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Chika Nishiyama, Tetsuhisa Kitamura, Tomohiko Sakai, Yukiko Murakami, Tomonari Shimamoto, Takashi Kawamura, Takahiro Yonezawa, Shohei Nakai, Seishiro Marukawa, Tetsuya Sakamoto, and Taku Iwami. Community‐Wide Dissemination of Bystander Cardiopulmonary Resuscitation and Automated External Defibrillator Use Using a 45‐Minute Chest Compression?Only Cardiopulmonary Resuscitation Training. Journal of the American Heart Association. 2019; 8., Background: Little is known about whether cardiopulmonary resuscitation (CPR) training can increase bystander CPR in the community or the appropriate target number of CPR trainings. Herein, we aimed to demonstrate community-wide aggressive dissemination of CPR training and evaluate temporal trends in bystander CPR. Methods and Results-?We provided CPR training (45-minute chest compression ―only CPR plus automated external defibrillator use training or the conventional CPR training), targeting 16% of residents. All emergency medical service― treated out-of-hospital cardiac arrests of medical origin were included. Data on patients experiencing out-of-hospital cardiac arrest and bystander CPR quality were prospectively collected from September 2010 to December 2015. The primary outcome was the proportion of high-quality bystander CPR. During the study period, 57 173 residents (14.7%) completed the chest compression?only CPR training and 32 423 (8.3%) completed conventional CPR training. The proportion of bystander CPR performed did not change (from 43.3% in 2010 to 42.0% in 2015; P for trend=0.915), but the proportion of high-quality bystander CPR delivery increased from 11.7% in 2010 to 20.7% in 2015 (P for trend=0.015). The 1-year increment was associated with high-quality bystander CPR (adjusted odds ratio, 1.461; 95% CI, 1.055?2.024). Bystanders who previously experienced CPR training were 3.432 times (95% CI, 1.170?10.071) more likely to perform high-quality CPR than those who did not. Conclusions-?We trained 23.0% of the residents in the medium-sized city of Osaka, Japan, and demonstrated that the proportion of high-quality CPR performed on the scene increased gradually, whereas that of bystander CPR delivered overall remained stable.

Background Little is known about the effectiveness of systematic cardiopulmonary resuscitation (CPR) training for elementary school children. Methods We introduced systematic training of chest compression-only CPR and automated external defibrillator (AED) use to elementary school students aged 10–12 years at 17 schools. The questionnaire compared student attitudes towards CPR and their knowledge about it before and after CPR training. We also evaluated parent and teacher views about CPR training in school education. The primary outcome was positive attitude, defined as “yes” and “maybe yes” on a 5 point Likert-type scale of student attitudes towards CPR.1 Results A total of 2047 elementary school students received CPR training. Of them, 1899 (92.8%) responded to the questionnaire regarding their attitude towards CPR before and after the training. Before training, 50.2% answered “yes” and 30.3% answered “maybe yes”, to the question: “If someone suddenly collapses in front of you, can you do something such as check response or call emergency?” After training, their answers changed to 75.6% and 18.3% for “yes” and “maybe yes”, respectively. Many of the students (72.3%, 271/370) who did not have a positive attitude before CPR training had a positive attitude after the training (P

Introduction: In Japan, the number of automated external defibrillators (AEDs) placed in public areas has climbed up to the estimated 530,000. We reported previously that a half of out-of-hospital cardiac arrests occurred within 100 m from a public AED in urban areas. However, shocks for defibrillation were given to less than 15% of those patients. The objectives of this study was to identify the limiting factors against the use of AEDs by bystanders. Methods: A prospective survey on out-of-hospital cardiac arrest was conducted in the city of Osaka (Dec 2016 through Mar 2017) and the city of Nagoya (Dec 2016 through Nov 2017) searching for patient demographics and AED settings including; absence/presence of a public AED on the scene, attachment of AED pads, delivery of shocks before the time of EMS arrival. Results: Of 558 cases of cardiac arrest registered during the survey period, an AED had already been delivered at the patient side by the time of EMS arrival in 92 case (16.5%). Of those, pads had been attached in 89 cased (96.7%). Shocks had been advised in 35 cases (39.3%) and to all but one of those cases at least 1 shock had been given by the bystanders. There were no statistically significant differences between the groups of cases with and without AEDs at the patient side regarding the patient age (65 years [IQR: 48-74] vs 63 years [IQR49-75], p=0.84), gender (p=0.68) and the time from call to EMS arrival (7 min [IQR: 6-9] vs 7 min [IQR: 6-9], p=0.74). Cases occurring indoors had more chances of AEDs being delivered on the patient side than cases occurring outdoors (24.0% vs 7.8%, p Conclusions: Our study indicates that once an AED is delivered at the patient side, pads are successfully attached and shocks are given if indicated in almost all cases. This suggests that finding and delivering an AED onto the patient side are the limiting factors against the use of AEDs by bystanders. In order to popularize the use of AEDs by bystanders, informing people with AED placement and clear direction to the AED location seem to be the key steps.

