Language：English   Publishing type：Research paper (scientific journal)   Publisher：Elsevier BV  

PURPOSE: We aimed to predict the neurological prognosis of cardiac arrest (CA) patients using quantitative imaging biomarkers extracted from brain computed tomography images. METHODS: We retrospectively enrolled 86 CA patients (good prognosis, 32; poor prognosis, 54) who were treated at three hospitals between 2017 and 2019. We then extracted 1131 quantitative imaging biomarkers from whole-brain and local volumes of interest in the computed tomography images of the patients. The data were split into training and test sets containing 60 and 26 samples, respectively, and the training set was used to select representative quantitative imaging biomarkers for classification. In univariate analysis, the classification was evaluated using the p-value of the Brunner-Munzel test and area under the receiver operating characteristic curve (AUC) for the test set. In multivariate analysis, machine learning models reflecting nonlinear and complex relations were trained, and they were evaluated using the AUC on the test set. RESULTS: The best performance provided p = 0.009 (<0.01) and an AUC of 0.775 (95% confidence interval, 0.590-0.960) for the univariate analysis and an AUCof0.813 (95% confidence interval, 0.640-0.985) for the multivariate analysis. Overall, the gray level with the maximum gradient in the histogram of the three-dimensionally low-pass-filtered image was an important feature for prediction across the analyses. CONCLUSIONS: Quantitative imaging biomarkers can be used in neurological prognosis prediction for CA patients. Relevant biomarkers may contribute to protocolized computed tomography image acquisition to ensure proper decision support in acute care.

DOI： 10.1016/j.ejmp.2024.103425

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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Language：English   Publishing type：Research paper (scientific journal)  

INTRODUCTION: Lithium exhibits a narrow margin between therapeutic doses and toxic blood concentrations, which can pose a substantial risk of toxic effects. Reportedly, lithium toxicity may be associated with a reduced anion gap; however, the precise relationship remains unclear. This study examined several different anion gap calculation methods to detect toxic lithium concentrations without directly measuring blood lithium concentrations. METHODS: Our retrospective study analyzed blood samples collected for lithium concentration measurements. The anion gap was determined using three different methods, both with and without albumin and lactate concentration corrections. Samples were categorized into two groups based on lithium concentration (<1.5 or ≥1.5 mmol/L), and anion gap values were compared. Correlation and logistic regression analyses were used to assess the relationship between each anion gap indicator and lithium concentration. Receiver operating characteristic curves were used for diagnostic analysis. RESULTS: Overall, 24 measurements were collected, with 41.7% of samples falling within the toxic range. The high-lithium concentration group exhibited significantly smaller anion gaps. Correlation and logistic regression analyses revealed a significant association between anion gap values and lithium concentrations. Areas under the receiver operating characteristic curve were: conventional anion gap 0.77 (95% CI: 0.55-0.94); albumin-corrected anion gap 0.85 (95% CI: 0.66-1.00); and both albumin- and lactate-corrected anion gap 0.86 (95% CI: 0.66-1.00). DISCUSSION: The anion gap is calculated as the difference between measured cations and anions. Accumulation of lithium (a cation) may decrease measured cations and decrease the calculated anion gap. Abnormal albumin and lactate concentrations may also alter the anion gap and affect its usefulness as a diagnostic marker for elevated serum lithium concentrations. A negative likelihood ratio of 0.1 suggests that the anion gap might be valuable in excluding toxicity. CONCLUSIONS: The corrected anion gap, accounting for albumin and lactate concentrations, may be beneficial in suggesting the possibility of toxic lithium concentrations.

DOI： 10.1080/15563650.2024.2380771

PubMed

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Language：Japanese   Publisher：(公財)日本心臓財団  

循環器救急医療では,病院前救急搬送システムとの連携とそれを司る「メディカルコントロール(MC)協議会」への参画が重要である.病院前救急医療への循環器医の参画状況を明らかにし,課題を抽出するため,日本循環器学会医師会員を対象に「病院前での循環器救急医療の実情に関するアンケート」調査をwebで実施した.このアンケートには1,377名の回答を得た.回答者の90%は勤務医で,約80%が所属している医療施設に循環器内科医として勤務しており,その施設の救急の内訳は2次救急が44%,3次救急が41%を占めた.それでも,「MC」という言葉を知っているのは60%に留まり,「MC」の言葉を知っている回答者のうちで,「MC協議会」に関与しているのは,わずか18%(145名)であり,救急隊が行った処置の事後検証に関与しているのは25%,救急隊が行う処置プロトコルの作成に関与しているのは8%に留まった.回答者が勤務している地域で「12誘導心電図伝送が行われている」のは35%以下で,院外での蘇生時に使用されたAEDの内部データは40%を超える地域では治療に役立てられていないことがわかった.自由記載する学会への要望では,AIテキストマイニングを用いて解析すると,(1)救急車からの12誘導心電図伝送システムの普及,(2)救急隊員への教育と搬送システムの構築,(3)AEDの内部データの入手,(4)都市部でのPCIセンターの集約化,(5)地方での緊急PCIの24時間体制の構築,が挙げられた.(著者抄録)

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Language：Japanese   Publisher：新潟県医師会  

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Language：Japanese   Publisher：東北救急医学会  

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：Japanese   Publisher：(一社)日本救急医学会  

体外式膜型人工肺(extracorporeal membrane oxygenation:ECMO)施行時に超音波検査で脱血カニューレ先端が下大静脈-右房接合部に存在することを確認したにもかかわらず上行腰静脈迷入が判明した症例を経験した。症例は70歳代の男性。呼吸不全に対してveno-venous ECMOを導入した。脱血カニューレを挿入する際に抵抗があったが,心窩部超音波検査でガイドワイヤが下大静脈内にあることを確認していたため手技を続行した。その後,ECMOの血液流量が減少したため画像検索を行ったところ,脱血カニューレが上行腰静脈を経由して下大静脈に到達していることが判明した。抜去に際して出血の懸念があった。緊急手術に対応できるように準備し,脱血カニューレ内腔にバルーン付きガイドカテーテルを挿入して閉塞させ,静脈造影しつつ抜去した。出血時は静脈塞栓術を行う予定であったが出血は生じなかった。本症例のような迷入経路がありうるため,心窩部超音波検査のみではカニューレの上行腰静脈迷入を除外できない。下腹部超音波検査やX線撮影で確認することも考えられるが,時間に余裕があれば血管造影室で透視下にECMOを導入すべきである。迷入したカニューレを抜去する際にはバルーン付きガイドカテーテルを用いた静脈造影が選択肢の一つとなりうる。(著者抄録)

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：Japanese   Publisher：新潟医学会  

【緒言】高齢患者の治療方針の決定には,年齢・患者背景・家族/本人の意志など複数の因子がからみ議論となることが多い.近年患者が健常なうちに前もって診療の意志決定をしておくAdvance Care Planning(ACP)が推奨されているが,救急・集中治療領域で普及しているとはいいがたい.今回我々は,当救命センター・ICUに入室した超高齢患者群でのACPの実態を後方視的に調査した.【方法】2015年1月から2019年12月までに当救命センター・ICUに入室した90歳以上の患者217例を対象とした.当施設で採用されている患者情報システム情報をもとにACPの有無と診療内容,転帰の関係を後方視的に検討した.【結果】対象患者217例のうちACPを有した"ACP有群"は73例(34%)であった.そのうち入室前にすでにACPを得ていた症例は9例(4%)で,入室後にACPを得た症例は64例(29%)であった.入室中ACP取得のなかった"ACP無群"は144例(66%)であった.侵襲的治療を受けた症例はACP有群で21例(29%),ACP無群で72例(50%)であった(p=0.003).救命センター・ICU入室期間(中央値)はACP有群3(2-5)日,ACP無群4(2-7)日であった(p=0.14).当病院入院期間(中央値)はACP有群10(2-20)日,ACP無群18(9-20)日であった(p=0.0009).当病院退院時にADLが悪化した症例はACP有群56例(77%),ACP無群71例(49%)(p<0.0001)であった.ADL変化の内訳はACP有群(自立38例(52%),要介護35例(48%)→自立1例(1.4%),介護33例(45%),死亡39例(53%)),ACP無群(自立105例(73%),介護39例(27%)→自立35例(24%),要介護104例(72%),死亡5例(3.5%))であった.【結論】超高齢者にもかかわらず入院前ACP取得率は4%に過ぎず,少なくとも当院においてACPは普及していなかった.ACPを有した大多数が救命センター・ICU入室後に得られており,救命センター・ICU入室期間がACP取得の機会として重要であった.またACPの有無で診療内容・転帰に差がありACP自体が診療内容に影響を与えた可能性があった.(著者抄録)

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：English   Publishing type：Research paper (scientific journal)  

In Japan, which has a super-aging society, there are increasing opportunities to perform mechanical thrombectomy for the elderly; however, there is no recorded evidence of thrombectomy for the elderly. This study examined the usefulness of thrombectomy in the elderly. We retrospectively analyzed patient data using a multicenter acute ischemic stroke registry (NGT-FAST). We examined outcomes in patients 75 years and older who underwent thrombectomies between January 1, 2021, and December 31, 2021. The patients were divided into two groups: the 75-84-year-old group and the 85+-year-old group. There was no difference in the pretreatment National Institutes of Health Stroke Scale score or Alberta Stroke Program Early Computed Tomography Score between the two groups, but the 85+-year-old group had a significantly lower rate of pre-stroke modified Rankin Scale (mRS) score of 0-2. There were no differences in time from onset to treatment or effective recanalization rate, but complications tended to be more common in the 85+-year-old group. The number of patients with a good outcome at discharge (an mRS score of 0-3) was significantly lower in the 85+-year-old group than in the 75-84-year-old group. In addition, 90.9% of patients in the 85+-year-old group with a pre-stroke mRS score of 3 deteriorated after treatment. The pre-stroke mRS score is very important in determining the indication for thrombectomy in the elderly because their preoperative condition is more likely to influence the outcome than that of younger patients.

DOI： 10.2176/jns-nmc.2023-0039

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Language：Japanese   Publisher：日本臨床麻酔学会  

本邦において破傷風は減少傾向だが,年間100例以上の発生報告があり,死亡率は10～20%に上る重篤な疾患である.最も症状が強くなるIII期は苦痛緩和を目的とした深鎮静が必要となりリハビリテーションが進まないが,回復期といわれるIV期まで安静を続けると廃用が進行する.つまり,重症患者管理において重要なリハビリテーションを破傷風患者に行うのが困難なことが臨床上の問題である.今回われわれは人工呼吸管理を要した重症全身性破傷風のIII期から,プロポフォールをデクスメデトミジンに変更した鎮痛鎮静管理によって覚醒を維持した状態でリハビリテーションを行うことが可能となり,機能障害なく退院した症例を経験したため報告する.(著者抄録)

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Language：Japanese   Publisher：(一社)日本呼吸療法医学会  

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Other Link： https://search.jamas.or.jp/default/link?pub_year=2023&ichushi_jid=J02315&link_issn=&doc_id=20230615460012&doc_link_id=10.50903%2Fjsrcm.40.1_79&url=https%3A%2F%2Fdoi.org%2F10.50903%2Fjsrcm.40.1_79&type=J-STAGE&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00007_3.gif

Language：English   Publishing type：Research paper (scientific journal)  

Identifying the host genetic factors underlying severe COVID-19 is an emerging challenge1-5. Here we conducted a genome-wide association study (GWAS) involving 2,393 cases of COVID-19 in a cohort of Japanese individuals collected during the initial waves of the pandemic, with 3,289 unaffected controls. We identified a variant on chromosome 5 at 5q35 (rs60200309-A), close to the dedicator of cytokinesis 2 gene (DOCK2), which was associated with severe COVID-19 in patients less than 65 years of age. This risk allele was prevalent in East Asian individuals but rare in Europeans, highlighting the value of genome-wide association studies in non-European populations. RNA-sequencing analysis of 473 bulk peripheral blood samples identified decreased expression of DOCK2 associated with the risk allele in these younger patients. DOCK2 expression was suppressed in patients with severe cases of COVID-19. Single-cell RNA-sequencing analysis (n = 61 individuals) identified cell-type-specific downregulation of DOCK2 and a COVID-19-specific decreasing effect of the risk allele on DOCK2 expression in non-classical monocytes. Immunohistochemistry of lung specimens from patients with severe COVID-19 pneumonia showed suppressed DOCK2 expression. Moreover, inhibition of DOCK2 function with CPYPP increased the severity of pneumonia in a Syrian hamster model of SARS-CoV-2 infection, characterized by weight loss, lung oedema, enhanced viral loads, impaired macrophage recruitment and dysregulated type I interferon responses. We conclude that DOCK2 has an important role in the host immune response to SARS-CoV-2 infection and the development of severe COVID-19, and could be further explored as a potential biomarker and/or therapeutic target.

