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Objective Facial lacerations, which are common in the emergency department, have usually been repaired by non-facial trauma specialists, such as emergency physicians. Given the ongoing discussion regarding quality assurance or the optimal training model on facial laceration repair for nonspecialists, we sought to determine the impact of a 1-year wound closure training provided to emergency physicians. We hypothesized a decrease in early complications following facial wound closure after the training. Methods A retrospective observational study was conducted between 2013 and 2015 at an academic center. We included patients with isolated facial lacerations that were repaired by emergency physicians and reviewed by board-certified plastic surgeons during a follow-up visit. Patients whose wounds were not reviewed within 3 days were excluded. The 1-year training curriculum, which consisted of several sessions of lecture, hands-on practice, and case review, had been developed by a multidisciplinary team and provided to emergency physicians. Patient data were divided between nonparticipant and participant groups, and a propensity score was developed to estimate the probability of being assigned to the participant group. The incidence of early complications, defined as the need for additional suturing or resuturing due to wound dehiscence, was compared among the groups after propensity score matching. Results Although 132 patients satisfied all the inclusion criteria, 11 were excluded due to delayed initial wound review. Among the 70 patients who were eventually included in the participant group, 40 were matched with those in the nonparticipant group. The incidence of early complications was significantly lower in the participant group than in the nonparticipant group (5.0% vs. 20.0%, odds ratio = 0.21, 95% confidence interval = 0.07-0.61, p = 0.04). Conclusions The 1-year training provided to emergency physicians reduced the incidence of early complications following facial laceration repair. Accordingly, future wound closure training models should consider the 1-year training curriculum presented herein.

Objective Bath-related sudden cardiac arrests frequently occur in Japan. This study aimed to describe the actual incidence and characteristics of bath-related accidents, including non-fatal events, and to establish the etiology of bath-related sudden cardiac arrest. Methods This prospective cross-sectional observational study was conducted in Tokyo Metropolis and Saga and Yamagata Prefectures between October 2012 and March 2013. Emergency personnel enrolled events in this study when they recognized that activation of the emergency medical system was related to bathing. Surveillance cards were delivered and collected from the emergency personnel and attending physicians. Results In total, 4,593 events were enrolled (1,528 cardiac arrests, 935 survivors in need of help, 1,553 patients with acute illnesses, and 577 patients with injuries) in this study. In the group of survivors in need of help and with acute illness, consciousness disturbance and lethargy without any organic disease were recognized as the main symptoms. Acute coronary syndrome and stroke were infrequently diagnosed. Of the survivors, 30% had a body temperature above 38°C. Their consciousness level significantly correlated with their body temperature. Emergency personnel reported that 79% of sudden cardiac arrests were from victims whose faces were submerged in the tub water, while 18% of survivors had their faces submerged in the tub water. Conclusion This study revealed that accidents, including non-lethal events, frequently occur. The key symptoms were consciousness disturbance and lethargy characterized as a functional disorder and accompanied by an elevated body temperature. Those findings suggest that heat illness during hot water immersion causes drowning.

To determine whether early lactate reduction is associated with improved survival and good neurologic outcome in patients with out-of-hospital cardiac arrest.Ad hoc data analysis of a prospective, multicenter observational study.Out-of-hospital cardiac arrest patients at 67 emergency hospitals in Kanto, Japan between January 2012 and March 2013.Adult patients with out-of-hospital cardiac arrest admitted to the hospital after successful resuscitation were identified.Blood lactate concentrations were measured at hospital admission and 6 h after hospital admission. Early lactate clearance was defined as the percent change in lactate level 6 h after a baseline measurement.The 543 patients (mean age, 65 ± 16 yr; 72.6% male) had a mean lactate clearance of 42.4% ± 53.7%. Overall 30-day survival and good neurologic outcome were 47.1% and 27.4%, respectively. The survival proportion increased with increasing lactate clearance (quartile 1, 29.4%; quartile 2, 42.6%; quartile 3, 51.5%; quartile 4, 65.2%; p0.001). Multivariate logistic regression analysis showed that lactate clearance quartile was an independent predictor of the 30-day survival and good neurologic outcome. In the Cox proportional hazards model, the frequency of mortality during 30 days was significantly higher for patients with lactate clearance in quartile 1 (hazard ratio, 3.12; 95% CI, 2.14-4.53), quartile 2 (hazard ratio, 2.13; 95% CI, 1.46-3.11), and quartile 3 (hazard ratio, 1.49; 95% CI, 1.01-2.19) than those with lactate clearance in quartile 4. Furthermore, multivariate logistic regression analysis revealed that lactate clearance was a significant predictor of good neurologic outcome at 30 days after hospital admission.Effective lactate reduction over the first 6 hours of postcardiac arrest care was associated with survival and good neurologic outcome independently of the initial lactate level.

Objective Bath-related sudden cardiac arrests occur frequently in Japan. Although previous studies have reported that most fatal events occurr in winter, the reason why such events exhibit a seasonal variation has not been elucidated. In this study, we hypothesized that the occurrence of bath-related deaths was correlated with a low air temperature. Methods This prospective cross-sectional observational study was conducted in the Tokyo Metropolitan area between October 2012 and March 2013. Data were collected for all cases involving the activation of the emergency medical system because of an accident or acute illness related to bathing that occurred in Tokyo during the study period. In particular, elderly (≥65 years) cardiac arrest victims who had been found in a bathtub filled with water were enrolled. The relationship between the daily number of cardiac arrest events and the lowest daily air temperature in Tokyo was studied using a nonlinear regression model. Results A total of 3,624 bath-related events were registered in this study. Among these events, 1,081 deaths of elderly individuals who had been found in a bathtub filled with water were recorded. A close correlation was observed between the daily number of events and the lowest daily air temperature. This correlation was described by the following equation: y=8.38e-0.07x, where y was the daily number of cardiac arrests and x was the lowest daily air temperature. Conclusion A low air temperature was closely correlated with the occurrence of bath-related cardiac arrest.