Introduction: An interruption of chest compressions during CPR adversely affects patient outcome. Currently, however, periodical interruptions are unavoidable to assess the ECG rhythms and to give shocks for defibrillation if indicated. Evidence suggests a 5-second interruption immediately before shocks may translate into ~15% reduction of the chance of survival. The objective of this study was to build, train and validate a convolutional neural network (artificial intelligence) for detecting shock-indicated rhythms out of ECG signals corrupted with chest compression artifacts during CPR. Methods: Our convolutional neural network consisted of 7 convolutional layers, 3 pooling layers and 3 fully-connected layers for binary classification (shock-indicated vs non-shock-indicated). The input data set was a spectrogram consisting of 56 frequency-bins by 80 time-segments transformed from a 12.16-seconds ECG signal. From AEDs used for 236 patients with out-of-hospital cardiac arrest, 1,223 annotated ECG strips were extracted. Ventricular fibrillation and wide-QRS ventricular tachycardia with HR>180 beats/min were annotated as shock-indicated, and the others as non-shock-indicated. The total length of the strips was 8:49:57 (hr:min:sec) and 8:02:07 respectively for shock-indicated and non-shock-indicated rhythms. Those strips were converted into 465,102 spectrograms allowing partial overlaps and were fed into the neural network for training. The validation data set was obtained from a separate group of 225 patients, from which annotated ECG strips (total duration of 62:11:28) were extracted, yielding 43,800 spectrograms. Results: After the training, both the sensitivity and specificity of detecting shock-indicated rhythms over the training data set were 99.7% - 100% (varying with training instances). The sensitivity and specificity over the validation data set were 99.3% - 99.7% and 99.3% - 99.5%, respectively. Conclusions: The convolutional neural network has accurately and continuously evaluated the ECG rhythms during CPR, potentially obviating the need for rhythm checks for defibrillation during CPR.

[Objectives]To evaluate the long-term effectiveness of 15-min refresher basic life support (BLS) training following 45-min chest compression-only BLS training. [Methods]After the 45-min chest compression-only BLS training, the participants were randomly assigned to either the refresher BLS training group, which received a 15-min refresher training 6 months after the initial training (refresher training group), or to the control group, which did not receive refresher training. Participants’ resuscitation skills were evaluated by a 2-min case-based scenario test 1 year after the initial training. The primary outcome measure was the number of appropriate chest compressions during a 2-min test period. [Results]140 participants were enrolled and 112 of them completed this study. The number of appropriate chest compressions performed during the 2-min test period was significantly greater in the refresher training group (68.9 ± 72.3) than in the control group (36.3 ± 50.8,p = 0.009). Time without chest compressions was significantly shorter in the refresher training group (16.1 ± 2.1 s versus 26.9 ± 3.7 s, p < 0.001). There were no significant differences in time to chest compression (29.6 ± 16.7 s versus 34.4 ± 17.8 s, p = 0.172) and AED use between the groups. [Conclusions]A short-time refresher BLS training program 6 months after the initial training can help trainees retain chest compression skills for up to 1 year. Repeated BLS training, even if very short, would be adopted to keep acquired CPR quality optimal (UMIN-CTR UMIN 000004101).

Objectives It is unclear how much the length of a cardiopulmonary resuscitation (CPR) training program can be reduced without ruining its effectiveness. The authors aimed to compare CPR skills 6 months and 1 year after training between shortened chest compression–only CPR training and conventional CPR training. Methods Participants were randomly assigned to either the compression-only CPR group, which underwent a 45-minute training program consisting of chest compressions and automated external defibrillator (AED) use with personal training manikins, or the conventional CPR group, which underwent a 180-minute training program with chest compressions, rescue breathing, and AED use. Participants' resuscitation skills were evaluated 6 months and 1 year after the training. The primary outcome measure was the proportion of appropriate chest compressions 1 year after the training. Results A total of 146 persons were enrolled, and 63 (87.5%) in the compression-only CPR group and 56 (75.7%) in the conventional CPR group completed the 1-year evaluation. The compression-only CPR group was superior to the conventional CPR group regarding the proportion of appropriate chest compression (mean ± SD = 59.8% ± 40.0% vs. 46.3% ± 28.6%; p = 0.036) and the number of appropriate chest compressions (mean ± SD = 119.5 ± 80.0 vs. 77.2 ± 47.8; p = 0.001). Time without chest compression in the compression-only CPR group was significantly shorter than that in the conventional CPR group (mean ± SD = 11.8 ± 21.1 seconds vs. 52.9 ± 14.9 seconds; p