DOI： 10.1038/s41586-022-05163-5

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Language：Japanese   Publisher：日本脳低温療法・体温管理学会  

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Language：English   Publishing type：Research paper (scientific journal)  

Coronavirus disease 2019 (COVID-19) is a recently-emerged infectious disease that has caused millions of deaths, where comprehensive understanding of disease mechanisms is still unestablished. In particular, studies of gene expression dynamics and regulation landscape in COVID-19 infected individuals are limited. Here, we report on a thorough analysis of whole blood RNA-seq data from 465 genotyped samples from the Japan COVID-19 Task Force, including 359 severe and 106 non-severe COVID-19 cases. We discover 1169 putative causal expression quantitative trait loci (eQTLs) including 34 possible colocalizations with biobank fine-mapping results of hematopoietic traits in a Japanese population, 1549 putative causal splice QTLs (sQTLs; e.g. two independent sQTLs at TOR1AIP1), as well as biologically interpretable trans-eQTL examples (e.g., REST and STING1), all fine-mapped at single variant resolution. We perform differential gene expression analysis to elucidate 198 genes with increased expression in severe COVID-19 cases and enriched for innate immune-related functions. Finally, we evaluate the limited but non-zero effect of COVID-19 phenotype on eQTL discovery, and highlight the presence of COVID-19 severity-interaction eQTLs (ieQTLs; e.g., CLEC4C and MYBL2). Our study provides a comprehensive catalog of whole blood regulatory variants in Japanese, as well as a reference for transcriptional landscapes in response to COVID-19 infection.

DOI： 10.1038/s41467-022-32276-2

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Language：Japanese   Publisher：(一社)日本救急医学会  

新型コロナウイルス感染症蔓延下において脳死下臓器提供数が減少しているなかで,脳死判定を目的とした転院搬送の是非に関する議論が始まっている。これをふまえ,全国救命センターにおけるコロナ禍での脳死判定や脳死下臓器移植に関わる現状と問題点を調査した。全国救命センター295施設に質問紙URLを送付し電子的に回収した。調査項目は施設背景,臓器提供の意思決定に関する質問,臓器提供も見据えた患者管理,脳死判定,臓器提供手術の問題点に関する質問,臓器提供を目的とした転院に関する質問とした。220施設より回答を得た(回答率74.6%)。コロナ禍において臓器提供を施行した施設は45施設(20.5%)存在した。臓器提供を行った施設とそうでなかった施設において,休日夜間帯に勤務をしている専門医数に差が見られた(平均3.04人対2.44人)。また,コロナ禍によって臓器提供に関する事項が影響を受けたと回答した施設は全国救命センターの43施設(19.6%)に及び,患者個室管理,家族の面会制限,チームの参集困難など,感染対策による影響と回答した施設がうち39施設(90.7%)に見られた。「脳死下臓器提供」を目的とした転院に関し,他施設に転送したいと回答した施設群(60施設:27%)は,院内連携が手薄く,マンパワーが少なく,また,脳死判定医が少ないこと,脳死判定の費用に関わる経済的問題に要因があると思われた。本研究によりコロナ禍における脳死下臓器提供に関わるハード,ソフト両面の課題が明確になった。とくに施設におけるマンパワー拡充のための施設間連携と経済的支援の拡充が今後の課題であると思われた。(著者抄録)

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Language：Japanese   Publisher：(株)へるす出版  

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Language：Japanese   Publisher：(株)へるす出版  

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Language：Japanese   Publisher：東北救急医学会  

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Language：Japanese   Publisher：(一社)日本救急医学会  

緊張性気腹は閉塞性ショックを呈し心肺停止に至ることがある。腹腔穿刺による緊急脱気によって容易に改善が見込めるため,迅速な診断と処置が望まれる。原因の明確な医原性の緊張性気腹症例がしばしば報告されているが,消化管穿孔などの非医原性の機序でも緊張性気腹を来しうる。このような場合,予備情報がないため病態の把握に時間がかかる可能性がある。今回我々は,上部消化管穿孔から緊張性気腹を呈し,緊急腹腔穿刺で改善した症例を経験したので報告する。患者は60歳の女性。感冒症状の後に呼吸苦が出現,意識障害を呈したため当院に救急搬送された。当院受診時は心肺停止状態であったが,直ちに蘇生処置を行い4分程度で自己心拍が再開した。胸部X線写真で腹腔内遊離ガスと横隔膜の挙上ならびに右上肺野に空洞を伴う腫瘤影を認め,腹部CTでは腹部の膨隆と多量の腹腔内遊離ガスならびに胃穿孔を疑う所見がみられた。緊急手術を行う方針となったが,ショック状態が遷延した。緊張性気腹と判断し18G留置針で試験穿刺を行ったところ,速やかに循環動態は安定した。開腹手術を施行し,ICUに入室となった。手術後循環状態は安定し経過したが,肺アスペルギルス症によると思われる喀血が出現し,コントロールができず第24病日に死亡退院となった。(著者抄録)

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BACKGROUND: Elevated blood lactate levels were reported as effective predictors of clinical outcome and mortality in ICU. However, there have been no studies simply comparing the timing of measuring lactates before vs. after ICU admission. METHODS: A total of 19,226 patients with transfer time ≤ 24 hr were extracted from the Medical Information Mart for Intensive Care IV database (MIMIC-IV). After 1:1 propensity score matching, the patients were divided into two groups: measuring lactates within 3 hr before (BICU group, n = 4,755) and measuring lactate within 3 hr after ICU admission(AICU group, n = 4,755). The primary and secondary outcomes were hospital mortality, hospital 28-day mortality, ICU mortality, ICU length of stay (LOS), hospital LOS, and restricted mean survival time (RMST). RESULTS: Hospital, hospital 28-day, and ICU mortality were significantly higher in AICU group (7.0% vs.9.8%, 6.7% vs. 9.4%, and 4.6% vs.6.7%, respectively, p<0.001 for all) Hospital LOS and ICU LOS were significantly longer in AICU group (8.4 days vs. 9.0 days and 3.0 days vs. 3.5 days, respectively, p<0.001 for both). After adjustment for predefined covariates, a significant association between the timing of measuring lactate and hospital mortality was observed in inverse probability treatment weight (IPTW) multivariate regression, doubly robust multivariate regression, and multivariate regression models (OR, 0.96 [95%CI, 0.95-0.97], OR 0.52 [95%CI, 0.46-0.60], OR 0.66 [95%CI, 0.56-0.78], respectively, p<0.001 for all), indicating the timing as a significant risk-adjusted factor for lower hospital mortality. The difference (BICU-AICU) of RMST at 28- days after ICU admission was 0.531 days (95%CI, 0.002-1.059, p<0.05). Placement of A-line and PA-catheter, administration of intravenous antibiotics, and bolus fluid infusion during the first 24-hr in ICU were significantly more frequent and faster in the BICU vs AICU group (67.6% vs. 51.3% and 126min vs.197min for A-line, 19.6% vs.13.2% and 182min vs. 274min for PA-catheter, 77.5% vs.67.6% and 109min vs.168min for antibiotics, and 57.6% vs.51.6% and 224min vs.278min for bolus fluid infusion, respectively, p<0.001 for all). Additionally, a significant indirect effect was observed in frequency (0.19879 [95% CI, 0.14061-0.25697] p<0.001) and time (0.07714 [95% CI, 0.22600-0.13168], p<0.01) of A-line replacement, frequency of placement of PA-catheter (0.05614 [95% CI, 0.04088-0.07140], p<0.001) and frequency of bolus fluid infusion (0.02193 [95%CI, 0.00303-0.04083], p<0.05). CONCLUSIONS: Measuring lactates within 3 hr prior to ICU might be associated with lower hospital mortality in unselected heterogeneous critically ill patients with transfer time to ICU ≤ 24hr, presumably due to more frequent and faster therapeutic interventions.

DOI： 10.1371/journal.pone.0277948

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Language：English   Publishing type：Research paper (scientific journal)  

© 2021, The Author(s). Background: Combinations of antidepressant duloxetine (at doses of 40–60 mg/day) and other antipsychotics are frequently used in clinical treatment; however, several fatal and nonfatal cases of duloxetine overdose have been documented. We experienced a patient who had taken an overdose of duloxetine (780 mg) in combination with other drugs in a suicide attempt. Case presentation: The patient was a 37-year-old man (body weight, 64 kg) with a history of gender identity disorder and depression. He intentionally took an overdose of duloxetine in combination with three other antipsychotic drugs (18 mg flunitrazepam, 850 mg quetiapine, and 1100 mg trazodone) and was emergently admitted to Kyoto Medical Center. The patient’s plasma concentration of duloxetine during ambulance transport was 57 ng/ml, and the level was still as high as 126 ng/mL at 32 h after administration. Duloxetine disappeared most slowly from plasma, in contrast to quetiapine, which was the fastest to clear among the four medicines determined in this patient. The observed concentrations of duloxetine in this overdose patient were generally within the 95% confidence intervals of the plasma concentration curves predicted using a physiologically based pharmacokinetic (PBPK) model. Conclusion: Even if more than 1 h (the generally recommended period) has passed after administration of duloxetine in such overdose cases, gastric lavage and/or administration of activated charcoal may be effective in clinical practice up to 6 h because of the typically slow elimination behavior illustrated by the PBPK model. Pharmacokinetic profiles visualized using PBPK modeling can inform treatment decisions in cases of drug overdose for medicines such as duloxetine in emergency clinical practice.

DOI： 10.1186/s40780-021-00189-9

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：English   Publishing type：Research paper (scientific journal)  

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members.As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

DOI： 10.1186/s40560-021-00555-7

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Purpose: Lengthy hospitalization places a burden on patients and healthcare resources. However, the factors affecting the length of hospital stay (LHoS) and length of emergency room stay (LERS) in non-fatal bicycle accidents are currently unclear. We investigated these factors to inform efforts to minimize hospitalization. Methods: We performed a retrospective analysis of data from non-fatal injured bicyclists admitted to the Emergency and Critical Care Center at Kyoto Medical Center between January 2012 and December 2016. We measured LHoS, LERS, mechanism of injury, head injury prevalence, polytrauma, operations performed, injury severity score (ISS), abbreviated injury scale (AIS) score, maximum AIS score, and trauma and injury severity score probability of survival. We conducted multiple regression analysis to determine predictors of LHoS and LERS. Results: Within the study period, 82 victims met the inclusion and exclusion criteria and were included. Mean age was (46.0 ± 24.7) years. Overall mean LHoS was (16.8 ± 25.2) days, mean LERS was (10.6 ± 14.7) days, median ISS was 9 (interquartile range (IQR): 3–16), median maximum AIS was 3 (IQR: 1–4), and median trauma and injury severity score probability of survival was 98.0% (IQR: 95.5%–99.6%). Age, maximum AIS, ISS, and prevalence of surgery were significantly greater in long LHoS and LERS group compared with short LHoS and LERS group (p < 0.05). Performance of surgery independently explained LHoS (p = 0.0003) and ISS independently explained LERS (p = 0.0009). Conclusion: Surgery was associated with long hospital stays and ISS was associated with long emergency room stays. To improve the quality life of the bicyclists, preventive measures for reducing injury severity or avoiding injuries needing operation are required.

DOI： 10.1016/j.cjtee.2021.03.003

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

日本集中治療医学会と日本救急医学会は,合同の特別委員会を組織し,2016年に発表した日本版敗血症診療ガイドライン(J-SSCG)2016の改訂を行った。本ガイドライン(J-SSCG2020)の目的は,J-SSCG2016と同様に,敗血症・敗血症性ショックの診療において,医療従事者が患者の予後改善のために適切な判断を下す支援を行うことである。改訂に際し,一般臨床家だけでなく多職種医療者にも理解しやすく,かつ質の高いガイドラインとすることによって,広い普及を目指した。J-SSCG2016ではSSCG2016にない新しい領域[ICU-acquircd weakness(ICU-AW)とpost-intensive care syndrome(POCS),体温管理など]を取り上げたが,J-SSCG2020では新たに注目すべき4領域(Patient-and Family-Centered Care, sepsis treatment system,神経集中治療,ストレス潰瘍)を追加し,計22領域とした。重要な118の臨床課題(clinical question:CQ)をエビデンスの有無にかかわらず抽出した。これらのCQには,本邦で特に注目されているCQも含まれる。多領域にわたる大規模ガイドラインであることから,委員25名を中心に,多職種(看護師,理学療法士,臨床工学技士,薬剤師)および患者経験者も含めたワーキンググループメンバー,両学会の公募によるシステマティックレビューメンバーによる総勢226名の参加・協力を得た。また,中立的な立場で横断的に活躍するアカデミックガイドライン推進班をJ-SSCG2016に引き続き組織した。将来への橋渡しとなることを企図して,多くの若手医師をシステマティックレビューチーム・ワーキンググループに登用し,学会や施設の垣根を越えたネットワーク構築も進めた。作成工程においては,質の担保と作業過程の透明化を図るために様々な工夫を行い,パブリックコメント募集は計2回行った。推奨作成にはGRADE方式を取り入れ,修正Delphi法を用いて全委員の投票により推奨を決定した。結果,118CQに対する回答として,79個のGRADEによる推奨,5個のGPS(good practice statement),18個のエキスパートコンセンサス,27個のBQ(background question)の解説,および敗血症の定義と診断を示した。新たな試みとして,CQごとに診療フローなど時間軸に沿った視覚的情報を取り入れた。J-SSCG2020は,多職種が関わる国内外の敗血症診療の現場において,ベッドサイドで役立つガイドラインとして広く活用されることが期待される。なお,本ガイドラインは,日本集中治療医学会と日本救急医学会の両機関誌のガイドライン増刊号として同時掲載するものである。(著者抄録)

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Language：Japanese   Publisher：(一社)日本救急医学会  