Oxidative stress plays a key role in the pathophysiology of post-cardiac arrest syndrome. Molecular hydrogen reduces oxidative stress and exerts anti-inflammatory effects in an animal model of cardiac arrest. However, its effect on human post-cardiac arrest syndrome is unclear. We consecutively enrolled five comatose post-cardiac arrest patients (three males; mean age, 65 ± 15 years; four cardiogenic, one septic cardiac arrest) and evaluated temporal changes in oxidative stress markers and cytokines with inhaled hydrogen. All patients were treated with target temperature management. Hydrogen gas inhalation (2% hydrogen with titrated oxygen) was initiated upon admission for 18 h. Blood hydrogen concentrations, plasma and urine oxidative stress markers (derivatives of reactive oxygen metabolites, biological antioxidant potential, 8-hydroxy-2'-deoxyguanosine, N ɛ-hexanoyl-lysine, lipid hydroperoxide), and cytokines (interleukin-6 and tumor necrosis factor-α) were measured before and 3, 9, 18, and 24 h after hydrogen gas inhalation. Arterial hydrogen concentration was measurable and it was equilibrated with inhaled hydrogen. Oxidative stress was reduced and cytokine levels were unchanged in cardiogenic patients, whereas oxidative stress was unchanged and cytokine levels were diminished in the septic patient. The effect of inhaled hydrogen on oxidative stress and cytokines in comatose post-cardiac arrest patients remains indefinite because of methodological weaknesses.

Background The prognosis of non-shockable out-of-hospital cardiac arrest is worse than that of shockable out-of-hospital cardiac arrest. We investigated the associations between the etiology and prognosis of non-shockable out-of-hospital cardiac arrest patients who experienced the return of spontaneous circulation after arriving at hospital. Methods and Results All subjects were extracted from the SOS-KANTO 2012 study population. The subjects were 3,031 adults: (i) who had suffered out-of-hospital cardiac arrest, (ii) for whom there were no pre-hospital data on ventricular fibrillation/pulseless ventricular tachycardia until arrival at hospital, (iii) who experienced the return of spontaneous circulation after arriving at hospital. We compared the patients' prognosis after 1 and 3 months between various etiological and presumed cardiac factors. The proportion of the favorable brain function patients that developed pulmonary embolism or incidental hypothermia was significantly higher than that of the patients with presumed cardiac factors (1 month, P

Background Hydrogen gas inhalation (HI) ameliorates cerebral and cardiac dysfunction in animal models of post-cardiac arrest syndrome (PCAS). HI for human patients with PCAS has never been studied. Methods and results Between January 2014 and January 2015, 21 of 107 patients with out-of-hospital cardiac arrest achieved spontaneous return of circulation. After excluding 16 patients with specific criteria, 5 patients underwent HI together with target temperature management (TTM). No undesirable effects attributable to HI were observed and 4 patients survived 90 days with a favorable neurological outcome. Conclusions HI in combination with TTM is a feasible therapy for patients with PCAS. (Circ J 2016; 80: 1870-1873).

Cases Forty-three male and 27 female patients with anterior shoulder dislocation, with an average age of 45 years, were treated with the “double traction method”. The reduction is carried out by two operators, with the patient in a supine position. The first operator holds the patient's wrist and pulls gently longitudinally. After the patient's muscle spasm adequately subsides, the second operator tows the humerus head laterally by using a towel wrapped around the proximal arm. Outcome Reduction was successful in 63 patients (90%). No iatrogenic fracture or neurovascular deficit occurred. Conclusion Movement of the patient's arm position causes pain-related muscle spasm. The double traction method is distinctive compared to other manual relocation maneuvers in that the patient's arm is kept at the same position throughout the whole procedure. This maneuver is an easy and safe reduction method for anterior shoulder dislocations, even for non-orthopedic surgeons. It should be an option worth considering for closed reduction in shoulder dislocations.

Aim We aim to examine the similarities and differences in areas of EM development, workload, workforce, and capabilities and support in the Asia region. Emerging challenges faced by our EM community are also discussed. Methods The National Societies for Emergency Medicine of Hong Kong, India, Japan, Malaysia, Philippines, Singapore, South Korea, Taiwan, Thailand and Turkey participated in the joint Japanese Association of Acute Medicine (JAAM) and Asian Conference of Emergency Medicine (ACEM) Special Symposium held in October 2013 at Tokyo, Japan. The findings are reviewed in this paper. Results Emergency medicine (EM) has over the years evolved into a distinct and recognized medical discipline requiring a unique set of cognitive, administrative and technical skills for managing all types of patients with acute illness or injury. EM has contributed to healthcare by providing effective, safe, efficient and cost-effective patient care. Integrated systems have developed to allow continuity of emergency care from the community into emergency departments. Structured training curriculum for undergraduates, and specialty training programs for postgraduates are in place to equip trainees with the knowledge and skills required for the unique practice of EM. Conclusion The practice of EM still varies among the Asian countries. However, as a region, we strive to continue in our efforts to develop the specialty and improve the delivery of EM.