Background Actual application of public-access automated external defibrillator (AED) pads to patients with an out-of-hospital cardiac arrest (OHCA) by the public has been poorly investigated. Methods AED applications, prehospital characteristics, and one-month outcomes of OHCAs occurring in Osaka Prefecture from 2011 to 2012 were obtained from the Utstein Osaka Project registry. Patients with a non-traumatic OHCA occurring before emergency medical service attendance were enrolled. The proportion of AED pads that were applied to the patients’ chests by the public and one-month outcomes were analysed according to the location of OHCA. Results In total, public-access AED pads were applied to 3.5% of OHCA patients (351/9978) during the study period. In the multivariate analyses, OHCAs that occurred in public places and received bystander-initiated cardiopulmonary resuscitation were associated with significantly higher application of public-access AEDs. Among the patients for whom public-access AED pads were applied, 29.6% (104/351) received public-access defibrillation. One-month survival with a favourable neurological outcome was significantly higher among patients who had an AED applied compared to those who did not (19.4% vs. 3.0%; OR: 2.76 [95% CI: 1.92–3.97]). Conclusion The application of public-access AEDs leads to favourable outcomes after an OHCA, but utilisation of available equipment remains insufficient, and varies considerably according to the location of the OHCA event. Alongside disseminating public-access AEDs, further strategic approaches for the deployment of AEDs at the scene, as well as basic life support training for the public are required to improve survival rates after OHCAs.

Decreased neutrophil apoptosis is associated with persistent inflammation, the severity of which correlates with serum IL-18 levels. IL-18 receptors as well as Toll-like receptors, including Toll-like receptor 4, a receptor for LPS, possess a highly conserved intracellular domain called "Toll-IL-1R domain" and activate overlapping signaling pathways. Here, we show that IL-18 modulates neutrophil apoptosis and compare its mechanism of action with LPS. We found that both IL-18 and LPS decreased neutrophil apoptosis in a similar dose- and time-dependent fashion. However, pretreatment with the phosphatidylinositol 3-kinase (PI3K) inhibitor LY294002 increased apoptosis more effectively in IL-18- than in LPS-stimulated cells, whereas the ERK inhibitor PD98059 had the same effect in both. In contrast, the p38 mitogen-activated protein kinase (MAPK) inhibitor SB203580 had no influence on apoptosis at all. Neutrophils constitutively expressed mRNA for IL-18 receptor beta, but little or no receptor alpha, both of which increased during coculture with either IL-18 or LPS in a time- and dose-dependent manner. Of the Bcl-2 family, antiapoptotic A1/Bfl-1 tended to increase on IL-18 and LPS stimulation, but was further increased despite increased apoptosis in the presence of MAPK inhibitors. Thus, human neutrophils can express mRNA for IL-18 receptors alpha and beta, and IL-18, like LPS, inhibits neutrophil apoptosis by activating PI3K and ERK pathways but not p38MAPK. However, PI3K may play more important role(s) in IL-18- than in LPS-induced inhibition of apoptosis. Mitogen-activated protein kinases seem to mediate antiapoptotic signals through factors other than Bcl-2 gene family expression.

Little is known about the effectiveness of systematic cardiopulmonary resuscitation (CPR) training for elementary school children.We introduced systematic training of chest compression-only CPR and automated external defibrillator (AED) use to elementary school students aged 10-12 years at 17 schools. The questionnaire compared student attitudes towards CPR and their knowledge about it before and after CPR training. We also evaluated parent and teacher views about CPR training in school education. The primary outcome was positive attitude, defined as "yes" and "maybe yes" on a 5 point Likert-type scale of student attitudes towards CPR.1 RESULTS: A total of 2047 elementary school students received CPR training. Of them, 1899 (92.8%) responded to the questionnaire regarding their attitude towards CPR before and after the training. Before training, 50.2% answered "yes" and 30.3% answered "maybe yes", to the question: "If someone suddenly collapses in front of you, can you do something such as check response or call emergency?" After training, their answers changed to 75.6% and 18.3% for "yes" and "maybe yes", respectively. Many of the students (72.3%, 271/370) who did not have a positive attitude before CPR training had a positive attitude after the training (P 0.001). Most students understood how to perform CPR (97.7%) and use an AED (98.5%). Parents (96.2%, 1173/1220) and teachers (98.3%, 56/57) answered that it was "good" and "maybe good" for children to receive the training at elementary schools.Systematic chest compression-only CPR training helped elementary school students to improve their attitude towards CPR.