日本集中治療医学会と日本救急医学会は,合同の特別委員会を組織し,2016年に発表した日本版敗血症診療ガイドライン(J-SSCG)2016の改訂を行った。本ガイドライン(J-SSCG2020)の目的は,J-SSCG2016と同様に,敗血症・敗血症性ショックの診療において,医療従事者が患者の予後改善のために適切な判断を下す支援を行うことである。改訂に際し,一般臨床家だけでなく多職種医療者にも理解しやすく,かつ質の高いガイドラインとすることによって,広い普及を目指した。J-SSCG2016ではSSCG2016にない新しい領域[ICU-acquircd weakness(ICU-AW)とpost-intensive care syndrome(POCS),体温管理など]を取り上げたが,J-SSCG2020では新たに注目すべき4領域(Patient-and Family-Centered Care, sepsis treatment system,神経集中治療,ストレス潰瘍)を追加し,計22領域とした。重要な118の臨床課題(clinical question:CQ)をエビデンスの有無にかかわらず抽出した。これらのCQには,本邦で特に注目されているCQも含まれる。多領域にわたる大規模ガイドラインであることから,委員25名を中心に,多職種(看護師,理学療法士,臨床工学技士,薬剤師)および患者経験者も含めたワーキンググループメンバー,両学会の公募によるシステマティックレビューメンバーによる総勢226名の参加・協力を得た。また,中立的な立場で横断的に活躍するアカデミックガイドライン推進班をJ-SSCG2016に引き続き組織した。将来への橋渡しとなることを企図して,多くの若手医師をシステマティックレビューチーム・ワーキンググループに登用し,学会や施設の垣根を越えたネットワーク構築も進めた。作成工程においては,質の担保と作業過程の透明化を図るために様々な工夫を行い,パブリックコメント募集は計2回行った。推奨作成にはGRADE方式を取り入れ,修正Delphi法を用いて全委員の投票により推奨を決定した。結果,118CQに対する回答として,79個のGRADEによる推奨,5個のGPS(good practice statement),18個のエキスパートコンセンサス,27個のBQ(background question)の解説,および敗血症の定義と診断を示した。新たな試みとして,CQごとに診療フローなど時間軸に沿った視覚的情報を取り入れた。J-SSCG2020は,多職種が関わる国内外の敗血症診療の現場において,ベッドサイドで役立つガイドラインとして広く活用されることが期待される。なお,本ガイドラインは,日本集中治療医学会と日本救急医学会の両機関誌のガイドライン増刊号として同時掲載するものである。(著者抄録)

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Language：Japanese   Publisher：(株)総合医学社  

＜point＞▼救急集中治療領域での心電図に対するエビデンス/ガイドラインについての整備、構築は具体的に定まったものはなく今後のさらなる発展が望まれる。▼外来・入院、入室時のスクリーニングとしてだけではなく、病態によっては特に経時的に確認を行うことが重要である。(著者抄録)

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Language：Japanese   Publisher：(株)総合医学社  

＜point＞▼救急集中治療領域での心電図に対するエビデンス/ガイドラインについての整備、構築は具体的に定まったものはなく今後のさらなる発展が望まれる。▼外来・入院、入室時のスクリーニングとしてだけではなく、病態によっては特に経時的に確認を行うことが重要である。(著者抄録)

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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Few studies have compared the sensitivities of autopsy and post mortem computed tomography (PMCT) in detecting rib fractures caused by cardiopulmonary resuscitation (CPR). We aimed to compare the characteristics between both modalities for accurately detecting CPR-related rib fractures. This single-centre observational study included adult patients with autopsy records and PMCT scans at our institution from January 2013 to March 2019. CPR-related rib fractures were evaluated using autopsy and PMCT findings. In 62 patients enrolled, 339 rib fractures were detected on autopsy and/or PMCT (222 fractures on both PMCT and autopsy, 69 on PMCT alone, and 50 on autopsy alone). The agreement of detection for both modalities was substantial (kappa coefficient, 0.78). In the logistic regression model, incomplete fractures detected by PMCT and age <75 years were significantly associated with findings that were negative on autopsy but positive on PMCT, while rib number (ribs 1-3 and 7-12) and fracture location (posterolateral and paravertebral) were significantly associated with negative PMCT findings but positive autopsy findings. Autopsy and PMCT showed complementary roles, and are thus necessary in accurately detecting CPR-related rib fractures. Combining both modalities may contribute to improved CPR quality and better understanding of discrepancy in characteristics between the two modalities.

DOI： 10.3390/diagnostics10090697

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Language：English   Publishing type：Research paper (scientific journal)  

© 2020 The Author(s). Background: The anticoagulant edoxaban is used clinically at doses of 30-60 mg/day; however, we experienced a patient who had taken an overdose of edoxaban of 750 mg. We investigated the pharmacokinetics of edoxaban in this patient by using liquid chromatography-tandem spectrometry to estimate the follow-up period in emergency clinical practice with this medicine. Case presentation: The patient was a 57-year-old woman (body weight, 69 kg) who had taken a single oral dose of 750 mg of edoxaban in a suicide attempt. She was emergently admitted to Kyoto Medical Center. The patient's edoxaban plasma concentrations during ambulance transport (8 h after oral administration) were ~ 4900 ng/ml, and the concentration gradually decreased to ~ 10 ng/mL and to detectable but unmeasurable levels of ~ 1.0 ng/mL at 60 h and 100 h, respectively. The linear range of the relationship between the dose and plasma concentration was assumed to have been exceeded during the first 8 h; however, the measured elimination rate of edoxaban was similar to that visualized curves predicted by a simplified physiologically based pharmacokinetic model previously established. Conclusion: Simplified physiologically based pharmacokinetic models for creating visualized curves have proven to be useful not only during drug discovery or chemical risk assessment but also in cases of medical poisoning. We used a physiologically based pharmacokinetic model previously established for edoxaban to predict the pharmacokinetics in the current case. It is hoped that the results of this study, which encompass drug monitoring data in the patient and visualized pharmacokinetic prediction, will serve as an index when setting the treatment and follow-up period in cases of drug overdose for medicines such as edoxaban in emergency clinical practice.

DOI： 10.1186/s40780-020-00176-6

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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Language：Japanese   Publisher：(株)へるす出版  

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Language：Japanese   Publisher：(一社)日本救急医学会  

80歳の女性。自殺目的にアルカリ製剤を服用し心穿部痛を主訴に来院した。computed tomography(CT)で下部食道壁半周の壁欠損と縦隔内遊離ガスと液体貯留を認めた。腐食性食道炎、食道穿孔と診断し、食道下部の減圧・吸引目的に経鼻胃管を留置、絶飲食、抗菌薬、プロトンポンプ阻害剤で治療を開始した。第2病日から経静脈栄養を開始した。第7病日のCT画像では縦隔内遊離ガスや液体貯留が残存していたが、第28病日のCT画像では改善が認められ、血液生化学検査でも炎症反応は改善していた。第30病日から第43病日まで瘢痕による食道狭窄予防に対してデキサメサゾンを経静脈的に投与した。第41病日の内視鏡による観察では、食道下位に食道穿孔後と思われる治癒期の潰瘍を認めたが、穿孔の残存はなかったため、経腸栄養を開始した。第73病日から経口摂取を開始し、遅発性の合併症なく第120日に転院となった。アルカリ製剤服用後に時間が経過した症例であっても、縦隔炎が限局している場合は保存的に加療することで救命が可能であると考えられた。(著者抄録)

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Language：Japanese   Publisher：(一社)日本救急医学会  

80歳の女性。自殺目的にアルカリ製剤を服用し心穿部痛を主訴に来院した。computed tomography(CT)で下部食道壁半周の壁欠損と縦隔内遊離ガスと液体貯留を認めた。腐食性食道炎、食道穿孔と診断し、食道下部の減圧・吸引目的に経鼻胃管を留置、絶飲食、抗菌薬、プロトンポンプ阻害剤で治療を開始した。第2病日から経静脈栄養を開始した。第7病日のCT画像では縦隔内遊離ガスや液体貯留が残存していたが、第28病日のCT画像では改善が認められ、血液生化学検査でも炎症反応は改善していた。第30病日から第43病日まで瘢痕による食道狭窄予防に対してデキサメサゾンを経静脈的に投与した。第41病日の内視鏡による観察では、食道下位に食道穿孔後と思われる治癒期の潰瘍を認めたが、穿孔の残存はなかったため、経腸栄養を開始した。第73病日から経口摂取を開始し、遅発性の合併症なく第120日に転院となった。アルカリ製剤服用後に時間が経過した症例であっても、縦隔炎が限局している場合は保存的に加療することで救命が可能であると考えられた。(著者抄録)

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Language：Japanese   Publisher：(株)医学書院  

＜文献概要＞押さえておきたい必須ポイント! ▼質の高い適切な胸骨圧迫を行い,胸骨圧迫の中断を最小限とすることが再強調された.▼心拍再開後で昏睡状態が持続する場合は,発生場所や初期波形にかかわらず体温管理療法を行うことが推奨された.▼ファーストエイドの章が新設された.

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Language：Japanese   Publisher：(公社)日本薬学会  

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Language：English   Publishing type：Research paper (scientific journal)  

BACKGROUND: The Osborn wave (OW) is often observed in hypothermic patients; however, whether OW in hypothermic patients is related to the development of fatal ventricular arrhythmia, including ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT), remains undetermined. This study aimed to estimate the association between OW and the incidence of fatal ventricular arrhythmias.Methods and Results: This retrospective study used the Japanese Accidental Hypothermia Network registry database and included 572 hypothermic patients. Patients were divided into the OW group (those with OW) and non-OW group (those without OW). The relationship between the development of fatal arrhythmias and presence of OW was assessed using the chi-squared test. All patients who developed VF/VT (n=10) had OW on electrocardiogram upon hospital arrival. The presence of OW had a sensitivity of 100%, specificity of 47.8%, positive predictive value of 4.0%, and negative predictive value of 100% for VF/VT development. The in-hospital mortality rate was 22.3% in the OW group and 21.2% in the non-OW group (P=0.781). CONCLUSIONS: OW was observed in all hypothermic patients with VF/VT. The occurrence of ventricular arrhythmias is highly unlikely in the absence of OW on the electrocardiogram. Although the presence of OW might be used to predict these fatal arrhythmias in hypothermic patients, there was no association between the presence of OW and in-hospital mortality.

DOI： 10.1253/circj.CJ-19-0856

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Language：Japanese   Publisher：(一社)国立医療学会  

社会全体の労働形態の変化にともない、夫婦ともに常勤の就労を行う「共働き医師」が急速に増加している。私たちの救命救急センターも、既婚者のほとんどが共働きである。共働き医師の増加により、医師の性別を問わず、養育や介護など「社会的弱者」の扶養義務と、医師としての責務との両立が可能である環境の整備が望まれている。重要な事項として「医師個人」ではなくむしろ「世帯全体」を支えるという視点があると思われる。たとえば共働き世帯における特徴として、「扶養のためのrush hour」の存在があり、そのため私たちの救命救急センターでは、time keeperを配置する、カンファレンス等がこの時間帯に重複しないように留意する、などの工夫を行っている。一方、「共働き」「非共働き」といった世帯環境による社会的特性は大きく異なり、このことが問題をさらに複雑にしていると考えられる。たとえば、現状の給与体系は画一な勤務条件を前提としているため、勤務内容・拘束時間などによるバリエーションがつけにくく、金銭的な理由により「共働き」「非共働き」といったグループ間での利害対立をおこしかねない状況に陥っていると思われる。同時に、就学児を有する中核医師の「金銭的な問題による離職のリスク」も重大な問題であり、それゆえに、給与体系・勤務体系にいかに柔軟性を持たせるか、が今後の課題ではないかと考えられる。救急医療は、労働集約性が高く、シフト勤務に適していることなどから、時間的な制約の多い共働き世帯にも十分適応できる分野と思われるが、シフト制の維持のための人員の確保や労働集約性の維持、労務管理などが課題と考えられる。(著者抄録)

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Publishing type：Research paper (scientific journal)   Publisher：Wiley  

DOI： 10.1002/ams2.491

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Other Link： https://onlinelibrary.wiley.com/doi/full-xml/10.1002/ams2.491

Language：English   Publishing type：Research paper (scientific journal)  

OBJECTIVE: Although a few studies have reported the efficacy of ultrasound-guided peripherally inserted central catheter placement for pediatric patients, the procedure still is challenging. Ultrasound-guided dynamic needle tip positioning technique is useful for vascular catheterization. There have been no reports on using dynamic needle tip positioning for peripherally inserted central catheter placement. The authors assessed the rate of successful peripherally inserted central catheter placement with dynamic needle tip positioning. DESIGN: Case series. SETTING: Single tertiary institution. PARTICIPANTS: Forty patients <5 years old who were admitted to the pediatric intensive care unit after cardiac surgeries and required peripherally inserted central catheter placement. INTERVENTIONS: Peripherally inserted central catheter placement was performed under ultrasound guidance with dynamic needle tip positioning. The authors recorded the first attempt and overall success rates of peripherally inserted central catheter and outer cannula placement, time needed for outer cannula and peripherally inserted central catheter placement, and number of attempts. MEASUREMENTS AND MAIN RESULTS: The first attempt and overall success rates of peripherally inserted central catheter placement were 85% (n = 34) and 97.5% (n = 39), respectively. The first attempt and overall success rates of outer cannula placement were 87.5% (n = 35) and 100% (n = 40), respectively. Time needed for outer cannula placement was 59.5 (interquartile range 40.5-80.5) seconds and for peripherally inserted central catheter placement was 112.5 (interquartile range 91.5-159.5) seconds. The number of attempts was 1 (interquartile range 1-1 [range 1-5]). CONCLUSIONS: In pediatric patients, ultrasound-guided peripherally inserted central catheter placement using dynamic needle tip positioning attained a high success rate.