Case We have reported six cases of Crowned dens syndrome (CDS) diagnosed by computed tomography (CT). Presenting cases were three male and three female, aged from 45 to 89 (averaged in 72). Outcome All cases showed calcification around the dens of axis in CTs. Neck pain in all cases relieved within at least 10 days, treated by non-steroidal anti-inflammatory drugs (NSAIDs) in five cases, and one by acetaminophens. Conclusion Bouvet et al. first reported CDS in 1985, as acute pseudogout of the neck, which causes neck pain. CDS is a radioclinical syndrome defined by the radiographic calcifications in a crown-like configuration around the odontoid process, accompanied clinically by acute neck pain, often with neck stiffness, fevers and raised inflammatory markers. CDS is thought to be a rare condition; however, it is frequently misdiagnosed. CDS is an important differential diagnosis in patients presenting with acute neck pain.

Background— We have previously shown that hydrogen (H 2 ) inhalation, begun at the start of hyperoxic cardiopulmonary resuscitation, significantly improves brain and cardiac function in a rat model of cardiac arrest. Here, we examine the effectiveness of this therapeutic approach when H 2 inhalation is begun on the return of spontaneous circulation (ROSC) under normoxic conditions, either alone or in combination with targeted temperature management (TTM). Methods and Results— Rats were subjected to 6 minutes of ventricular fibrillation cardiac arrest followed by cardiopulmonary resuscitation. Five minutes after achieving ROSC, post–cardiac arrest rats were randomized into 4 groups: mechanically ventilated with 26% O 2 and normothermia (control); mechanically ventilated with 26% O 2 , 1.3% H 2 , and normothermia (H 2 ); mechanically ventilated with 26% O 2 and TTM (TTM); and mechanically ventilated with 26% O 2 , 1.3% H 2 , and TTM (TTM+H 2 ). Animal survival rate at 7 days after ROSC was 38.4% in the control group, 71.4% in the H 2 and TTM groups, and 85.7% in the TTM+H 2 group. Combined therapy of TTM and H 2 inhalation was superior to TTM alone in terms of neurological deficit scores at 24, 48, and 72 hours after ROSC, and motor activity at 7 days after ROSC. Neuronal degeneration and microglial activation in a vulnerable brain region was suppressed by both TTM alone and H 2 inhalation alone, with the combined therapy of TTM and H 2 inhalation being most effective. Conclusions— H 2 inhalation was beneficial when begun after ROSC, even when delivered in the absence of hyperoxia. Combined TTM and H 2 inhalation was more effective than TTM alone.

Limited clinical evidence demonstrates the effectiveness of direct retroperitoneal pelvic packing for hemorrhage control in pelvic fractures due to the difficulty in measuring pressure on the pelvic walls within the pelvic cavity after retroperitoneal pelvic packing. Using a cadaver model, the authors aimed to assess whether retroperitoneal pelvic packing generates pressure that exceeds the venous return and arterial pressure in the pelvis. The pressure on the pelvic wall was measured in 5 fresh Japanese cadavers. Sensors were placed at 4 points on the pelvic wall, and the pressure at each point was measured after the insertion of each of 3 sponges, per the procedure originally described for direct retroperitoneal pelvic packing. In each specimen, the average pressure across all 4 points on the pelvic wall increased with the addition of each sponge, reaching 12.3±4.5 mm Hg when all 3 sponges were inserted. Furthermore, the pressure at the pelvic floor and posterior pelvic brim increased significantly, whereas the pressure at the anterior and middle pelvic brim increased nonsignificantly. The results of this study suggest that retroperitoneal pelvic packing provides pressure on the pelvic wall that exceeds the venous pressure and is thus effective for the control of venous hemorrhage in pelvic fractures. Currently, the recommended procedure combines external fixation for venous bleeding, transcatheter arterial embolization, and pelvic packing; however, the authors' results suggest that pelvic packing alone may be effective for controlling venous hemorrhage in pelvic fracture. [ Orthopedics. 2017; 40(6);e947–e951.]

Background Mechanical cardiopulmonary resuscitation ( mCPR ) for patients with out‐of‐hospital cardiac arrest attending the emergency department has become more widespread in Japan. The objective of this study is to determine the association between the mCPR in the emergency department and clinical outcomes. Methods and Results In a prospective, multicenter, observational study, adult patients with out‐of‐hospital cardiac arrest with sustained circulatory arrest on hospital arrival were identified. The primary outcome was survival to hospital discharge. The secondary outcomes included a return of spontaneous circulation and successful hospital admission. Multivariate analyses adjusted for potential confounders and within‐institution clustering effects using a generalized estimation equation were used to analyze the association of the mCPR with outcomes. Between January 1, 2012 and March 31, 2013, 6537 patients with out‐of‐hospital cardiac arrest were eligible; this included 5619 patients (86.0%) in the manual CPR group and 918 patients (14.0%) in the mCPR group. Of those patients, 28.1% (1801/6419) showed return of spontaneous circulation in the emergency department, 20.4% (1175/5754) had hospital admission, 2.6% (168/6504) survived to hospital discharge, and 1.2% (75/6419) showed a favorable neurological outcome at 1 month after admission. Multivariate analyses revealed that mCPR was associated with a decreased likelihood of survival to hospital discharge (adjusted odds ratio, 0.40; 95% confidence interval, 0.20–0.78; P =0.005), return of spontaneous circulation (adjusted odds ratio, 0.71; 95% confidence interval, 0.53–0.94; P =0.018), and hospital admission (adjusted odds ratio, 0.57; 95% confidence interval, 0.40–0.80; P =0.001). Conclusions After accounting for potential confounders, the mCPR in the emergency department was associated with decreased likelihoods of good clinical outcomes after adult nontraumatic out‐of‐hospital cardiac arrest. Further studies are needed to clarify circumstances in which mCPR may benefit these patients.