We investigated the acute hematological changes caused by interleukin-18 (IL-18) in mice. Intraperitoneal administration of IL-18 (2 μg/mouse) resulted in biphasic decreases in the number of leukocytes in the blood. The first phase of decrease occurred within 2 h of IL-18 administration and was followed by a transient increase at 5 h. The second phase of decrease occurred at around 6 h, reaching a nadir which lasted for more than 24 h. In mice deficient in inducible nitric oxide (NO) synthase, the first phase of reduction of leukocytes did not occur although the second phase of decrease was observed. In mice deficient in gamma interferon (IFN-γ) or in mice depleted of natural killer cells and incapable of producing IFN-γ, IL-18 had no effect on the number of circulating leukocytes. Levels of nitrite and/or nitrate in the serum were elevated within 2 h after administration of IL-18, reaching a peak at 4 h and then decreasing gradually to the basal level over a 24-h period of time. On the other hand, serum IFN-γ levels changed in a biphasic manner, reaching a peak at 2 h after IL-18 administration, followed by a decrease in the basal level and a second increase at 6 h. Levels of IL-18 receptor mRNAs also showed biphasic changes in correlation with the changes in serum IFN-γ levels. These results suggest that the changes in the leukocyte number following IL-18 administration are mediated by NO and IFN-γ, with NO being involved in the first phase of reduction and IFN-γ being involved in both phases.

Introduction: We have previously estimated the cost of and quality-adjusted life year (QALY) gained with ~200,000 AEDs placed in Japan between 2004 through 2009, and reported that the maximum likelihood estimate (MLE) of the incremental cost-effectiveness ratio (ICER) to be ~$93,980/QALY. To evaluate the robustness of the estimated ICER, we conducted a sensitivity analysis using Monte Carlo simulation. Methods: Over the study period, 3,927 patients received public access defibrillation (PAD). A control group was created by extracting, from the national database, another group of 3,927 cardiac arrest patients who did not receive PADs but otherwise matched with regard to confounders including age, sex, response time and others. The difference of the total QALY in the 2 groups yielded incremental effectiveness gained by the PAD program. The sum of the total cost for AED purchase and maintenance, cost of BLS training for first responders, and differential cost for medical care yielded the incremental cost. The value for each variable needed to calculate the incremental cost and effectiveness was randomly varied in such a way that followed the pre-defined probability density function (Table). Monte Carlo simulation was repeated 10,000 times to estimate the MLE and its 95% CI for ICER. Results: The MLE (95% CI) for the incremental cost and incremental effectiveness was ~$ 580 million (577- 583 million) and ~7,559 (6,298- 8,858) QALY, yielding ICER of $77,320 ($65,503- 92,017) /QALY (figure). Conclusions: Our estimate of the ICER seemed to be relatively robust to several assumptions. The ICER of the whole Japan PAD program seemed to be higher than desirable but still acceptable.

Introduction: Cerebral tissue oxygen saturation measured with transcranial near-infrared spectroscopy (NIRS) has been reported to predict neurological outcome of cardiac arrest patients. Because NIRS values are confounded by extracranial tissues, there can be considerable inter-device variation in the measured values. We compared hyperventilation-induced changes in NIRS values measured with 2 commercially available devices in healthy volunteers. Methods: After obtaining an approval from the ethics committee at Iseikai hospital and written informed consents, 29 healthy volunteers joined the study. Probes of NIRO™ 200NX (Hamamatsu Photonics, Japan) and INVOS™ 5100C (Covidien, USA) were applied respectively on the right and left side of the volunteers’ forehead. After obtaining the baseline values, the volunteers were asked to hyperventilate for 40 seconds attempting to reduce the end-tidal CO 2 by ~20 mmHg. Measurements were repeated, after 20 minutes of resting interval, with the probes applied on the contralateral sides. Hyperventilation-induced response of the NIRS value was categorized as “correct” when the average value over the 5 second period toward the end of the hyperventilation decreased by >15% the baseline or “erroneous” otherwise. Results: The mean (± SD) end-tidal CO 2 decreased from the baseline value of 36 ± 5.1 mmHg to 15.2 ± 4.4 mmHg during hyperventilation. Out of 58 measurements with each of the devices, NIRO values were “correct” in 54 (93.1%) measurements, whereas INVOS values were “correct” in 32 (52.2%) measurements. NIRO presented “erroneous” values on both sides of the forehead in no volunteers whereas INVOS presented “erroneous” values in 7 (35%) of 29 volunteers. Discussion: Hyperventilation consistently decreases cerebral blood flow in healthy subjects. Thus, the results of the present study suggest that NIRS devices may fail to reflect correct changes in cerebral tissue oxygen saturation in ~7% of measurements with NIRO and in ~48% with INVOS. The bilateral “erroneous” measurements with INVOS in 7 (35%) volunteers may suggest that INVOS is subject to confounding by extracranial tissues. A potential source of confounding may include the scalp where blood flow increases during hyperventilation.