DOI： 10.1053/j.jvca.2019.04.029

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：SPRINGER  

Purpose The development of new-onset atrial fibrillation (AF) in critically ill patients may be associated with poor outcomes. However, it is unknown whether sustained new-onset AF contributes to worse outcome. The aim of this study was to assess whether sustained new-onset AF is associated with stroke and death and to look for a possible dose-response relationship between AF duration and death. Methods In a prospective cohort study conducted in 32 intensive care units in Japan from 2017 to 2018, we enrolled adult patients with new-onset AF. We compared patients with AF duration longer than 48 h with those with AF duration shorter than 48 h. To assess a dose-response relationship between AF duration and hospital mortality, we conducted landmark analysis and time-dependent Cox regression analysis. Results Among a total of 423 new-onset AF patients, hospital mortality was 25%, and the incidence of in-hospital stroke was 4.6%. AF duration longer than 48 h was not independently associated with hospital mortality (adjusted odds ratio: 1.52; 95% Confidence Interval: 0.87-2.64). The incidence of in-hospital stroke was 7.6% in patients with AF duration longer than 48 h and 3.8% in those with AF duration shorter than 48 h (p = 0.154). When analyzing time more continuously, we observed a time-dependent association between AF duration and hospital mortality (p = 0.005 by landmark analysis and p = 0.019 by Cox analysis). Conclusions Sustained new-onset AF was time-dependently associated with hospital mortality in ICU patients, albeit with some uncertainty since AF duration longer than 48 h was not independently associated with in-hospital death or stroke.

DOI： 10.1007/s00134-019-05822-8

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Authorship：Last author   Language：English   Publishing type：Research paper (scientific journal)   Publisher：Wiley  

Aim: To assess the feasibility and predictive ability of regional cerebral oxygen saturation monitoring during cardiopulmonary resuscitation by emergency medical technicians.Methods: This prospective observational study included 33 cardiac arrest patients who received cardiopulmonary resuscitation in a prehospital setting. Patients were connected to a near-infrared spectrometer through two disposable probes immediately after entering the ambulance. The monitor, which showed regional cerebral oxygen saturation readings, was obscured by covering it with a sheet of paper. Regional cerebral oxygen saturation was measured continuously until hospital arrival. Outcome variables included the prehospital return of spontaneous circulation, survival to hospital admission, and survival at 90 days.Results: For patients who survived >90 days after hospital admission (n = 2), the mean regional cerebral oxygen saturation values upon ambulance and hospital arrival were 24% and 60%, respectively; for patients who did not survive (n = 31), the mean regional cerebral oxygen saturation values were 15% and 17%, respectively. Regional cerebral oxygen saturation values increased to a greater extent between ambulance arrival and hospital arrival in patients who survived >90 days (median, 36%; interquartile range, 32-40%) than in those who did not survive (0; 0-6%; P = 0.07). Additionally, regional cerebral oxygen saturation values were not related to the prehospital return of spontaneous circulation or survival to hospital admission.Conclusion: Regional cerebral oxygen saturation could be monitored during resuscitation by emergency medical technicians, and it can be used during physiological monitor-guided cardiopulmonary resuscitation.

DOI： 10.1002/ams2.528

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Other Link： https://onlinelibrary.wiley.com/doi/full-xml/10.1002/ams2.528

Language：Japanese   Publisher：(一社)日本災害医学会  

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Language：Japanese   Publisher：(一社)日本災害医学会  

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Language：Japanese   Publisher：(一社)日本呼吸療法医学会  

気道狭窄を伴う甲状腺腫の手術を予定されている70歳女性が、湿性咳嗽と呼吸困難のために救急外来に搬送された。CT上気道狭窄の進行を認め、緊急気道確保のために麻酔科医と頭頸部外科医に応援を要請したが、応援医の到着前に低酸素状態から心停止となった。心肺蘇生を行い、自己心拍が再開した。気道はマスク換気で辛うじて開通したが、挿管困難が予想された。体外式膜型人工肺(extracorporeal membrane oxygenation:ECMO)スタンバイ下に緊急気管切開術を施行したが有効な気道確保に至らず、甲状腺腫減量術を追加して気道確保に成功し、救命しえた。英国Difficult Airway Society(DAS)ガイドライン上では、マスク換気・気管挿管・声門上器具による換気不良および酸素化不良の際には、外科的気道確保を遅滞なく施行することが推奨されているが、巨大甲状腺腫の場合は、外科的気道確保も困難になる場合がある。そのため、酸素化維持のためのECMOの導入も常に念頭に置きながら適切な気道確保法を選択する必要がある。(著者抄録)

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OBJECTIVE: The authors compared the occurrence of posterior wall puncture using the short-axis out-of-plane and long-axis in-plane approaches with that using the combined short-axis-and-long-axis approach that the authors previously showed to be effective in observational and manikin studies. DESIGN: Randomized controlled study. SETTING: Single tertiary institution. PARTICIPANTS: One hundred twenty patients who underwent cardiac or vascular surgery under general anesthesia. INTERVENTIONS: The patients were divided randomly into combined short-axis-and-long-axis (n = 40), short-axis out-of-plane (SA-OOP) (n = 40), and long-axis in-plane (LA-IP) (n = 40) groups and received ultrasound-guided central venous catheterization at the right internal jugular vein. MEASUREMENTS AND MAIN RESULTS: Successful guidewire insertion without posterior wall puncture was performed in 40 patients (100%) in the combined short-axis-and-long-axis approach group, 28 (70%) in the short-axis out-of-plane approach group, and 38 (95%) in the LA-IP approach group (combined short-axis-and-long-axis v SA-OOP, p = 0.0002 [relative risk = 1.43; 95% CI: 1.17-1.75]; combined short-axis-and-long-axis v LA-IP, p = 0.49 [relative risk = 1.05; 95% CI: 0.98-1.13]). Procedure durations were 28.5 (24.1-36.4) seconds in the combined short-axis-and-long-axis group, 31.7 (24.4-40.6) seconds in the SA-OOP group, and 24.3 (20.8-32.1) seconds in the long-axis in-plane group (combined short-axis-and-long-axis v SA-OOP, p = 0.53; combined short-axis-and-long-axis v LA-IP, p = 0.044). CONCLUSION: The combined short-axis-and-long-axis approach for ultrasound-guided central venous catheterization had a lower posterior wall puncture rate than the SA-OOP approach, but there was no significant difference with the long-axis in-plane approach.

DOI： 10.1053/j.jvca.2019.03.051

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Language：Japanese   Publisher：(一社)日本呼吸療法医学会  

気道狭窄を伴う甲状腺腫の手術を予定されている70歳女性が、湿性咳嗽と呼吸困難のために救急外来に搬送された。CT上気道狭窄の進行を認め、緊急気道確保のために麻酔科医と頭頸部外科医に応援を要請したが、応援医の到着前に低酸素状態から心停止となった。心肺蘇生を行い、自己心拍が再開した。気道はマスク換気で辛うじて開通したが、挿管困難が予想された。体外式膜型人工肺(extracorporeal membrane oxygenation:ECMO)スタンバイ下に緊急気管切開術を施行したが有効な気道確保に至らず、甲状腺腫減量術を追加して気道確保に成功し、救命しえた。英国Difficult Airway Society(DAS)ガイドライン上では、マスク換気・気管挿管・声門上器具による換気不良および酸素化不良の際には、外科的気道確保を遅滞なく施行することが推奨されているが、巨大甲状腺腫の場合は、外科的気道確保も困難になる場合がある。そのため、酸素化維持のためのECMOの導入も常に念頭に置きながら適切な気道確保法を選択する必要がある。(著者抄録)

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OBJECTIVES: This study evaluated whether the dynamic needle tip positioning technique increased the success rate of ultrasound-guided peripheral venous catheterization in pediatric patients with a small-diameter vein compared with the static ultrasound-guided technique. DESIGN: Randomized controlled study. SETTING: Single institution, Osaka Women's and Children's Hospital. PATIENTS: The study population included 60 pediatric patients less than 2 years old who required peripheral venous catheterization in the PICU. INTERVENTIONS: Patients were randomly divided into the dynamic needle tip positioning (n = 30) or static group (n = 30). Each group received ultrasound-guided peripheral venous catheterization with or without dynamic needle tip positioning, respectively. The Fisher exact test, Kaplan-Meier curve plots, log-rank tests, and Mann-Whitney U test were used in the statistical analysis. MEASUREMENTS AND MAIN RESULTS: The first-attempt success rate was higher in the dynamic needle tip positioning group than in the static group (86.7% vs 60%; p = 0.039; relative risk = 1.44; 95% CI, 1.05-2.0). The overall success rate within 10 minutes was higher in the dynamic needle tip positioning group than in the static group (90% vs 63.3%; p = 0.03; relative risk = 1.42; 95% CI, 1.06-1.91). Significantly fewer attempts were made in the dynamic needle tip positioning group than in the static group (median [interquartile range, range] = 1 [1-1, 1-2] vs 1 [1-2, 1-3]; p = 0.013]). The median (interquartile range) catheterization times were 51.5 seconds (43-63 s) and 71.5 seconds (45-600 s) in the dynamic needle tip positioning and static groups, respectively (p = 0.01). CONCLUSIONS: Dynamic needle tip positioning increased the first-attempt and overall success rates of ultrasound-guided peripheral venous catheterization in pediatric patients less than 2 years old.

DOI： 10.1097/PCC.0000000000002034

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Language：Japanese   Publisher：(株)羊土社  

＜薬の使い方のポイント・注意点＞・頻脈性不整脈は「異常パルスのスピード」で分類し、そのスピードと異常パルスの発生場所から心房頻拍や上室性頻拍を定義する・頻脈性の発生機序は3つ:リエントリー、異常自動能、トリガードアクティビティ・抗不整脈薬はイオンチャネルとの関係で覚える(著者抄録)

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OBJECTIVE: Arterial catheterization for infants and small children is technically challenging. This study evaluated whether the dynamic needle tip positioning (DNTP) technique improved the success rate of ultrasound-guided radial artery catheterization in patients with a radial artery depth ≥4 mm compared with the conventional ultrasound-guided technique. DESIGN: Randomized controlled study. SETTING: Single institution, Osaka Women's and Children's Hospital. PARTICIPANTS: Patients (n = 40; age <3 years) with artery depth ≥4 mm. INTERVENTIONS: Patients were divided randomly into 2 groups. The DNTP group received ultrasound-guided radial artery catheterization with DNTP; the conventional group received catheterization without DNTP. MEASUREMENTS AND MAIN RESULTS: First-attempt success rates were 85% and 50% in the DNTP and conventional groups, respectively (p = 0.018; relative risk = 1.7; 95% CI: 1.06-2.73). Overall success rates within 10 minutes were 95% and 60% in the DNTP and conventional groups, respectively (p = 0.008; relative risk = 1.58; 95% CI: 1.09-2.3). Posterior wall puncture rates were 5% and 50% in the DNTP and conventional groups, respectively (p = 0.0014; relative risk = 0.1; 95% CI: 0.014-0.71). Significantly fewer attempts were made in the DNTP group (median = 1 v 1.5; p = 0.01). The median catheterization times were 38 seconds (34-55.5) and 149 seconds (49.5-600) in the DNTP and conventional groups, respectively (p = 0.0003). CONCLUSION: Dynamic needle tip positioning improved first-attempt and overall success rates of ultrasound-guided radial artery catheterization in pediatric patients with a radial artery depth ≥4 mm.

DOI： 10.1053/j.jvca.2018.12.002

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OBJECTIVE: Visualizing the needle tip using the short-axis out-of-plane (SA-OOP) ultrasound-guided central venous catheterization approach is difficult and results in posterior wall puncture (PWP). To improve needle tip visualization in the long-axis view, combining the SA-OOP and the long-axis in-plane approaches has been suggested. The authors, who previously reported on the utility of this technique using a manikin model, examined the feasibility of this novel method (referred to as the combined short-axis and long-axis [CSLA] approach) and compared the CSLA approach with the SA-OOP approach in humans for the present study. DESIGN: Prospective observational study. SETTING: Single institution, Rakuwakai Otowa Hospital. PARTICIPANTS: Patients undergoing cardiac or vascular surgeries. INTERVENTIONS: The CSLA and SA-OOP approaches were used for ultrasound-guided right jugular venous puncture. The puncturing procedures were determined arbitrarily preoperatively without consideration of the patient's neck anatomy and were based on the operator's preference without randomization. MEASUREMENTS AND MAIN RESULTS: The study comprised 100 patients. Successful guidewire insertion without PWP was performed in 48 patients (96%) in the CSLA approach group and 33 (66%) in the SA-OOP approach group; the rate was significantly higher in the CSLA approach group (p = 0.0001). The procedural durations were 27.5 (range 17.0-122.0) seconds in the CSLA approach group and 25.0 (range 15.0-158.0) seconds in the SA-OOP approach group (p = 0.19). CONCLUSIONS: This study showed that the CSLA approach to ultrasound-guided central venous catheterization might help prevent PWP.