Background Bath-related sudden cardiac arrest frequently occurs in Japan, but the mortality data have not been sufficiently reported.Methods and Results:This prospective cross-sectional observational study was conducted in the Tokyo Metropolis, Saga Prefecture and Yamagata Prefecture between October 2012 and March 2013 (i.e., in winter). We investigated the data for all occurrences in these areas for which the emergency medical system needed to be activated because of an accident or acute illness related to bathing. Emergency personnel enrolled the event when activation of the emergency medical system was related to bathing. Of the 4,599 registered bath-related events, 1,527 (33%) were identified as bath-related cardiac arrest events. Crude mortality (no. deaths per 100,000) during the observational period was 10.0 in Tokyo, 11.6 in Yamagata and 8.5 in Saga. According to the mortality data for age and sex, the estimated number of bath-related deaths nationwide was 13,369 in winter, for the 6 months from October (95% CI: 10,862-16,887). Most cardiac arrest events occurred in tubs filled with water with the face submerged in the water. This suggests that drowning plays a crucial role in the etiology of such phenomena. Conclusions The estimated nationwide number of deaths was 13,369 (95% CI: 10,862-16,887) in winter, for the 6 months from October. Crude mortality during the winter season was 10.0 in Tokyo, 11.6 in Yamagata and 8.5 in Saga.

Background Hydrogen gas inhalation (HI) reduced infarct size and mitigated adverse left ventricular (LV) remodeling in a rat model of acute myocardial infarction (AMI). We designed a prospective, open-label, rater-blinded clinical pilot study in patients experiencing ST-elevated MI (STEMI).Methods and Results:The 20 patients with an initial diagnosis of STEMI were assigned to either an HI group (1.3% H2with 26% oxygen) or a control group (26% oxygen). There were no HI-related severe adverse events. In the full analysis set, the cardiac salvage index as evaluated using cardiac magnetic resonance imaging at 7 days after primary percutaneous coronary intervention (PCI), showed no significant between-group difference (HI: 50.0±24.3%; control: 60.1±20.1%; P=0.43). However, the improvement from day 7 in the HI group was numerically greater than that in the control group in some of the surrogate outcomes at 6-month follow-up, including the LV stroke volume index (HI: 9.2±7.1 mL/m2; control: -1.4±7.2 mL/m2; P=0.03) and the LV ejection fraction (HI: 11.0%±9.3%; control: 1.7%±8.3%; P=0.11). Conclusions The first clinical study has shown that HI during PCI is feasible and safe and may also promote LV reverse remodeling at 6 months after STEMI. The study was not powered to test efficacy and a further large-scale trial is warranted. (Clinical trials registration: UMIN00006825).

It has recently been reported that voltage-dependent Ca channel subtypes, e.g., L-, T-, N-, and P/Q-type, are expressed in renal arterioles and renal tubules, and the inhibition of these channels exerts various effects on renal microcirculation. For example, selective blockade of L-type Ca channels with nifedipine preferentially dilates the afferent arteriole and potentially induces glomerular hypertension. On the other hand, recently developed Ca channel blockers (CCBs) such as mibefradil and efonidipine block both T-type and L-type Ca channels and consequently dilate both afferent and efferent arterioles, leading to lowering of intraglomerular pressure. Interestingly, aldosterone has recently been recognized as a factor exacerbating renal diseases, and its secretion from adrenal gland is mediated by T-type Ca channels. Furthermore, T-type CCBs were shown to ameliorate renal dysfunction by suppressing inflammatory processes and renin secretion. On the basis of histological evaluations, N-type Ca channels are present in peripheral nerve terminals innervating both afferent and efferent arterioles. Further, it was suggested that N-type CCBs such as cilnidipine suppress renal arteriolar constriction induced by enhanced sympathetic nerve activity, thereby lowering intraglomerular pressure. Taken together, various Ca channel subtypes are present in the kidney and blockade of selective channels with distinct CCBs exerts diverse effects on renal microcirculation. Inhibition of T-type and N-type Ca channels with CCBs is anticipated to exert pleiotropic effects that would retard the progression of chronic kidney disease through modulation of renal hemodynamic and non-hemodynamic processes.

Aim Approximately 14,000 cases of sudden death during bathing are reported annually in Japan. The cause of the deaths is still unclear. Because Japanese-style bathing is characterized by whole-body bathing in high temperature water (41–45°C), we hypothesized that heat exposure causes sudden death as a result of hyperthermia. Methods The aim was to clarify the relationship between heat exposure and mortality in an animal experiment. In the experiment, 44 male Wistar rats weighing 180–255 g were anesthetized with sodium pentobarbital, and their body temperature was measured with a thermometer inserted into the esophagus. The animals were immersed up to their shoulder in 40–45°C water until respiratory arrest occurred or until they awoke from the anesthesia. Results All animals immersed in water heated to ≥41°C died, whereas all animals immersed in 40°C water awakened from the anesthetic. The mean interval between the start of immersion and respiratory arrest in 41°C, 42°C, 43°C, 44°C, and 45°C water was 105 min, 54 min, 34 min, 27 min, and 22 min, respectively. Regression analysis revealed a significant relationship between the interval and water temperature (r2 = 0.96, P

Objective The clinical features of bacteremia due to Campylobacter jejuni (C. jejuni) have yet to be fully elucidated. Methods and results The cases of C. jejuni bacteremia were retrospectively reviewed during a twelve-year period in a single institute. C. jejuni was identified in 7 patients through blood cultures, and disease onset occurred between June and October. Except for 2 previously healthy individuals, 5 patients had underlying diseases (chronic liver diseases, n=3; hematological malignancies, n=2). All patients were febrile, but 2 patients did not present with gastrointestinal symptoms. C. jejuni isolates were susceptible to gentamicin and macrolides, but about half of them were resistant to fluoroquinolones. Disease outcomes were favorable, and no deaths related to C. jejuni bacteremia were observed. Conclusion These results suggest that C. jejuni bacteremia could occur primarily or secondarily to gastroenteritis with a seasonal peak and that prognosis would be favorable regardless of the underlying diseases.