Bystander cardiopulmonary resuscitation including automated external defibrillator use increases the chance of survival after out-of-hospital cardiac arrest. However, bystanders may be distressed by witnessing out-of-hospital cardiac arrest and may hesitate to initiate cardiopulmonary resuscitation. The present study examined factors associated with layperson confidence in carrying out resuscitation of out-of-hospital cardiac arrest patients.We carried out a cross-sectional survey in February 2012. Laypeople were asked about background characteristics, whether they had performed cardiopulmonary resuscitation, had received cardiopulmonary resuscitation training, were aware of the location of the neighborhood automated external defibrillator, and felt confident in performing resuscitation, and their potential emotional distress if a resuscitation attempt were to prove unsuccessful.Participants comprised 4,853 respondents. Of these, 2,372 (49%) had received cardiopulmonary resuscitation training, and 3,607 (74%) knew where the neighborhood automated external defibrillator was located. Confidence in performing chest compressions was reported by 2,667 (55%), confidence in performing rescue breathing by 2,498 (52%), and confidence in using an automated external defibrillator by 2,822 (58%). Potential emotional distress if a resuscitation attempt proved unsuccessful was reported by 4,247 (88%). Multivariate regression analysis showed that having carried out cardiopulmonary resuscitation, having received cardiopulmonary resuscitation training, and awareness of the neighborhood automated external defibrillator location were significantly associated with confidence in performing cardiopulmonary resuscitation.Our results suggest that more extensive cardiopulmonary resuscitation training and information regarding neighborhood automated external defibrillator locations may increase layperson confidence in initiating resuscitation.

Case: An 11-month-old boy bruised his head and experienced convulsions, followed by a coma with decerebrate rigidity. Initial CT scans showed an acute interhemispheric subdural hematoma and diffuse brain swelling. On day 2, he developed dilated pupils, absent light reflex, and sudden hypotension. Dopamine (DOA) and antidiuretic hormone (ADH) were administered to maintain his circulation. CT scans on day 3 revealed brain tamponade. The patient was diagnosed as brain dead on day 15. The patient was thereafter maintained under mechanical ventilation. DOA and ADH requirements decreased gradually, resulting in shift from DOA to docarpamine on day 146 and in the cessation of ADH administration on day 245. On day 139, autolysed brain parenchyma was discharged through the anterior fontanel and necrotic skin, resulting in the appearance of pneumocephalus on CT scans on day 299. Repeated EEGs, ABRs, dynamic CTs and intracranial Power Dopplers supported the diagnosis of brain death. Nevertheless, the patient's height increased consistently from 74cm on day 1 to 82cm on day 253. The secretion of thyroid stimulating hormone was detected until day 252. The boy developed septic renal failure and died on Day 326. Discussion and Conclusion: Although brain death in adults is usually followed by early cardiac arrest, the infant in this case was sustained in a state of brain death for over 300 days using ordinary intensive care. An analysis of endocrinological function and growth records may help to clarify the mechanism of the patient's sustained heart beat.

体位呼吸療法(腹臥位,前傾側臥位)を併用した非侵襲的陽圧呼吸法(NIPPV)を急性呼吸不全症例に適用し,改善した6例(成功群)と,経過中に挿管を要した6例(不成功群)を比較し,本法における予後影響因子を検討した。両群間で治療開始時の重症度スコア,PaO2/FIO2最低値に有意差はなかったが,成功群のほうがより発症後早期であった。不成功群では有意に呼吸回数が多く,PaCO2が低く(高度過換気),代謝性アシドーシスが強かった。挿管を要した理由は主に呼吸筋疲労,敗血症ショック,咳嗽時のPaO2低下などであった。本法では呼吸疲労がないこと,意識清明で咳嗽が安全に行えること,下側肺障害があり体位依存性に肺酸素化能が改善することなどが前提であるが,さらに,(1)代謝性アシドーシスが進行性でない,(2)発症後早期(3日以内)で肺障害が極端に高度でない,(3)原病態が制御可能,(4)呼吸数が40min-1以下で過換気が高度でない(PaCO2>30mmHg)などの条件が予後の良否を決定する。

Objective: To improve sterilization methods for preventing stopcock infection in central venous lines.Design: Prospective, noninterventional study.Setting: General intensive care unit at a university teaching hospital.Measurements and Results: Thirty-six stopcocks connected to the central venous line in critically ill patients were studied. Sixteen stopcocks were wiped with cotton wett with 70% ethyl alcohol at the injection port immediately before intravenous medication (wiping group), and twenty stopcocks were sterilized by spraying 70% ethyl alcohol into the injection port (spray group). Microbiological analysis was performed after using the stopcocks for 24 hours. Pathogenetic bacteria were isolated from five stopcocks (31.3%) and fungi were detected from four stopcocks (25.0%) in the wiping group. Pathogenetic bacteria and fungi were isolated from one stopcock (5.0%) and three stopcocks (15.0%), respectively in the spray group.Conclusion: This study showed that spraying 70% ethylalcohol on stopcocks is significantly more effective (P