DOI： 10.1053/j.jvca.2018.08.005

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Language：Japanese   Publisher：(一社)日本臨床救急医学会  

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Language：Japanese   Publisher：日本臨床知識学会  

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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Language：Japanese   Publisher：(一社)日本腹部救急医学会  

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Language：Japanese   Publisher：(一社)日本腹部救急医学会  

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In the treatment of severe infections in critical care settings, the selection of initial empirical antimicrobials affects patient outcomes and antimicrobial overuse. The application of a comprehensive treatment guidance might facilitate appropriate antimicrobial selection. Therefore, we developed such an antimicrobial guidance for use in emergency and critical care center and verified its efficacy. We retrospectively analyzed the data of 195 patients (96 patients before guidance introduction [control group] and 99 after guidance introduction [intervention group]) who were ultimately diagnosed with bacteremia to assess the effects of the guidance (the intervention). The appropriateness of the empirical therapy was greater in the intervention than in the control group (96% vs. 90%, respectively; P = 0.10). Moreover, the rate of carbapenem use was significantly lower in the intervention than in the control group (6% vs. 20%, respectively; P < 0.01). The control and intervention groups had similar 28-day survival rates of 81% and 85%, respectively; P = 0.50). These findings imply that introducing an empirical antimicrobial guidance in emergency outpatient and emergency intensive care settings could improve antimicrobial stewardship without affecting patient mortality. The data of this study can be used as a reference for establishing the study design of a large-scale prospective trial, aimed at verifying guidance efficacy.

DOI： 10.1016/j.jiac.2018.08.014

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Language：Japanese   Publisher：(株)医学書院  

＜文献概要＞Point ・電気的除細動とは心臓に電流を流し,頻拍性不整脈を洞調律に復帰させる処置である.・ペーシングは症候性徐脈に対して,電気的に心筋を刺激し心拍数を増加させる処置である.・ペーシングには経皮ペーシングと経静脈ペーシングがある.

DOI： 10.11477/mf.1438200193

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DOI： 10.1111/ggi.13524

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：Japanese   Publisher：(一社)日本救急医学会  

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BACKGROUND: Early dumping syndrome characterized by palpitation, dizziness, cold sweat, feebleness, and abdominal symptoms, occurs within 30 minutes after meals in patients who have undergone gastrectomy. This case report describes the case of a patient who presented with severe distributive shock due to early dumping syndrome; he recovered within a few hours after massive fluid infusion and vasopressor administration. CASE PRESENTATION: Our patient was a 68-year-old Japanese man who underwent total gastrectomy for gastric cancer and was diagnosed as having late dumping syndrome. On admission, he developed severe shock and was treated with massive fluid administration. Based on the history of the present illness, past medical history, normal findings of blood chemistry test, transient course, and Sigtad score, which helps diagnose dumping syndrome, early dumping syndrome was considered the cause of severe distributive shock. CONCLUSIONS: Early dumping syndrome can cause severe shock requiring massive fluid infusion and vasopressor administration. It should be considered a cause of severe distributive shock in patients who have undergone gastrectomy.

DOI： 10.1186/s13256-018-1800-2

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：Springer New York LLC  

Intra-abdominal injury is an uncommon complication of chest tube insertion. A 66-year-old man had empyema and underwent chest tube insertion for drainage. Massive hemorrhage occurred
the postprocedural radiograph showed the malpositioned chest tube in the mediastinum. Computed tomography scan showed that the tube’s tip penetrated through the liver capsule and passed through the hepatic vein to the right ventricle. Hepatic tract embolization with coiling was performed during chest tube removal under a controlled condition with the hepatic tract occluded by a balloon catheter. The balloon catheter was placed from the right jugular vein using the pull-through technique, establishing a through-and-through guidewire. This is the first report of successful removal of a chest tube malpositioned in the hepatic vein by balloon-assisted hepatic tract embolization without complication.

DOI： 10.1007/s00270-018-1974-4

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：Elsevier Ireland Ltd  

Aim: Target temperature management (TTM) is used in comatose post-cardiac arrest patients, but the recommended temperature range is wide. This study aimed to assess the effectiveness of TTM at 32–34 °C while considering the degree of cerebral injury and cerebral circulation, as assessed by regional cerebral oxygen saturation (rSO2). Methods: This is a secondary analysis of prospectively collected registry data from comatose patients who were transferred to 15 hospitals in Japan after out-of-hospital cardiac arrest (OHCA) from 2011 to 2013. The primary outcome was all-cause mortality at 90 days after OHCA, and the secondary outcome was favorable neurological outcomes as evaluated according to the Cerebral Performance Category. We monitored rSO2 noninvasively with near-infrared spectroscopy, which could assess cerebral perfusion and the balance of oxygen delivery and uptake. Results: We stratified 431 study patients into three groups according to rSO2 on hospital arrival: rSO2 ≤40% (n = 296), rSO2 41–60% (n = 67), and rSO2 ≥61% (n = 68). Propensity score analysis revealed that TTM at 32–34 °C decreased all-cause mortality in patients with rSO2 41–60% (average treatment effect on treated [ATT] by propensity score matching [PSM] −0.51, 95%CI −0.70 to −0.33
ATT by inverse probability of treatment weighting [IPW] −0.52, 95%CI −0.71 to −0.34), and increased favorable neurological outcomes in patients with rSO2 41–60% (ATT by PSM 0.50, 95%CI 0.32–0.68
ATT by IPW 0.52, 95%CI 0.35–0.69). Conclusion: TTM at 32–34 °C effectively decreased all-cause mortality in comatose OHCA patients with rSO2 41–60% on hospital arrival in Japan.

DOI： 10.1016/j.resuscitation.2018.02.007

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：Elsevier Inc.  

This data article contains raw data and supplementary analyzed data regarding to the article entitled “Effect of target temperature management at 32–34 °C in cardiac arrest patients considering assessment by regional cerebral oxygen saturation: A multicenter retrospective cohort study”. We examined the effectiveness of target temperature management (TTM) at 32–34 °C considering degrees of patients’ cerebral injury and cerebral circulation assessed by regional cerebral oxygen saturation (rSO2). The research is a secondary analysis of prospectively collected registry, in which comatose patients who were transferred to 15 hospitals in Japan after out-of-hospital cardiac arrest (OHCA), and we included 431 study patients. Propensity score analysis revealed that TTM at 32–34 °C decreased all-cause mortality in patients with rSO2 41–60%, and increased favorable neurological outcomes in patients with rSO2 41–60% in the original research article. With regard to the balance of covariates of propensity-score matching (PSM) and inverse-probability weighting (IPW) analyses, some covariates were not well balanced after the analyses between groups. The overlap plots indicate the overlap of densities of the propensity scores are low in group rSO2 41–60% and group rSO2 ≥ 61%. When patients were limited to those who achieved return of spontaneous circulation (ROSC) until/on hospitals arrival, TTM still tended to decrease all-cause mortality and increase favorable outcomes in group rSO2 41–60%.

DOI： 10.1016/j.dib.2018.02.050

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Language：Japanese   Publisher：(一社)日本臨床救急医学会  

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：BioMed Central Ltd.  

Background: Although median sternotomy is standard during cardiac surgery, the procedure is associated with a risk of injury to mediastinal organs. Here, we discuss two cases of tracheal injury following median sternotomy during cardiac surgery. Case presentation: Ventilation failure occurred in a 78-year-old Japanese man and a 71-year-old Japanese man after median sternotomy, and tracheal injury was identified. The sites of injury were directly repaired and covered with mediastinal fat tissue, following which ventilation was successful. The burn-like deposits observed at the site of tracheal injury and on the removed endotracheal tube support the notion that the injuries in our patients were caused by electrocautery prior to median sternotomy. In one case, short sternotracheal distance may have contributed to tracheal injury during post-sternal manipulation. In both cases, the relative inexperience of both surgeons also supports the suspected cause of injury. Conclusions: Tracheal injury represents a potential complication following median sternotomy, especially when performed by inexperienced surgeons or in cases of short sternotracheal distance. Anesthesiologists should consider this rare yet potentially lethal complication.

DOI： 10.1186/s13256-018-1591-5

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84歳の男性。自転車で走行中に転倒し、頭部を受傷し当院搬送となった。頭部CT(computed tomography)で右前頭葉脳挫傷を認め入院となった。第9病日に痙攣および意識レベル低下を認め、第11病日に低血圧および発熱を来した。第14病日に多尿を認め、同日の血液検査から下垂体前葉機能低下症および中枢性尿崩症と診断した。残余検体を用いて測定した入院時のホルモン値はすべて正常値であった。画像診断上、後方視的に、来院時頭部CTでは下垂体出血は不明瞭であったが、第6病日の頭部CTで明確であった。頭部外傷後亜急性期に下垂体出血により下垂体機能低下症に至ったと考えられ、甲状腺ホルモン、副腎皮質ホルモン、抗利尿ホルモンの補充を開始した。第167病日に他院転院となった。頭部外傷後に下垂体機能低下症を来すことがあるが、その際頭部外傷の後遺症により下垂体機能低下症状が不顕性化する可能性がある。従って、とくに重症頭部外傷例では下垂体機能低下症を疑い、積極的に内分泌学的評価を行うことが重要である。(著者抄録)

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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64歳の女性。めまい、悪心、腹痛を訴え救急車で来院した。来院時造影CT所見にて後腹膜に巨大な血腫を認め、後上膵十二指腸動脈瘤破裂による活動性の出血が疑われた。緊急腹部血管造影をし、同部位に対しコイル塞栓術を行い止血に成功した。術翌日から経口摂取を開始したが嘔気、嘔吐症状が継続し食事量の増量に難渋した。術後のCTや上部消化管内視鏡の所見で十二指腸が圧排され狭小化しており、後腹膜血腫による十二指腸閉塞症状との診断に至った。ある程度、食事量が確保できた時点で転院となり、転院先の病院の腹部エコーと当院のCTの所見で正中弓状靱帯症候群と診断された。その後、正中弓状靱帯症候群に対し侵襲的治療を行わず経過観察を行っている症例を経験したので報告する。(著者抄録)

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DOI： 10.1371/journal.pone.0202111

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© 2017 Takeshita et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Objectives: Visualizing the needle tip using the short-axis (SA) ultrasound-guided central venous catheterization approach can be challenging. It has been suggested to start the process with the SA approach and then switch to the long-axis (LA); however, to our knowledge, this combination has not been evaluated. We compared the combined short- and long-axis (SLA) approach with the SA approach in a manikin study. Methods: We performed a prospective randomized controlled cross-over study in an urban emergency department and intensive care unit. Resident physicians in post-graduate years 1–2 performed a simulated ultrasound-guided internal jugular vein puncture using the SA and SLA approaches on manikins. Twenty resident physicians were randomly assigned to two equal groups: (1) one group performed punctures using the SA approach followed by SLA; and (2) the other performed the same procedures in the opposite order. We compared the success rate and procedure duration for the two approaches. Procedural success was defined as insertion of the guide-wire into the vein while visualizing the needle tip at the time of anterior wall puncture, without penetrating the posterior wall. Results: Six resident physicians (30%) performed both approaches successfully, while 12 (60%) performed the SLA approach, but not the SA, successfully. Those who performed the SA approach successfully also succeeded with the SLA approach. Two resident physicians (10%) failed to perform both approaches. The SLA approach had a significantly higher success rate than the SA approach (P < 0.001). The median (interquartile range) procedure duration was 59.5 [46.0–88.5] seconds and 45.0 [37.5–84.0] seconds for the SLA and SA approaches, respectively. The difference of the duration between the two procedures was 15.5 [0–28.5] seconds. There was no significant difference in duration between the two approaches (P = 0.12). Conclusions: Using the SLA approach significantly improved the success rate of internal jugular vein puncture performed by novice physicians on a manikin model, without increasing procedural duration. Further clinical trials are warranted to confirm the procedure’s utility in actual patients. Trial registration: UMIN Clinical Trials Registry UMIN000026199.

DOI： 10.1371/journal.pone.0189258

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© 2017 Yamanaka et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Background Long durational chest compression (CC) deteriorates cardiopulmonary resuscitation (CPR) quality. The appropriate number of CC personnel for minimizing rescuer’s fatigue is mostly unknown. Objective We determined the optimal number of personnel needed for 30-min CPR in a rescue-team. Methods We conducted a randomized, manikin trial on healthcare providers. We divided them into Groups A to D according to the assigned different rest period to each group between the 2 min CCs. Groups A, B, C, and D performed CCs at 2, 4, 6, and 8 min rest period. All participants performed CCs for 30 min with a different rest period; participants allocated to Groups A, B, C, and D performed, eight, five, four, and three cycles, respectively. We compared a quality change of CCs among these groups to investigate how the assigned rest period affects the maintenance of CC quality during the 30-min CPR. Results This study involved 143 participants (male 58 [41%]; mean age, 24 years,) for the evaluation. As participants had less rest periods, the quality of their CCs such as sufficient depth ratio declined over 30-min CPR. A significant decrease in the sufficient CC depth ratio was observed in the second to the last cycle as compared to the first cycle. (median changes; A: −4%, B: −3%, C: 0%, and D: 0% p < 0.01). Conclusions A 6 min rest period after 2 min CC is vital in order to sustain the quality of CC during a 30-min CPR cycle. At least four personnel may be needed to reduce rescuer’s fatigue for a 30-min CPR cycle when the team consists of men and women.