Recent advances in stem cell research have resulted in methods to generate kidney organoids from human pluripotent stem cells (hPSCs), which contain cells of multiple lineages including nephron epithelial cells. Methods to purify specific types of cells from differentiated hPSCs, however, have not been established well. For bioengineering, cell transplantation, and disease modeling, it would be useful to establish those methods to obtain pure populations of specific types of kidney cells. Here, we report a simple two-step differentiation protocol to generate kidney tubular organoids from hPSCs with direct purification of KSP (kidney specific protein)-positive cells using anti-KSP antibody. We first differentiated hPSCs into mesoderm cells using a glycogen synthase kinase-3β inhibitor for 3 days, then cultured cells in renal epithelial growth medium to induce KSP+ cells. We purified KSP+ cells using flow cytometry with anti-KSP antibody, which exhibited characteristics of all segments of kidney tubular cells and cultured KSP+ cells in 3D Matrigel, which formed tubular organoids in vitro. The formation of tubular organoids by KSP+ cells induced the acquisition of functional kidney tubules. KSP+ cells also allowed for the generation of chimeric kidney cultures in which human cells self-assembled into 3D tubular structures in combination with mouse embryonic kidney cells.

Micafungin (MCFG) concentrations in the plasma and in burn eschar were investigated after daily intravenous infusion (1 h) of MCFG (200 mg) in three patients with severe burns. MCFG treatment was initiated more than 72 h after the burn injuries. The MCFG concentrations in the plasma were determined at the end of the first administration of MCFG, immediately before the second dosing, at the end of the MCFG infusion after at least 4 days from the initial treatment, and immediately before the subsequent dosing using high-performance liquid chromatography. In addition, the trough levels in burn eschar after both the initial administration and repeated administration were measured. The peak and trough levels in the plasma were comparable to or slightly lower than the reported values in healthy volunteers. The mean (range) MCFG concentrations in the burn eschar after initial administration and repeated administration were 1.41 μg/mL (

Patients with coronary spasm generally have a good prognosis, although it can result in sudden cardiac arrest (SCA) and syncope. We hypothesized that the nature of coronary spasm triggering lethal arrhythmias may be different from that which induces angina-only.Clinical characteristics were examined in patients who had experienced SCA (n = 18) or syncope (n = 28) triggered by coronary spasm. These characteristics were compared to those of patients who had coronary spastic angina-only (n = 52).SCA and syncope occurred frequently during daytime in 57% and 68%, respectively. Spontaneous ST-segment changes during daytime were recorded more often in patients with SCA (50%) and syncope (39%) than angina-only patients (4%, p0.01 for each). Nocturnal angina occurred less frequently in patients with SCA (33%) and syncope (32%) than angina-only patients (83%, p0.01 for each). Severe multivessel spasm, daytime ST-segment changes, and younger age were significant predictors of SCA. Daytime ST-segment changes and active smoking were related to syncope.The circadian variance of coronary spasm triggering SCA or syncope may be different from that inducing typical coronary spastic angina. The coronary spasm should be evaluated for patients with aborted SCA or recurrent syncope of unknown cause, even though the patients have not experienced the typical nocturnal angina.

Background— Acute aortic dissection (AAD) is a life-threatening vascular disease without effective pharmaceutical therapy. Matrix metalloproteinases (MMPs) are implicated in the development of chronic vascular diseases including aneurysm, but the key effectors and mechanism of action remain unknown. To define further the role of MMPs in AAD, we screened circulating MMPs in AAD patients, and then generated a novel mouse model for AAD to characterize the mechanism of action. Methods and Results— MMP9 and angiotensin II were elevated significantly in blood samples from AAD patients than in those from the patients with nonruptured chronic aortic aneurysm or healthy volunteers. Based on the findings, we established a novel AAD model by infusing angiotensin II to immature mice that had been received a lysyl oxidase inhibitor, β-aminopropionitrile monofumarate. AAD was developed successfully in the thoracic aorta by angiotensin II administration to β-aminopropionitrile monofumarate-treated wild-type mice, with an incidence of 20%, 80%, and 100% after 6, 12, and 24 hours, respectively. Neutrophil infiltrations were observed in the intima of the thoracic aorta, and the overexpression of MMP9 in the aorta was demonstrated by reverse transcription polymerase chain reaction, gelatin zymography, and immunohistochemistry. The incidence of AAD was reduced significantly by 40% following the administration of an MMP inhibitor and was almost blocked completely in MMP −/− mice without any influence on neutrophil infiltration. Neutrophil depletion by injection of anti-granulocyte-differentiation antigen-1 (anti-Gr-1) antibody also significantly decreased the incidence of AAD. Conclusions— These data suggest that AAD is initiated by neutrophils that have infiltrated the aortic intima and released MMP9 in response to angiotensin II.