We reported two cases of severe acute pulmonary failure who were successfully treated with face (nasal) CPAP mask and the application of postural improving effect on the pulmonary oxygenation (Non-invasive respiratory support), instead of the conventional respiratory therapy including endotracheal intubatin (ETI), mechanical ventilation (CMV) etc.. First case was a 16 year old female who had bronchopneumonia from aplastic anemia, and her PaO2/FIO2 (P/F) ratio was improved from 146 in supine position to 174 in right anterolateral position. Second case was a 21 year old male who had ARDS from acute myelogenous leukemia, and his P/F ratio was improved from 94 in supine position to 183 in left anterolateral position. Subsequently, clinical management was performed keeping these patients in anterolateral position in which their PaO2 were improved within life saving range (over 60mmHg). And they were put into prone position for short periods (2 hours maximum) several times a day. Their P/F ratio were improved rapidly and exceeded 300 in all positions by the 5th ICU day.Face (Nasal) CPAP mask is superior to permit patient to drink and eat something, to keep orally contact with others, and breath freely, moreover to avoid the pulmonary injuries associated with ETI, CMV, high PEEP, and high FIO2 inhalation.Thsee cases suggest that if PaO2 improve over 20mmHg with turning to anterolateral position in acute respiratory failure patient, even severe, respiratory treatments could be performed successfully with face (nasal) CPAP mask, instead of active conventional therapeutic skills.

A case of thrombotic thrombocytopenic purpura (TTP) is reported. The patient (32yrs) underwent cesarean section because of severe eclampsia, then developed TTP in the postpartum period. She was treated aggressively with plasma exchange, antiplatelet agents, anticoagulants and steroids. Her platelet count recovered after the second plasma exchange and her condition was well managed for about 10 days. However, TTP became worse on the 21st postoperative day due to infection. Despite further treatment, including plasma exchange, the patient died on the 29th postoperative day.Nine cases of TTP in pregnancy and the postpartum period from the past 10 years are also reviewed.

A case of MOF following the fume inhalation is reported. The clinical course and high concentrations of cadmium measured in the blood and urine samples (but low concentrations of silver, cupper and zinc) strongly suggested acute cadmium poisoning. Following early toxic signs resembling those of a common cold, toxicity advanced to include the acute respiratory distress syndrome, renal failure and hepatic dysfunction. The patient was treated with various active therapies including mechanical ventilation, artificial hemofration (CVVHF), plasma exchange (PE), and steroid and CaNa2EDTA administration, and subsequently left the ICU on the 52nd ICU day, with mild renal dysfunction. Although the patient was in a semicomatous state in the eary stage of the clinical course, the possibility that it resulted from acute cadmium poisoning is unclear.

The aim of this experiment was to determine the influence of pH on MRSA growth. MRSA growth wau suppressed in acidic medium, and the degree of suppression paralleled the degree of acidity. The results showed that MRSA hardly grew in the media with a pH below 4, few cultures were identified at pH 2 and 3. A bacteriocidal effect was noted in the media with a pH below 3. At pH 5, cultures were markedly inhibited, and even at pH 6, culture failed to yield certain strains of MRSA.The usefulness of antibiotics can not be denied, but proper implementation of infection control should be excuted to avoid the outbreaks of resistant pathogens. Although treatment with dilute hydrochloric acid (pH 2) may only be applicable in superficial infections such as MRSA colitis, it seems to be promising as an attempt of antimicrobial therapy without any induction of resistant strains.

Background Although early shock with an automated external defibrillator (AED) is one of the several key elements to save out-of-hospital cardiac arrest (OHCA) victims, it is not always easy to find and retrieve a nearby AED in emergency settings. We developed a cell phone web system, the Mobile AED Map, displaying nearby AEDs located anywhere. The simulation trial in the present study aims to compare the time and travel distance required to access an AED and retrieve it with and without the Mobile AED Map. Methods Design: Randomised controlled trial. Setting: Two fields where it was estimated to take 2min (120–170m) to access the nearest AED. Participants were randomly assigned to either the Mobile AED Map group or the control group. We provided each participant in both groups with an OHCA scenario, and measured the time and travel distance to find and retrieve a nearby AED. Results Forty-three volunteers were enrolled and completed the protocol. The time to access and retrieve an AED was not significantly different between the Mobile AED Map group (400±238s) and the control group (407±256s, p =0.92). The travel distance was significantly shorter in the Mobile AED Map group (606m vs. 891m, p =0.019). Trial field conditions affected the results differently. Conclusions Although the new Mobile AED Map reduced the travel distance to access and retrieve the AED, it failed to shorten the time. Further technological improvements of the system are needed to increase its usefulness in emergency settings (UMIN000002043).