DOI： 10.1371/journal.pone.0189412

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Language：Japanese   Publisher：(株)羊土社  

(1)頻脈性不整脈には先天的な副伝導が原因のタイプと、心疾患や全身状態の増悪を反映した異常心筋が原因となっているタイプがあり、治療の考え方が全く異なる(2)抗不整脈薬にはチャネル(Na・K・Ca)をブロックする薬剤と、「総合感冒薬」のごとく包括的な作用をもつもの(β遮断薬、アミオダロンなど)がある(3)本稿では、特に頻脈性不整脈に関して薬剤投与を含めた救急・ICUでの診療アルゴリズムを呈示する(著者抄録)

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：SPRINGER JAPAN KK  

© 2017, Japanese Society of Anesthesiologists. The authors report a case involving an elderly patient who experienced repetitive perioperative cardiac arrest caused by laryngomalacia. The patient underwent surgery under general anesthesia; however, 2 h after initial extubation, he experienced cardiopulmonary arrest. Return of spontaneous circulation was achieved by immediate resuscitation. Four hours later, a second extubation was performed without any neurological complications. However, 2 h later, he experienced cardiopulmonary arrest again. Immediately after the third extubation, 12 h after the second cardiopulmonary arrest, fiberoptic laryngoscopy revealed laryngomalacia. His respiratory condition stabilized after emergent tracheostomy. Laryngomalacia should be considered even in adult cases when signs of upper airway obstruction manifest after extubation.

DOI： 10.1007/s00540-017-2373-8

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Language：Japanese   Publisher：(株)医学書院  

＜Point＞ACSの初期対応については迅速な診断および,酸素,アスピリン,硝酸薬およびモルヒネを用いた治療を行う.診断確定のために採血結果を待つことで再灌流療法が遅れてはならない.初期救急医療機関では,緊急PCIを施行できる施設への搬送は受診時から30分以内とする.常に「急変するもの」としての対応が必要である.モニター装着,静脈路確保,蘇生デバイスの準備は速やかに実施されるべきである.ACSの除外は難しく,心電図とバイオマーカーのみでは不完全であり,専門医による心エコーなどの評価を積極的に実施するべきである.地域の実情,特にPCIセンターがあるかどうかにより治療戦略が大きく異なるため,事前に状況を把握しておくことが重要である.(著者抄録)

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Language：Japanese   Publisher：(一社)日本救急医学会  

症例は21歳の男性、バイク乗車中に乗用車と衝突し前医に救急搬送された。CT検査で左肺挫傷、肝損傷、右腎梗塞を認め当院転院搬送となった。当院入院日に血管外漏出を伴う肝損傷に対して血管内塞栓術を施行した。入院第4病日のCT検査で中肝静脈から下大静脈内に不造影領域を認め、静脈血栓症の診断のもとに経静脈持続ヘパリン投与(10,000単位/日)を開始した。以後APTT 47.1〜78.5秒を目標にヘパリンを調整(10,000〜20,000単位/日)したが、第19病日のCT検査で血栓の増大傾向を認めた。血栓除去術の高度侵襲性を考慮し、ヘパリンの増量(30,000〜40,000単位/日)で対処した。APTTはその後89.1秒まで延長し(第20病日)、ワーファリンの経口内服を開始した。第43病日のCT検査で血栓の縮小傾向を確認し、退院となった。本症例は、広範な肝損傷後に稀ではあるが重篤な下大静脈血栓症が発症しうる可能性を考慮することの重要性を示唆している。(著者抄録)

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：Japanese   Publisher：(一社)日本交通科学学会  

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Case: A 52-year-old woman was admitted to our hospital with hypotension after falling from the fifth floor of an apartment building. Contrast-enhanced computed tomography showed liver injury with extravasation of contrast material from the hepatic artery, and extrahepatic portal venous injury with extravasation and pseudoaneurysm. Intra-abdominal hemorrhage was not observed, and bleeding was confined to the retroperitoneal space. Hepatic arteriography showed extravasation, while portal venography showed pseudoaneurysm but no extravasation. After transarterial embolization, the patient's vital signs improved. Non-operative management was selected for the portal venous injury. Outcome: Computed tomography on the 58th hospital day revealed disappearance of the portal venous pseudoaneurysm. The patient was discharged on the 90th hospital day without any complications. Conclusion: This case shows that non-operative management can be selected for portal venous injury when there is no retroperitoneal injury and bleeding is confined to the retroperitoneal space.

DOI： 10.1002/ams2.247

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：BioMed Central Ltd.  

Background: Extracorporeal membrane oxygenation is an established life-saving procedure for severe acute respiratory failure due to various causes. In general, the duration of extracorporeal membrane oxygenation ranges from 1 to 2 weeks, with withdrawal recommended if no improvement is noted. We report a successful case of long-term extracorporeal membrane oxygenation management for respiratory failure due to invasive pulmonary Aspergillus infection. Case presentation: A 64-year-old Asian man with no previous underlying medical conditions was transferred to our hospital for fever and dyspnea. On admission, he presented with bilateral diffuse infiltration shadow on X-ray and chest computed tomography readings, and severe hypoxemia with a partial pressure of oxygen in arterial blood/fraction of inspired oxygen ratio of 55. He was intubated and underwent mechanical ventilation. A bronchial-alveolar lavage was performed prior to administration of antibiotics, and as the bacterial culture was positive for Aspergillus fumigatus, antifungal treatment was then initiated. His respiratory status deteriorated on the 11th admission day, with no improvement on any mechanical ventilator settings. Venous-venous extracorporeal membrane oxygenation was introduced. Extracorporeal membrane oxygenation was used for an extended period of time, with respiratory improvement delayed until the 39th admission day. Extracorporeal membrane oxygenation discontinuation was possible on the 44th day, and he was removed from the ventilator on the 64th day. Conclusions: Long-term extracorporeal membrane oxygenation might be considered if the primary causes of respiratory failure necessitating extracorporeal membrane oxygenation can be expected to be resolved, such as in the case of effective antimicrobial therapy for a definite pathogen. Our case indicates that extracorporeal membrane oxygenation can be used during treatment of respiratory failure due to invasive aspergillosis for the recommended treatment duration of 4 to 8 weeks.

DOI： 10.1186/s13256-017-1381-5

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Language：Japanese   Publisher：国立病院総合医学会  

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DOI： 10.1002/ams2.202

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：CAMBRIDGE UNIV PRESS  

Copyright © Cambridge University Press 2015. Although outbreaks of acute respiratory infection (ARI) at shelters are hypothesized to be associated with shelter crowding, no studies have examined this relationship. We conducted a retrospective study by reviewing medical records of evacuees presenting to one of the 37 clinics at the shelters in Ishinomaki city, Japan, during the 3-week period after the Great Eastern Japan Earthquake and tsunami in 2011. On the basis of a locally weighted scatter-plot smoothing technique, we categorized 37 shelters into crowded (mean space <5·5 m2/per person) and non-crowded (5·5 m2) shelters. Outcomes of interest were the cumulative and daily incidence rate of ARI/10 000 evacuees at each shelter. We found that the crowded shelters had a higher median cumulative incidence rate of ARI [5·4/10 000 person-days, interquartile range (IQR) 0-24·6, P = 0·04] compared to the non-crowded shelters (3·5/10 000 person-days, IQR 0-8·7) using Mann-Whitney U test. Similarly, the crowded shelters had an increased daily incidence rate of ARI of 19·1/10 000 person-days (95% confidence interval 5·9-32·4, P < 0·01) compared to the non-crowded shelters using quasi-least squares method. In sum, shelter crowding was associated with an increased incidence rate of ARI after the natural disaster.

DOI： 10.1017/S0950268815001715

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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Objectives: We determined whether crowding at emergency shelters is associated with a higher incidence of sleep disturbance among disaster evacuees and identified the minimum required personal space at shelters. Design: Retrospective review of medical charts. Setting: 30 shelter-based medical clinics in Ishinomaki, Japan, during the 46 days following the Great Eastern Japan Earthquake and Tsunami in 2011. Participants: Shelter residents who visited eligible clinics. Outcome measures: Based on the result of a locally weighted scatter-plot smoothing technique assessing the relationship between the mean space per evacuee and cumulative incidence of sleep disturbance at the shelter, eligible shelters were classified into crowded and non-crowded shelters. The cumulative incidence per 1000 evacuees was compared between groups, using a Mann-Whitney U test. To assess the association between shelter crowding and the daily incidence of sleep disturbance per 1000 evacuees, quasi-least squares method adjusting for potential confounders was used. Results: The 30 shelters were categorised as crowded (mean space per evacuee <5.0 m2, 9 shelters) or noncrowded (≥5.0 m2, 21 shelters). The study included 9031 patients. Among the eligible patients, 1079 patients (11.9%) were diagnosed with sleep disturbance. Mean space per evacuee during the study period was 3.3 m2 (SD, 0.8 m2) at crowded shelters and 8.6 m2 (SD, 4.3 m2) at non-crowded shelters. The median cumulative incidence of sleep disturbance did not differ between the crowded shelters (2.3/1000 person-days (IQR, 1.6-5.4)) and non-crowded shelters (1.9/1000 person-days (IQR, 1.0-2.8); p=0.20). In contrast, after adjusting for potential confounders, crowded shelters had an increased daily incidence of sleep disturbance (2.6 per 1000 person-days; 95% CI 0.2 to 5.0/1000 person-days, p=0.03) compared to that at non-crowded shelters. Conclusions: Crowding at shelters may exacerbate sleep disruptions in disaster evacuees; therefore, appropriate evacuation space requirements should be considered.

DOI： 10.1136/bmjopen-2015-009711

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：ELSEVIER IRELAND LTD  

© 2015 The Authors. Aim: This study investigated the value of regional cerebral oxygen saturation (rSO2) monitoring upon arrival at the hospital for predicting post-cardiac arrest intervention outcomes. Methods: We enrolled 1195 patients with out-of-hospital cardiac arrest of presumed cardiac cause from the Japan-Prediction of Neurological Outcomes in Patients Post-cardiac Arrest Registry. The primary endpoint was a good neurologic outcome (cerebral performance categories 1 or 2 [CPC1/2]) 90 days post-event. Results: A total of 68 patients (6%) had good neurologic outcomes. We found a mean rSO2 of 21%±13%. A receiver operating characteristic curve analysis indicated an optimal rSO2 cut-off of ≥40% for good neurologic outcomes (area under the curve 0.92, sensitivity 0.81, specificity 0.96). Good neurologic outcomes were observed in 53% (55/103) and 1% (13/1092) of patients with high (≥40%) and low (<40%) rSO2, respectively. Even without return of spontaneous circulation (ROSC) upon arrival at the hospital, 30% (9/30) of patients with high rSO2 had good neurologic outcomes. Furthermore, 16 patients demonstrating ROSC upon arrival at the hospital and low rSO2 had poor neurologic outcomes. Multivariate analyses indicated that high rSO2 was independently associated with good neurologic outcomes (odds ratio=14.07, P<0.001). Patients with high rSO2 showed favourable neurologic prognoses if they had undergone therapeutic hypothermia or coronary angiography (CPC1/2, 69% [54/78]). However, 24% (25/103) of those with high rSO2 did not undergo these procedures and exhibited unfavourable neurologic prognoses (CPC1/2, 4% [1/25]). Conclusion: rSO2 is a good indicator of 90-day neurologic outcomes for post-cardiac arrest intervention patients.

DOI： 10.1016/j.resuscitation.2015.07.049

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© 2015 The Authors. Aim: Our study aimed at filling the fundamental knowledge gap on the characteristics of regional brain oxygen saturation (rSO2) levels in out-of-hospital cardiac arrest (OHCA) patients with or without return of spontaneous circulation (ROSC) upon arrival at the hospital for estimating the quality of cardiopulmonary resuscitation and neurological prognostication in these patients. Methods: We enrolled 1921 OHCA patients from the Japan - Prediction of Neurological Outcomes in Patients Post-cardiac Arrest Registry and measured their rSO2 immediately upon arrival at the hospital by near-infrared spectroscopy using two independent forehead probes (right and left). We also assessed the percentage of patients with a good neurological outcome (defined as cerebral performance categories 1 or 2) 90 days post cardiac arrest. Results: After 90 days, 79 (4%) patients had good neurological outcomes and a median lower rSO2 level of 15% (15-20%). Compared to patients without ROSC upon arrival at the hospital, those with ROSC had significantly higher rSO2 levels (56% [39-65%] vs. 15% [15-17%], respectively; P<0.01), and significantly correlated right- and left-sided regional brain oxygen saturation levels (R=0.94 vs. 0.66, respectively). In both groups, the percentage of patients with a good 90-day neurological outcome increased significantly in proportion to their rSO2 levels upon arrival at the hospital (P<0.01). Conclusion: Our data indicate that measuring rSO2 levels might be effective for both monitoring the quality of resuscitation and neurological prognostication in patients with OHCA.

DOI： 10.1016/j.resuscitation.2015.07.013

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DOI： 10.1016/j.resuscitation.2015.05.016

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：Japanese   Publisher：日本脳死・脳蘇生学会  

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Language：Japanese   Publisher：(株)ニュー・サイエンス社  

NIRS(近赤外線分光法)で測定するrSO2(組織酸素飽和度)は、心臓血管外科手術中の脳血流管理のスタンダードなパラメータである。近年その他の領域での使用が拡大しているが、救急領域においては、院外心肺停止患者に対する研究がいくつか発表され、「蘇生後の集学的治療への適応」のトリアージや、「心肺蘇生の質」をモニタリングするフィードバックデバイスとして注目されている。(著者抄録)

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© 2014 Elsevier Inc. Background The prevalence of anisakiasis is rare in the United States and Europe compared with that in Japan, with few reports of its presentation in the emergency department (ED). This study describes the clinical, hematologic, computed tomographic (CT) characteristics, and treatment in gastric and small intestinal anisakiasis patients in the ED.Methods We retrospectively reviewed the data of 83 consecutive anisakiasis presentations in our ED between 2003 and 2012. Gastric anisakiasis was endoscopically diagnosed with the Anisakis polypide. Small intestinal anisakiasis was diagnosed based on both hematologic (Anisakis antibody) and CT findings.Results Of the 83 cases, 39 had gastric anisakiasis and 44 had small intestinal anisakiasis based on our diagnostic criteria. Although all patients had abdominal pain, the gastric anisakiasis group developed symptoms significantly earlier (peaking within 6 hours) than the small intestinal anisakiasis group (peaking within 48 hours), and fewer patients with gastric anisakiasis needed admission therapy (5% vs 57%, P <.01). All patients in the gastric and 40 (91%) in the small intestinal anisakiasis group had a history of raw seafood ingestion. Computed tomographic findings revealed edematous wall thickening in all patients, and ascites and phlegmon of the mesenteric fat were more frequently observed in the small intestinal anisakiasis group.Conclusions In the ED, early and accurate diagnosis of anisakiasis is important to treat and explain to the patient, and diagnosis can be facilitated by a history of raw seafood ingestion, evaluation of the time-to-symptom development, and classic CT findings.