Background The American Heart Association and European Resuscitation Council guidelines for cardiopulmonary resuscitation present rules for termination of resuscitation (TOR) in cases of out-of-hospital cardiac arrest (OHCA). In Japan, only doctors are legally allowed TOR in OHCA cases. Objective This study aimed to develop a new TOR rule that suits the actual situations of the Japanese emergency medical services system. Methods Five different combinations of the TOR rule criteria were compared regarding specificity and positive predictive value (PPV) for 1-month survival with unfavorable neurologic outcomes. The criteria were unwitnessed by emergency medical service personnel, unwitnessed by bystanders, initial unshockable rhythm in the field, initial asystole in the field, no shock delivered, no prehospital return of spontaneous circulation, unshockable rhythm at hospital arrival, and asystole at hospital arrival. Results A total of 13,291 cases were included. The following combination provided the highest specificity and PPV for predicting 1-month unfavorable neurologic outcomes and death: unwitnessed by bystanders, initial asystole in the field, and asystole at hospital arrival. The specificity and PPV for the combination of the three criteria for predicting 1-month unfavorable neurologic outcomes were 0.992 and 0.999, and for predicting death at 1 month after OHCA were 0.986 and 0.998, respectively. Conclusions OHCA patients fulfilling the criteria unwitnessed by bystanders and asystole in the field and at hospital arrival had universally poor outcomes. Termination of resuscitation after hospital arrival for these patients may decrease unwarranted treatments.

Cardiopulmonary resuscitation (CPR) has recently been added to the school curriculum worldwide and is currently taught to students between the ages of 10 and 16 years. The effect of the age of trainees on their satisfaction with CPR training has yet been elucidated. The aim of this study was to compare the satisfaction of trainees of different ages who participated in CPR training in schools in Japan. In total, 392 primary school students (10-11 years old), 1798 junior high school students (12-13 years old), and 4162 high schools students (15-16 years old) underwent the same 3-h course of CPR training, according to the guidelines of 2000 for Emergency Cardiovascular Care and CPR. The course was evaluated by a questionnaire completed by the participants. Primary school students responded most positively to all questions, including those reflecting enjoyment and the confidence of participants to apply CPR (Jonckheere-Terpstra test: P < 0.01). Exploratory factor analysis defined three latent variables (reaction, concentration, and naivete) based on the seven variables addressed in the questionnaire. In the causal relationships analyzed by structural equation modeling (SEM), naivete (which is related to age) directly affected the other latent variables. The current model suggested that the students' satisfaction with CPR training was strongly related to their age. Primary school students enjoyed CPR training more and were more confident in their ability to perform CPR than junior high and high school students were. Therefore, children aged 10-11 years may be the most appropriate candidates for the introduction of CPR training in schools.

Mesenchymal stem/stromal cells (MSCs) reside in the bone marrow and maintain their stemness under hypoxic conditions. However, the mechanism underlying the effects of hypoxia on MSCs remains to be elucidated. This study attempted to uncover the signaling pathway of MSC proliferation. Under low-oxygen culture conditions, MSCs maintained their proliferation and differentiation abilities for a long term. The Notch2 receptor was up-regulated in MSCs under hypoxic conditions. Notch2-knockdown (Notch2-KD) MSCs lost their cellular proliferation ability and showed reduced gene expression of hypoxia-inducible transcription factor (HIF)-1α, HIF-2α, and c-Myc. Overexpression of the c-Myc gene in Notch2-KD MSCs allowed the cells to regain their proliferation capacity. These results suggested that Notch2 signaling is linked to c-Myc expression and plays a key role in the regulation of MSC proliferation. Our findings provide important knowledge for elucidating the self-replication competence of MSCs in the bone marrow microenvironment.

Purpose: This study examines patterns of diseases that were treated at the Iwate Prefectural Hanaizumi Regional Clinic after the Great East Japan Earthquake, which occurred on March 11, 2011, and caused serious damage in Japan. Methods: Data on patients’ address, age, sex, and medical conditions, obtained from medical records of 583 (178 men, 405 women) patients who visited the clinic during that time period were analyzed. Results: The diseases for which the clinic provided care were the same as those listed in a textbook of emergency medicine and previous reports. Conclusions: It is important that emergency surgeons understand these common post-disaster disease patterns in order to provide disaster victims with appropriate care.

The hemoglobin (Hb) level is an essential determinant of oxygen delivery. The restoration of blood perfusion to vital organs and the capacity for oxygen delivery may be associated with ischemia and reperfusion injuries during cardiac arrest and after cardiac arrest. However, whether the Hb level is associated with neurologic outcome in post-cardiac arrest patients remains unclear.Emergency medical service information and clinical demographics were compiled for witnessed out-of-hospital cardiac arrest patients with coma after the restoration of spontaneous circulation. The study end point was defined as a favorable neurologic outcome at 28 days. We evaluated the relationship between the Hb level at the time of hospital arrival and the neurologic outcome using univariate analyses and a multivariate logistic regression analysis.There were 137 witnessed cardiac arrest patients: 49 (35.7%) survived and 34 (24.8%) achieved a favorable neurologic outcome. Univariate analyses showed that the favorable outcome group was characterized as having a higher Hb level, a younger age, a higher percentage of male patients, and ventricular fibrillation as the initial cardiac rhythm. In a multivariate analysis adjusting for potential confounding factors, the Hb level at the time of hospital arrival (odds ratio, 1.26; 95% confidence interval, 1.00-1.58) was an independent predictor of a favorable neurologic outcome.A higher Hb level at the time of hospital arrival was associated with a favorable short-term neurologic outcome among post-cardiac arrest patients with a presumed cardiac etiology.