Previous reports have described several facility categories as important locations for public access defibrillation (PAD) program. However, in decision-making process as to what specific facilities may deserve PAD programs, each facility needs to estimate the number of shockable cardiac arrest (CA). Such estimation depends not only on the expected number of visitors/workers but also on the profile of the visitors/workers, which may vary among types of facilities. [Methods] Nagoya City has a population of 2.2 million with ~2,000 CA annually. Locations of CA were abstracted from data collected by Nagoya FD from 2003 through 2007. Types of public facilities were tallied and grouped into 36 categories consistent with Ordinance for Enforcement of Fire Service Act, and the number of CA within each category was determined. Data on the number of visitors/workers in each category were collected from governmental databases on metropolitan statistics. The incidence rate was calculated as numbers of all CA and CA with VF per 1 billion person.year. [Results] In 8 location categories, the databases for CA and the database for numbers of visitors/workers coincided in the categorization rules of the locations. The incidence rates are shows in the table . [Discussion] The incidence rate of shockable CA varies substantially among the location categories, presumably reflecting the variations of age distribution, average length of stay and intensity of physical activities of people who gather there. Schools (teachers) and factories have the highest incidence of shockable CA. However, our data may indicate that a school with small numbers of workers (teachers) may have a low priority of a PAD program. On the contrary, a station with low incidence rate of 0.05 may be a preferred target of a PAD program if a large number of travelers are expected to pass through. Thus our study provides fundamental data to detect important and cost-effective target locations of a PAD program. Number of CA per 1 billion preson.year

We developed the AED enlightenment animation DVD (the AED Animation) as a readable and friendly educational material for learning cardiopulmonary resuscitation (CPR) and AED by citizens. The aim of the present study was to investigate how well did schoolchildren understand the contents of the AED Animation, and how the AED Animation has educational and ripple effects to schoolchildren. [Methods] Prior to the investigation of schoolchildren, 28 elementary school teachers watched the AED Animation and answered a questionnaire to see if the AED animation arouse schoolchildren, and to evaluate its psychological and educational impacts. Then in fourth, fifthand sixth grades elementary school students (total of 1189) watched the AED Animation and answered questionnaire-based survey. [Results] 94 percent of the students answered “ the AED Animation is good for me”, 80 percent of them wanted to be able to do CPR and use AED as the characters of the AED Animation did, and 67 percent of them wanted there parents to watch the AED Animation. [Conclusions] The AED Animation is a good educational material for schoolchildren that raises interest in AED/CPR, and its educational effects was more than elementary school teachers expected.

BackgroundThe correlation between fracture type and mortality in patients with pelvic fracture has been previously investigated. The purpose of this study was to determine whether instability of the pelvic ring as assessed by Tile’s classification is a predictor of death in patients with pelvic fractures.Materials and methodsThe clinical course of consecutive patients with pelvic fractures was retrospectively reviewed. Eighty-seven patients with pelvic ring fractures were included in the study. As potential predictive factors, fracture type according to Tile’s classification, and generally used traumatic parameters (injury severity score, revised trauma score, and probability of survival) were analyzed.ResultsThe mortality was significantly higher in patients with unstable fracture patterns (P P ConclusionThe present study suggests that patients with unstable pelvic fractures have an increased risk of death associated with exacerbated injury severity.

This paper presents a general control representation for medically-proposed methods of mechanical ventilation, and then proposes an improved configuration with a disturbance observer and with a predictive control block against an existing proportional assist ventilation (PAV) method. The trade-off relation between robust stability margin and responsibility has been shown using parSparinfin - 1 in Nyquist diagrams and time-response results with our mechanical ventilator SSV-200 connected to our lung simulator (LUNGOO). Also, a clinical issue of expiratory asynchrony is compared between two methods with the same test construction. The actual clinical tests for these performances will be expected with a next new version of our SSV. We also present on-line identification methods for patient's airway resistance and respiratory compliance which are necessary for implementation of PAV. Animal test results and a few clinical test results of our techniques are also reported for these identification methods

We describe here a case of suicidal poisoning by saponated cresol ingestion. A 41 year-old male was found unconsciousness in a park in the early morning, and an empty bottle of saponated cresol was found beside him. His death was confirmed approximately 2 hours later, despite attempts at resuscitation and intensive care. The autopsy revealed severe morphological damage of the upper gastrointestinal tract and congestion of the lung. We also observed by histopathological examination severe lung edema and severe erosion of the esophagus and stomach. Toxicological analysis also identified a high concentration of cresol isomer in the blood and gastric contents. The cause of death was given as cresol poisoning, based on the results of the autopsy and toxicological examination.