DOI： 10.1016/j.ajem.2014.09.010

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Other Link： http://orcid.org/0000-0003-3676-0135

Language：English   Publishing type：Research paper (scientific journal)   Publisher：PUBLIC LIBRARY SCIENCE  

© 2014 Kawano et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Background: Although increasing staff numbers during shifts when emergency department (ED) crowding is severe can help meet patient demand, it remains unclear how different types of added staff, particularly junior residents, may affect crowding. Methods: To identify associations between types of staff and ED crowding, we conducted a cross-sectional, single-center study in the ED of a large, teaching hospital in Japan between January and December 2012. Patients who visited the ED during the study period were enrolled. We excluded (1) patients previously scheduled to visit the ED, and (2) neonates transferred from other hospitals. During the study period, 27,970 patients were enrolled. Types of staff analyzed were junior (first and second year) residents, senior (third to fifth year) residents, attending (board-certified) physicians, and nurses. A generalized linear model was applied to length of ED stay for all patients as well as admitted and discharged patients to quantify an association with the additional staff. Results: In the model, addition of one attending physician or senior resident was associated with decreased length of ED stay for total patients by 3.88 or 1.64 minutes, respectively (95% CI, 2.20-5.56 and 0.81-2.48 minutes); while additional nursing staff had no association. Surprisingly, however, one additional junior resident was associated with prolonged length of ED stay for total patients by 0.97 minutes (95% CI 0.37-1.57 minutes) and for discharged patients by 1.01 minutes (95% CI 0.45-1.59 minutes). Conclusion: Staffing adjustments aimed at alleviating ED crowding should focus on adding more senior staff during peakvolume shifts.

DOI： 10.1371/journal.pone.0110801

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Other Link： http://orcid.org/0000-0003-3676-0135

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© 2014 Kawano et al. Study Objective: We compared the effects of execution of diagnostic tests in the emergency department (ED) and other common factors on the length of ED stay to identify those with the greatest impacts on ED crowding. Methods: Between February 2010 and January 2012, we conducted a cross-sectional, single-center study in the ED of a large, urban, teaching hospital in Japan. Patients who visited the ED during the study period were enrolled. We excluded (1) patients scheduled for admission or pharmaceutical prescription, and (2) neonates requiring intensive care transferred from other hospitals. Multivariate linear regression was performed on log-transformed length of ED stay in admitted and discharged patients to compare influence of diagnostic tests and other common predictors. To quantify the range of change in length of ED stay given a unit change of the predictor, a generalized linear model was used for each group. Results: During the study period, 55,285 patients were enrolled. In discharged patients, laboratory blood tests had the highest standardized β coefficient (0.44) among common predictors, and increased length of ED stay by 72.5 minutes (95% CI, 72.8-76.1 minutes). In admitted patients, computed tomography (CT) had the highest standardized β coefficient (0.17), and increased length of ED stay by 32.7 minutes (95% CI, 40.0-49.9 minutes). Although other common input and output factors were significant contributors, they had smaller standardized β coefficients in both groups. Conclusions: Execution of laboratory blood tests and CT had a stronger influence on length of ED stay than other common input and output factors.

DOI： 10.1371/journal.pone.0108447

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DOI： 10.1016/j.resuscitation.2014.05.014

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：EXCERPTA MEDICA INC-ELSEVIER SCIENCE INC  

There is little information on the effect of contrast-induced nephropathy (CIN) on long-term mortality after percutaneous coronary intervention in patients with or without chronic kidney disease (CKD). Of 4,371 patients who had paired serum creatinine (SCr) measurements before and after percutaneous coronary intervention and were discharged alive in the Coronary REvascularization Demonstrating Outcome Study in Kyoto registry, the incidence of CIN (an increase in SCr of ≥0.5 mg/dl from the baseline) was 5% in our study cohort. The rate of CIN in patients with CKD was 11%, although it was 2% without CKD (p <0.0001). During a median follow-up of 42.3 months after discharge, 374 patients (8.6%) died. After adjustment for prespecified confounders, CIN was significantly correlated with long-term mortality in the entire cohort (hazard ratio [HR] 2.26, 95% confidence interval [CI] 1.62 to 2.29, p <0.0001) and in patients with CKD (HR 2.62, 95% CI 1.91 to 3.57, p <0.0001) but not in patients without CKD (HR 1.23, 95% CI 0.47 to 2.62, p = 0.6). Sensitivity analyses confirmed these results using the criteria defined as elevations of the SCr by ≥25% and 0.3 mg/dl from the baseline, respectively. In conclusion, CIN was significantly correlated with long-term mortality in patients with CKD but not in those without CKD. © 2014 Elsevier Inc. All rights reserved.

DOI： 10.1016/j.amjcard.2014.05.009

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：ELSEVIER IRELAND LTD  

Aim: To investigate the association between regional brain oxygen saturation (rSO2) at hospital arrival and neurological outcomes at 90 days in patients with out-of-hospital cardiac arrest (OHCA). Methods: The Japan-Prediction of neurological Outcomes in patients post cardiac arrest (J-POP) registry is a prospective, multicenter, cohort study to test whether rSO2 predicts neurological outcomes after OHCA. We measured rSO2 in OHCA patients immediately after hospital arrival using a near-infrared spectrometer placed on the forehead with non-blinded fashion. The primary endpoint was "neurological outcomes" at 90 days after OHCA. Results: EMS providers are not permitted to terminate CPR in the field in Japan, and so most patients with OHCA who are treated by EMS personnel are transported to emergency hospitals. Among 1017 OHCA patients, 672 patients including 52 comatose patients with pulses detectable (8%) and 620 cardiac arrest patients (92%) at hospital arrival were enrolled prospectively and consecutively. Twenty-nine patients with good neurological outcome had a significantly higher value of rSO2 at hospital arrival than 643 patients with poor neurological outcome (mean [±SD] 55.6±20.8% vs. 19.7±11.0%, p<0.001). Receiver operating curve analysis indicated an optimal rSO2 cutoff point of >42% for predicting good neurological outcome, with sensitivity 0.79 (95% confidence interval [CI], 0.60-0.92), specificity 0.95 (95% CI, 0.93-0.96), positive predictive value, 0.41 (95% CI, 0.28-0.55), negative predictive value, 0.99 (95% CI, 0.98-1.00), and area under the curve 0.90 (95% CI, 0.88-0.92). Conclusion: The rSO2 at hospital arrival can predict good neurological outcome at 90 days after OHCA. © 2014 The Authors.

DOI： 10.1016/j.resuscitation.2014.02.012

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Objective: Although it has been suggested that the increase in older population contributes to overcrowding in emergency departments (EDs), there are limited data defining this relationship. This study examines whether patients' mean age per day affects length of ED stay. Methods: This cross-sectional analysis evaluated how patient age affects length of ED stay. The study was conducted at an ED attached to Fujisawa City Hospital, Japan, between 1 November 2009 and 31 October 2010. Patients scheduled to visit for childbirth and patients under age 15 were excluded. The primary outcome measure was the relationship between length of ED stay and patient age. The secondary outcome was the relationship between patient age and patient dispositions indicated by column chart and 100% staked column chart. Results: Over the study period, there were 17 744 patient visits to the ED. The study included 15 840 (89.3%) patients. The mean (SD) age of these patients was 56.9 (21.5) years. In single and multiple linear regression analyses, mean patient age per day was an important factor in length of ED stay for the total number of patients visiting the ED (single linear regression analysis: regression coefficient=1.59 min/year, r2=0.005, p<0.001; multiple linear regression analysis: regression coefficient=0.72 min/year, r2=0.24, p<0.001). The ratio of admitted and transferred patients increased with patient age. Conclusion: The increase in older patients visiting the ED has a direct significant negative effect on overcrowding in the ED.

DOI： 10.1136/emermed-2012-202050

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Introduction: Little is known about oxyhemoglobin (oxy-Hb) levels in the cerebral tissue during the development of anoxic and ischemic brain injury. We hypothesized that the estimated cerebral oxy-Hb level, a product of Hb and regional cerebral oxygen saturation (rSO(2)), determined at hospital arrival may reflect the level of neuroprotection in patients with post-cardiac arrest syndrome (PCAS).
Methods: The Japan Prediction of neurological Outcomes in patients with Post cardiac arrest (J-POP) registry is a prospective, multicenter, cohort study to test whether 602 predicts neurologic outcomes after out-of-hospital cardiac arrest (OHCA). This study assessed a subgroup of consecutive patients who fulfilled the J-POP registry criteria and successfully achieved return of spontaneous circulation (ROSC) from OHCA. The primary outcome measure was the neurologic status at 90 days.
Results: We analyzed data from 495 consecutive comatose survivors who were successfully resuscitated from OHCA, including 119 comatose patients with prehospital return of spontaneous circulation (ROSC; 24.0%) and 376 cardiac arrests at hospital arrival. In total, 75 patients (15.1%) presented with good neurologic outcomes. Univariate analysis revealed that the cerebral oxy-Hb levels were significantly higher in patients with good outcomes. Multivariate logistic regression using the backward-elimination method confirmed that the oxy-Hb level was a significant predictor of good neurologic outcomes (adjusted odds ratio, 1.27; 95% confidence interval (Cl), 1.11 to 1.46). Analysis of the area under the receiver operating characteristic curve (AUc) revealed that an oxy-Hb cut-off of 55 provided optimal sensitivity and specificity for predicting good neurologic outcomes (AUC, 0.87; 95% Cl, 0.83 to 0.91; sensitivity, 77.3%; specificity, 85.6%). The oxy-Hb level appeared to be an excellent prognostic indicator with significant advantages over rSO(2) and base excess, according to AUC analysis. The significant trend for good neurologic outcomes was consistent, even in the subgroup of patients who achieved return of spontaneous circulation on hospital arrival (1st quartile, 0; 2nd quartile, 16.7%; 3rd quartile, 29.4%; 4th quartile, 53.3%; P &lt; 0.05).
Conclusions: The cerebral oxy-Hb level may predict neurologic outcomes and is a simple and excellent indicator of neuroprotection in patients with PCAS.

DOI： 10.1186/s13054-014-0500-6

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© 2014 Hayashida et al. Introduction: Little is known about oxyhemoglobin (oxy-Hb) levels in the cerebral tissue during the development of anoxic and ischemic brain injury. We hypothesized that the estimated cerebral oxy-Hb level, a product of Hb and regional cerebral oxygen saturation (rSO2), determined at hospital arrival may reflect the level of neuroprotection in patients with post-cardiac arrest syndrome (PCAS). Methods: The Japan Prediction of neurological Outcomes in patients with Post cardiac arrest (J-POP) registry is a prospective, multicenter, cohort study to test whether rSO2 predicts neurologic outcomes after out-of-hospital cardiac arrest (OHCA). This study assessed a subgroup of consecutive patients who fulfilled the J-POP registry criteria and successfully achieved return of spontaneous circulation (ROSC) from OHCA. The primary outcome measure was the neurologic status at 90 days. Results: We analyzed data from 495 consecutive comatose survivors who were successfully resuscitated from OHCA, including 119 comatose patients with prehospital return of spontaneous circulation (ROSC; 24.0%) and 376 cardiac arrests at hospital arrival. In total, 75 patients (15.1%) presented with good neurologic outcomes. Univariate analysis revealed that the cerebral oxy-Hb levels were significantly higher in patients with good outcomes. Multivariate logistic regression using the backward-elimination method confirmed that the oxy-Hb level was a significant predictor of good neurologic outcomes (adjusted odds ratio, 1.27; 95% confidence interval (CI), 1.11 to 1.46). Analysis of the area under the receiver operating characteristic curve (AUC) revealed that an oxy-Hb cut-off of 5.5 provided optimal sensitivity and specificity for predicting good neurologic outcomes (AUC, 0.87; 95% CI, 0.83 to 0.91; sensitivity, 77.3%; specificity, 85.6%). The oxy-Hb level appeared to be an excellent prognostic indicator with significant advantages over rSO2 and base excess, according to AUC analysis. The significant trend for good neurologic outcomes was consistent, even in the subgroup of patients who achieved return of spontaneous circulation on hospital arrival (1st quartile, 0; 2nd quartile, 16.7%; 3rd quartile, 29.4%; 4th quartile, 53.3%; P < 0.05). Conclusions: The cerebral oxy-Hb level may predict neurologic outcomes and is a simple and excellent indicator of neuroprotection in patients with PCAS. Trial registration: UMIN Clinical Trials Registry UMIN000005065. Registered 1 April 2011.