Summary Objective: Plasma triglyceride (TG) levels were reported to be high in chronic kidney disease (CKD) patients undergoing haemodialysis (HD) treatment. One of the atherogenic causes of hypertriglyceridemia is the increase in TG-rich lipoprotein remnants, which are equivalent to remnant-like particle cholesterol (RLP-C). Here, we compared the plasma levels of TG, a representative indicator of TG-rich lipoproteins and RLP-C, as well as the TG/RLP-C ratio between CKD patients undergoing HD and controls, in an effort to elucidate the atherogenicity of TG-rich lipoproteins in CKD patients on HD. Materials and methods: Plasma lipid and apo(lipo)protein levels and the TG/RLP-C ratio were compared between 49 CKD patients undergoing HD and 627 controls. Blood sampling for lipid and apoprotein analysis was performed in a 12-h fasting state. Controls were divided into four subgroups according to TG level (from highest to lowest). RLP-C and apo(lipo)proteins were measured using the immunoprecipitation method and turbidimetric immunoassay, respectively. In addition, a comparison between HD patients and age-, gender-, and plasma TG level-matched controls was performed. Results: Plasma TG levels were 107 ± 70 (mean ± SD) mg/dl in HD patients and 115 ± 72 mg/dl in controls. Plasma RLP-C levels were 6.7 ± 4.5 mg/dl in HD patients and 4.6 ± 3.5 mg/dl in the controls (p

The rapid diagnosis of pathogens and prompt initiation of appropriate antibiotic therapy are critical factors to reduce the morbidity and mortality associated with sepsis. In this study, we evaluated a multiplex polymerase chain reaction (PCR-M) test that detects bacteria and fungi in whole-blood specimens, comparing its features to those of a blood culture (BC). Following evaluation of the performance for sensitivity and specificity of PCR-M, 78 blood samples from 54 patients with suspected bacterial infections were evaluated. Whole-blood samples for PCR-M were collected at the same time as BC, and PCR-M results were compared with BC results. As a result, minimum sensitivity of the kit was 1-100 cfu/ml. The PCR-M test correctly identified specificity for 13 out of 14 strains blinded to the assay analyst. Of 78 blood samples examined, 56 (72%) were negative by both methods, and 22 (28%) were positive by at least one of the two methods. PCR-M detected organisms in 21 cases (27%) compared with 12 cases (15%) in BC. The correlation of positives between PCR-M and BC was 92% (11/12), and both methods identified the same organisms in these 11 cases. With higher positive rate compared with BC, PCR-M could detect and identify potentially significant microorganisms within a few hours by using a small volume of a single whole-blood sample. Early detection of microorganisms has the potential to facilitate early determination of appropriate treatment and antimicrobial selection.

Stonefish is a dangerous and venomous fish commonly found in the shallow waters of the Pacific region. Its envenomation is reported worldwide with increasing frequency. Although envenomation usually occurs in those engaged in marine sports, chefs may suffer envenomation during cutting stonefish, which is eaten either sliced raw, boiled, or deep-fried by Japanese. Since many people cook and eat Japanese food, it is important to know that cutting a stonefish for cooking carries the risk of envenomation. However, most primary and emergency physicians have not encountered cases of envenomation during food preparation. Here we describe a case of envenomation occurring while cooking. The patient was a healthy 33-year-old man working as a chef in a Japanese restaurant. He was presented to an academic emergency department after suddenly developing severe pain in his right fourth finger while cutting a stonefish. The finger was reddish, swollen, and tender. The pain reduce d after immersing his hand in hot water, and disappeared within 18 h without any complication. In this report, we describe the history of stonefish envenomation and provide a brief review of the literature related to this form of envenomation.

There have been few reports published in English on emergency medicine (EM) in Japan; the main reason for this is that the concept of EM was different in Japan from that in western countries. In the 1960s, legislation was passed in Japan that implemented emergency medical services, and emergency hospitals were designated by the government. There were no emergency medicine specialists, and so surgeons/physicians without specialist training in emergency medicine provided care to emergency patients (the multispecialist-type model). The Japanese Association for Acute Medicine (JAAM), an academic society for emergency physicians, was founded in 1973. In its pioneering days, this association focused mostly on trauma/burn care and also influenced policymaking. In 1977, the government built emergency medical service centers (the ICU-type model) and reorganized all emergency medical facilities into three levels. With the aging of society, the number of non-trauma patient! s presenting at hospitals, especially in the elderly population, has increased and has resulted in some cases of refusal by hospitals to accept emergency patients. A new postgraduate medical education curriculum was legislated in 2004 that mandated EM training for all postgraduates and encouraged reinforcement of emergency departments in teaching hospitals. The JAAM established a committee to promote the ER-type model of EM in 2003. By 2007, more than 150 JAAM-affiliated hospitals had implemented this type of EM. In conclusion, emergency medicine in Japan is currently based on a mixture of three models: the multispecialist-type, the ICU-type and the ER-type models.