The release of the immunomodulator, interleukin 18 (IL-18) into sera early in acute pancreatitis (AP) corresponds to disease severity. IL-18 induces nitric oxide (NO), which is involved in the pathophysiology of pancreatitis. The objective of this study was to clarify the role of IL-18 in pathogenesis and NO production during early AP using recombinant mouse (rm) IL-18 protein and IL-18 gene knockout (KO) mice. After pretreatment with phosphate-buffered saline or rmIL-18, wild-type (WT) or KO mice were injected intraperitoneally with phosphate-buffered saline (sham) or cerulein (AP) hourly for 3 h. Blood, pancreas, spleen, and liver were collected until 24 h after the first dose. Main outcome measures were serum IL-18, amylase and lipase levels, histological evaluation of the pancreas with parenchyma vacuolization of acinar cells, mRNA expression of inducible NO synthase (iNOS) in the pancreas, and spleen, liver, and plasma NO metabolite level. Serum IL-18 was significantly increased immediately after induction of AP in WT mice. Serum amylase, lipase, and the numbers of acinar cells with parenchyma vacuolization were significantly higher in the group AP/KO than in the group AP/WT, but these parameters were improved by dose-dependent pretreatment with rmIL-18 administration in both groups. Pancreatic iNOS gene expression and plasma NO metabolites were significantly increased by 6 h after the initiation of AP, but were significantly lower in the group AP/KO than in the AP/WT mice. Pretreatment with rmIL-18 also significantly increased these levels in both groups. Splenic and hepatic iNOS expression was not changed after the initiation of AP in WT mice, whereas pretreatment with rmIL-18 also increased these levels. Administration of aminoguanidine, a selective iNOS inhibitor, before AP induction abolished the protective effect of pretreatment with rmIL-18 on pancreatic injury. IL-18 appears to protect the pancreas during early induced-induced AP in mice, probably through induction of NO release from an iNOS source. IL-18 may be a target for new AP therapeutics.

Interrelation of plasma nitrotyrosine (NT) concentrations in patients of septic shock and their prognosis was examined. Blood samples were obtained from 12 patients during the first episode of septic shock at hospitalization, and their plasma NT concentrations were measured. Five patients died within five days after hospitalization, but seven patients recovered. Plasma NT concentrations (means +/- SE) of the non-survivors and survivors were 0.68 +/- 0.13 nmol/mL (n = 7), and 0.21 +/- 0.05 nmol/mL (n = 5), respectively, the former being significantly higher than the latter. The present results suggest that plasma concentration of NT relates to prognosis in human septic shock, although further studies with a larger patient population are necessary for confirmation of the suggestion.

ufficient breathing correctly. The majority was afraid of exacerating the condition or causing death by intervening as a first esponder. The response rate at follow-up was 61%. There was a ignificant improvement in correct answers on themultiple-choice est (p< .001). The proportion of students feeling well prepared to erform BLS was increased from 30% to 90% (p< .001), and the fear f being the first responder was reduced from 6.8±2.2 to 5.5±2.4 n a visual analog scale (p< .001). Conclusion: Knowledge of key areas of BLS is poor among high chool students despite previous training. One hands-on training ession run by junior doctors seems to be an efficient method to mpower the students to be first responders to out-of-hospital ardiac arrest.

The mechanism of the relaxation response of rat aorta to the phosphodiesterase inhibitors oxpentifylline and theophylline was studied. Oxpentifylline induced a greater vasorelaxation response in the intact strips than in those without endothelium. The endothelium-dependent relaxation response to oxpentifylline was inhibited by nitro-l-arginine but not by indomethacin, and the endothelium-independent relaxation response was potentiated by the combination with isoprenaline but not sodium nitroprusside. Theophylline induced a similar relaxation response in vascular strips with and without endothelium. The relaxation response to theophylline was not inhibited by indomethacin or nitro-l-arginine in intact strips, but was potentiated by combination with isoprenaline or sodium nitroprusside in the denuded strips. These results suggest that the two phosphodiesterase inhibitors oxpentifylline and theophylline induce vasorelaxation by different mechanisms. Oxpentifylline can induce both endothelium-dependent relaxation, which is probably mediated by an endothelium-derived relaxing factor, and endothelium-independent relaxation, which may be due to an inhibitory action on phosphodiesterase of vascular smooth muscle. In contrast, theophylline can induce endothelium-independent relaxation alone, without modulation by the endothelium.

The effects of saikosaponins-a.-b1,-b2,-c, and-d on hepatic damage induced by halothane and hypoxia were investigated in the rat. Inhalation of halothane under a hypoxic condition significantly increased serum glutamic oxaloacetic transaminase (GOT) and glutamic pyruvic transaminase (GPT) levels in rats pretreated with phenobarbital compared with rats pretreated without phenobarbital. Pretreatment with saikosaponin (especially-a and-d) and with phenobarbital suppressed the increase in serum GOT and GPT levels in comparison with the rats treated with phenobarbital, halothane, and hypoxia. Histological observation also confirmed that pretreatment with saikosaponin had a protective effect against liver cell damage caused by halothane and hypoxia. Saikosaponins-a and-d, the most effective saikosaponins against hepatic damage, inhibited the increases in cytochrome P450 and NADPH-cytochromec reductase activity which are induced by phenobarbital treatment. Therefore, it is suggested that the cytoprotective effect of saikosaponin against halothane-induced hepatitis under hypoxia is caused by inhibition of phenobarbital stimulation of the enzyme system for hepatic drug metabolism.