December 31, 2007. The deviation of AG calculated using the BGA and that calculated by the central hospital laboratory were extracted. From the data obtained using the BGA, the independent risk factor causing a significant error in AG was statistically analyzed. Results: A total of 2922 patients were enrolled, of which 339 were defined as the significant error group. Male sex, abnormal Hco 3 −, abnormal lactate, abnormal K, abnormal Cl, and abnormal Na were the independent risk factors producing the significant error. The results indicate that regardless of whether the original electrolyte data of the patients are abnormal, when the electrolyte measurement results obtained using the BGA are abnormal, the calculated AG might show a significant error. In addition, the fact that lactate was determined as a risk factor indicates that AG might be more useful in patients who have intoxication than in those under an unstable state in terms of vital signs. Conclusion: When risk factors are present, the medical condition of a patient should be reevaluated by comparing results without heavily relying on the AG obtained by a BGA. [Copyright &y& Elsevier]

Abstract: A large quantity of white gas containing titanium dioxide and hydrogen chloride was generated unexpectedly during an experiment in a chemical laboratory. Fourteen students and staff complained of nausea, dyspnea, or respiratory irritation immediately after inhaling the gas. On arrival at Saint Luke''s International Hospital, more than half of the patients presented with low-grade fever. Symptoms spontaneously resolved soon after admission, although the low-grade fever persisted until the following morning. Low-grade fever after inhalation exposure is not explicable by hydrogen chloride inhalation and therefore appeared to be caused by titanium dioxide inhalation, manifesting as metal fume fever. Titanium dioxide is thought to have no remarkable human toxicity and is considered to be safe clinically. To our knowledge, this is the first report of titanium dioxide inhalation as the potential cause of metal fume fever in humans. Correlations between the degree of fever and quantity and concentration of inhaled titanium dioxide remain to be determined. [Copyright &y& Elsevier]

OBJECTIVE: We aimed to generate equation to predict arterial lactate (a-Lac) using venous lactate (v-Lac) and other lab data. METHODS: A prospective cross-sectional study was conducted on emergency patients in the emergency department for 6 months at a general hospital in Tokyo, Japan. We collected arterial and venous gas analysis data. Patients were eligible for entry into the study if an arterial blood gas analysis was required for appropriate diagnostic care by the treating physician. Univariate linear regression analysis was conducted to generate an equation to calculate a-Lac incorporating only v-Lac. A multivariate forward stepwise logistic regression model (p-value of 0.05 for entry, 0.1 for removal) was used to generate an equation including v-Lac and other potentially relevant variables. Bland-Altman plot was drawn and the two equations were compared for model fitting using R-squares. RESULTS: Seventy-two arterial samples from 72 participants (61% male; mean age, 58.2 years) were included in the study. An initial regression equation was derived from univariate linear regression analysis:'(a-Lac) = -0.259 + (v-Lac) x 0.996'. Subsequent multivariate forward stepwise logistic regression analysis, incorporating v-Lac and Po2, generated the following equation:'(a-Lac) = -0.469+(venous Po2) x 0.005 + (v-Lac) x 0.997'. Calculated R-squares by single and multiple regression were 0.94 and 0.96, respectively. CONCLUSION: v-Lac estimates showed a high correlation with arterial values and our data provide two clinically useful equations to calculate a-Lac from v-Lac data. Considering clinical flexibility, 'Lac = -0.259 + v-Lac x 0.996' might be more useful while avoiding a time-consuming and invasive procedure. [ABSTRACT FROM AUTHOR]

A 74-year-old man was brought to the emergency department (ED) due to a 1-hour course of dyspnea and dysphonia. At arrival in the ED, his airway was managed by bag-valve-mask ventilation. The patient was intubated using a Macintosh laryngoscope with a gum elastic bougie guide. An indirect endoscopic examination revealed prominent epiglottal swelling. Simultaneously, we found a bilateral conjugate deviation to the right and a positive Barré sign for the left arm. Diffusion-weighted magnetic resonance imaging, magnetic resonance angiography, and computed tomography with contrast enhancement revealed a right cerebral hemisphere infarction and dissection of the brachiocephalic artery to the right internal carotid artery. After admission, the patient stated that the movement of his left arm was intact when he became aware of the dyspnea and that he noticed the paralysis of his left arm during transportation to the ED. We believed that these signs resulted from the right hemisphere brain infarction caused by dissection of the brachiocephalic artery to the right internal carotid artery, secondary to the acute epiglottitis. A decrease of intrathoracic pressure due to an upper airway obstruction may cause distention of the intrathoracic arteries and an afterload increase on the left ventricle. The patient was moved to another hospital for rehabilitation on the 20th day after admission. This is the first report of a brain infarction after a dissection of the intrathoracic arteries secondary to acute epiglottitis. Patients with acute epiglottitis should be closely monitored for both airway management and the pathology caused by decreasing intrathoracic pressure. [ABSTRACT FROM AUTHOR]