In older people, falls are major reasons for transporting to emergency departments (ED). Falls are etiologically classified into syncopal falls and non-syncopal ones. The aim of this study is to clarify the characteristics of syncopal falls in community-living older people transported to ED. The retrospective chart review was performed on patients older than 65 years, transported to the ED of Keio University Hospital in Tokyo because of falls during a 12-month period. Age, sex, blood pressure and pulse rate at the arrival to ED, episode of syncope, type of fall, sustained injury and medical problems were screened. We analyzed the differences between syncopal falls and non-syncopal ones. Patients with syncopal falls were given blood tests, electrocardiograms, and standing tests for orthostatic hypotension. The number of syncopal falls was 33 (29.5%), and that of non-syncopal ones was 79 (69.3%). Syncopal falls frequently occurred on same level compared with from one level to another (84.8% versus 9.1%). In patients with syncopal falls, the frequency of falling on the same level was significantly higher than that in patients with non-syncopal falls (84.8% vs 60.8%). Patients with syncopal falls significantly sustained fewer fractures (12.1% vs 34.2%), and used more antihypertensive agents (45.5% vs 18.9%) than those with non-syncopal ones, respectively. The 14 syncopal fall patients were given standing tests, and four patients presented orthostatic hypotension. In community-living older people transported to ED, syncopal falls frequently occurred on the same level, and the patients with syncopal falls were found to have sustained fewer fractures and use more antihypertensive agents.

The Meiji Jingu Baseball Stadium attracts a large number of spectators in the Tokyo metropolitan area. To clarify the demand for medical care at a public ballpark, we analyzed following two types of medical records maintained at the stadium: (1) "Report of Aid": a record of patients visiting the first-aid station in 2003 season and (2) "Report of Accidents": a record of patients referred to clinics/hospitals between 1996 and 2003 season. (1) In 2003, approximately 1,582,000 spectators watched 67 professional baseball games (60 night games). Of the 247 spectators received medical care at the first-aid station (3.7 persons per game, 1/6,405 spectators), 128 (51.8%) had trauma and 109 (44.1%) had illness. The incidence of trauma was relatively higher before the start and near the end of the night games. The risk of becoming sick/wounded per spectator or the number of the sick/wounded per game differed depending on the participating sports teams. (2) Ninety-three spectators referred to clinics/hospitals during the 8-year period from 1996 to 2003, of which 57 were transferred by ambulance. Direct ball injury accounted for 65 (69.9%) cases of trauma, followed by stumbling/falls (18 cases, 19.4%). Twenty patients were diagnosed to have fractures at the clinics/hospitals. Intrinsic cardiopulmonary arrest occurred in one spectator. Trauma due to direct ball injury accounted for the largest number of wounded patients referred to clinics/hospitals. Treatment to patients at the first-aid station in the stadium may optimize the frequency of hospital visits. Records of medical care are effective to analyze the demand for medical preparedness. Language: en

The mortality of severe sepsis has markedly decreased since the implementation of the Surviving Sepsis Campaign guidelines. The next logical step is to examine the necessity of individualized management guidelines for targeted therapy against specific bacteria. Streptococcus pneumoniae is the leading cause of community-acquired severe sepsis; however, little is known regarding the prognostic factors in adult patients with S pneumoniae sepsis. We aimed to identify prognostic factors in patients with S pneumoniae sepsis and to explore a subgroup of patients at high risk for death with detailed Sequential Organ Failure Assessment (SOFA) score analysis.We retrospectively reviewed the records of patients with S pneumoniae infection treated between 1st January 2006 and 31st July 2012. We identified prognostic factors for 28-day mortality using univariate and multivariate logistic regression models.Of 171 patients (median age, 72 years) with S pneumoniae infection who were included in this study, the 28-day mortality was 17% (29/171). The SOFA score (odds ratio, 2.25; 95% confidence interval, 1.60-3.18; P.001) and bacteremia (odds ratio, 19.0; 95% confidence interval, 4.06-90.20; P.001) were identified as prognostic factors for the 28-day mortality. In a subgroup analysis with a cutoff value of the SOFA score determined by receiver operating characteristic analysis, patients with bacteremia and a SOFA score of at least 7 had a significantly higher mortality than did patients without bacteremia and a SOFA score lower than 7 (84% vs 0%, respectively).Bacteremia and a SOFA score at least 7 were independent prognostic factors of poor outcome in S pneumoniae sepsis.

Objective The aim of this study was to compare the values of a noninvasive blood pressure (NIBP) measurement during cuff inflation (inflationary NIBP) and deflationary NIBP measurements and to verify whether inflationary NIBP is equivalent to conventional deflationary NIBP and is acceptable for clinical use in the emergency room (ER). Materials and methods A total of 2981 NIBP data points were collected from 175 patients (age, 56.5±22.2 years; range, 7–92 years) who had been treated in the resuscitation area of the ER at Keio University Hospital. The data points were obtained using two alternate algorithms with a standard monitor (BSM-6000). One algorithm consisted of continuous inflationary and deflationary measurements in a single cycle (dual algorithm, 1502 data points); this algorithm was used to verify the success rate and the precision of the data. The second algorithm (1479 data points) consisted of only conventional deflationary measurements and was used to verify the duration of the measurement cycle. Results The success rate of the inflationary NIBP (completed using only the inflationary method) was 69.0%. Failures in the inflationary measurements were caused by arrhythmia and/or body motions. The mean difference and SD of the systolic pressure and the diastolic pressure between inflationary NIBP and deflationary NIBP were −0.6±8.8 and 3.5±7.5 mmHg, respectively. The confidence intervals were −0.6 (95% confidence interval=−1.1 to −0.1) and 3.5 (95% confidence interval=3.0 to 4.0) mmHg. The coefficients of correlation were 0.96 and 0.93. Inflationary NIBP was capable of determining the NIBP more quickly compared with deflationary NIBP (average of 15.9 vs. 34.2 s; P