DOI： 10.1186/s13054-014-0500-6

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Language：English   Publisher：LIPPINCOTT WILLIAMS & WILKINS  

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DOI： 10.11281/shinzo.45.402

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DOI： 10.1016/j.resuscitation.2012.05.016

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DOI： 10.1016/j.resuscitation.2011.12.027

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Background: The predictive value of T-wave alternans (TWA) for lethal ventricular tachyarrhythmia in patients with left ventricular (LV) dysfunction is controversial. Also, long-term arrhythmia risk of patients ineligible for the TWA test is unknown. Methods: This was a multicenter, prospective observational study of patients with LV ejection fraction ≤40% due to ischemic or non-ischemic cardiomyopathies, designed to evaluate the prognostic value of TWA for lethal ventricular tachyarrhythmia. The primary end point was a composite of sudden cardiac death, sustained rapid ventricular tachycardia (VT) or ventricular fibrillation (VF), and appropriate defibrillator therapy for rapid VT or VF. Results: Among 453 patients enrolled in the study, 280 (62%) were eligible for the TWA test. TWA was negative in 82 patients (29%), who accounted for 18% of the total population. The median of follow-up was 36 months. The 3-year event-free rate for the primary end point was significantly higher in TWA-negative patients (97.0%) than in TWA non-negative patients (89.5%, P = 0.037) and those ineligible for the TWA test (84.4%, P = 0.003). Multivariable analysis identified both non-negative TWA [hazard ratio (HR) 4.43; 95% confidence interval (CI) 1.02-19.2; P = 0.047) and ineligibility for the TWA test (HR 6.89; 95% CI 1.59-29.9; P = 0.010) to be independent predictors of the primary end point. Conclusions: TWA showed high negative predictive ability for lethal ventricular tachyarrhythmia in patients with LV dysfunction, although the TWA-negative patients accounted for only 18% of the entire population. Those ineligible for the TWA test had the highest risk for lethal ventricular tachyarrhythmia. © The Author(s) 2011.

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Aim To investigate the association between regional brain oxygen saturation (rSO(2)) on hospital arrival and neurological outcomes at hospital discharge in patients with out-of-hospital cardiac arrest (OHCA).
Methods A prospective cohort study was conducted, registering 179 patients with OHCA who were referred to Senri Critical Care Medical Centre between April 2009 and June 2010. Of these patients, 92 met the inclusion criteria. The primary end point was "neurological outcomes" at hospital discharge according to the "Utstein style" guidelines.
Results The overall rate of good neurological outcome at hospital discharge was 14% (n = 13). Sixty-one patients with rSO(2) &lt;= 25% showed poor neurological outcome in the receiver operating curve analysis (optimal cut-off point, 25%; sensitivity, 0.772; specificity, 1.000; positive predictive value, 1.000; area under the curve (AUC), 0.919; p &lt; 0.0001). The AUC for rSO(2) was greater than that for base excess (p = 0.0461) or lactate (p = 0.0128) measured on hospital arrival. Since rSO(2) &gt;40% was previously collated with good neurological outcome after cardiovascular surgery, we categorised our patients into three groups in a post hoc analysis: patients with rSO(2) &lt;= 25% (n = 61); patients with rSO(2) 26-40% (n = 9) and patients with rSO(2) &gt;40% (n = 22). Patients with good neurological outcome were as follows: 0 (0%)/61 with rSO(2) &lt;= 25%; two (22.2%)/9 with rSO(2) 26-40% and 11 (50.0%)/22 with rSO(2) &gt;40% (p &lt; 0.0001).
Conclusion rSO(2) on hospital arrival may help predict neurological outcomes at hospital discharge in patients with OHCA. (C) 2011 Elsevier Ireland Ltd. All rights reserved.

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DOI： 10.3165/jjpn.25.47

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DOI： 10.14442/general.11.63

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DOI： 10.14442/general.11.63

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Background It has been reported that mineralocorticoid receptor antagonist improves the prognosis of chronic heart failure (CHF). Recently, hemoglobin A1c (HbA(1c)) levels have been reported to be an independent risk factor for mortality in CHF, suggesting the important role of insulin resistance in CHF. We compared the metabolic effect of a selective mineralocorticoid receptor blocker eplerenone with spironolactone in CHF patients.
Methods One hundred seven stable outpatients with mild CHF, who were already receiving standard therapy for CHF, were randomized (1:2) to spironolactone (25 mg/d) or eplerenone (50 mg/d). Plasma levels of B-type natriuretic peptide, adiponectin, HbA1c and cortisol were measured before and after 4 months treatment with spironolactone or eplerenone.
Results There were no differences in baseline characteristics including hemodynamic parameters and plasma levels of biomarkers between 2 groups. In both groups, plasma B-type natriuretic peptide levels were significantly decreased and plasma aldosterone levels were significantly increased after 4 months. In patients receiving spironolactone (n=34), plasma adiponectin levels were significantly decreased (12.6 +/- 1.4-11.2 +/- 1.3 mu g/mL, P&lt;.0001) and HbA(1c) and cortisol levels were significantly increased (5.61 +/- 0.1-5.8 +/- 0.1%, P&lt;.0001, 11.3 +/- 0.8-14.7 +/- 1.3 mu g/dL, P=.003, respectively). In patients receiving spironolactone, there was a significant positive correlation between the change in cortisol and the change in HbA(1c) (r=0.489, P=.003). In contrast, in patients receiving eplerenone (n=73), plasma levels of adiponectin, HbA(1c) and cortisol did not change.
Conclusion These findings indicated that the metabolic effect of eplerenone differed from that of spironolactone and that eplerenone had a superior metabolic effect especially on HbA(1c) in CHF patients. (Am Heart J 2010;160:915-21.)

DOI： 10.1016/j.ahj.2010.04.024

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DOI： 10.1016/j.ijcard.2009.01.040

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DOI： 10.1016/j.ijcard.2009.02.010

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DOI： 10.1016/j.ijcard.2009.02.010

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An 87-year-old woman was admitted to the emergency department due to disturbance of consciousness. Subsequently, the condition was identified as shock. We diagnosed a right common iliac artery aneurysm (CIAA) rupture with contrast-enhanced abdominal computed tomography, which did not show extravasation of the contrast agent but showed a rugged vessel wall; it also revealed bilateral CIAA. Hemorrhagic shock responded to fluid resuscitation. Further, the patient had risk factors for surgery including advanced age, history of an abdominal surgery, hypertension, and dementia. Therefore, our therapeutic strategy for the right CIAA rupture was to perform endovascular aneurysm repair (EVAR) rather than an abdominal surgery because EVAR is less invasive than open surgery. Preoperative planning of EVAR includes occluding bilateral internal iliac arteries followed by placing a stent graft. The patient's hemodynamics stabilized after surgery, and she returned home without any complications. We therefore suggest that patients who have risk factors for abdominal surgery and in whom hemorrhagic shock responds to fluid resuscitation might benefit from EVAR for an iliac artery rupture.

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DOI： 10.3893/jjaam.21.372

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DOI： 10.1136/emj.2008.066803

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A 63-year-old man with <I>Russula subnigricans</I> intoxication presented with vomiting (1 hr after consumption), diarrhea (after 4 hr), back pain (after 18 hr), and dyspnea (after 21 hr), without any hemodynamic abnormalities. In the emergency department, all laboratory data indicated the occurrence of progressive rhabdomyolysis. Our therapeutic strategy for <I>R. subnigricans</I> poisoning included primary fluid resuscitation to achieve an inferior vena cava diameter (IVC) of >20 mm or central venous pressure (CVP) of >8 mmHg and prevent renal failure and other organ failure due to rhabdomyolysis. Fluid therapy with approximately 7-7.5 L of crystalloid a day was required until the 3rd day after <I>R. subnigricans</I> intake in order to maintain the CVP above 8 mmHg, which resulted in a urine output of over 1-2 ml&middot;kg<SUP>-1</SUP>&middot;h<SUP>-1</SUP>. The highest level of serum creatine kinase was 46,876 IU/l on day 3, and continuous hemodiafiltration or plasma exchange was not required because normal renal function could be maintained using fluid therapy. We conclude that initial fluid therapy with the aim of achieving an IVC diameter >20 mm or CVP >8 mmHg may reduce harmful reactions to <I>R. subnigricans</I> intoxication and prevent progressive rhabdomyolysis and concomitant renal failure.

DOI： 10.3893/jjaam.20.836

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Background. The incidence of strokes has not decreased after coronary artery bypass graft surgery (CABG). The purpose of this study is to identify incidence, risk factors, and temporal pattern of strokes after on-pump and off-pump CABG.
Methods. We analyzed 2,516 consecutive patients who underwent first elective isolated CABG. The primary end-point was strokes within 30 days. The temporal onset of the deficits was classified by consensus as either an "early stroke," which is present just after emergence from anesthesia, or a " delayed stroke," which is present after first awaking from surgery without a neurologic deficit.
Results. More than half of strokes (29 of 46; 63%) were delayed strokes. Patients undergoing off-pump CABG had significantly lower risk of early stroke (0.1% versus 1.1%, p = 0.0009), whereas the incidence of delayed strokes was not different significantly (0.9% versus 1.4%, p = 0.3484) between patients undergoing on-pump and off-pump CABG. In multivariate analyses, undergoing off-pump CABG was an independent protective factor for all strokes (relative risk 0.29, 95% confidence interval: 0.14 to 0.56, p = 0.0005) and early strokes (relative risk 0.05, 95% confidence interval: 0.003 to 0.24, p &lt; 0.0001), but it was not an independent protective factor for delayed strokes (relative risk 0.54, 95% confidence interval: 0.24 to 1.17, p = 0.1210).
Conclusions. Undergoing off-pump CABG reduces the incidence of perioperative stroke mainly by minimizing early strokes; however, the risk of delayed strokes is not different between patients undergoing on-pump and off-pump CABG. (Ann Thorac Surg 2009; 87: 1839-45) (C) 2009 by The Society of Thoracic Surgeons

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＜point＞心原性ショックとは「容量負荷などの治療に抵抗する、心機能低下に伴う低血圧・末梢循環不全」と定義される。心原性ショックの治療成績は、IABP/PCPSなどのmechanical supportやSTEMIに対する再灌流療法により著しく改善している。心原性ショックの治療においては、血行動態が完全に破綻する前にいかに速やかに治療を行うかが救命の鍵となるので、通常から循環器チームとより良い連携関係を構築し、実際の診療においてスピード感のある対応が可能となるように準備しておくことが大切。(著者抄録)

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Objectives This study describes a novel heterozygous gain- of- function mutation in the cardiac sodium (Na+) channel gene, SCN5A, identified in a Japanese family with lone atrial fibrillation (AF).
Background SCN5A mutations have been associated with a variety of inherited arrhythmias, but the gain- of- function type modulation in SCN5A is associated with only 1 phenotype, long-QT syndrome type 3 (LQTS3).
Methods We studied a Japanese family with autosomal dominant hereditary AF, multiple members of which showed an onset of AF or frequent premature atrial contractions at a young age.
Results The 31- year- old proband received radiofrequency catheter ablation, during which time numerous ectopic firings and increased excitability throughout the right atrium were documented. Mutational analysis identified a novel missense mutation, M1875T, in SCN5A. Further investigations revealed the familial aggregation of this mutation in all of the affected individuals. Functional assays of the M1875T Na+ channels using a whole- cell patch- clamp demonstrated a distinct gain- of- function type modulation; a pronounced depolarized shift (+ 16.4 mV) in V-1/2 of the voltage dependence of steady- state inactivation; and no persistent Na+ current, which is a defining mechanism of LQTS3. These biophysical features of the mutant channels are potentially associated with increased atrial excitability and normal QT interval in all of the affected individuals.
Conclusions We identified a novel SCN5A mutation associated with familial AF. The mutant channels displayed a gain- of- function type modulation of cardiac Na+ channels, which is a novel mechanism predisposing to increased atrial excitability and familial AF. This is a new phenotype resulting from the SCN5A gain-of-function mutations and is distinct from LQTS3.

DOI： 10.1016/j.jacc.2008.07.013

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：LIPPINCOTT WILLIAMS & WILKINS  

Background-Observational registries comparing coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) have reported long-term survival results that are discordant with those of randomized trials.
Methods and Results-We conducted a multicenter study in Japan enrolling consecutive patients undergoing first CABG or PCI between January 2000 and December 2002. Among 9877 patients enrolled, 5420 (PCI: 3712, CABG: 1708) had multivessel disease without left main involvement. Because age is an important determinant when choosing revascularization strategies, survival analysis was stratified by either age &gt;= 75 or &lt; 75 years. Analyses were also performed in other relevant subgroups. Median follow-up interval was 1284 days with 95% follow-up rate at 2 years. At 3 years, unadjusted survival rates were 91.7% and 89.6% in the CABG and PCI groups, respectively (log rank P = 0.26). After adjustment for baseline characteristics, survival outcome tended to be better after CABG (hazard ratio for death after PCI versus CABG [HR], 95% confidence interval [CI]: 1.23 [0.99-1.53], P = 0.06). Adjusted survival outcomes also tended to be better for CABG among elderly patients (HR [95% CI]: 1.37 [0.98-1.92] P = 0.07), but not among nonelderly patients (HR [95% CI]: 1.09 [0.82-1.46], P = 0.55). Unadjusted and adjusted survival outcome for CABG and PCI were not significantly different in any subgroups when elderly patients were excluded from analysis.
Conclusions-In the CREDO-Kyoto registry, survival outcomes among patients &lt; 75 years of age were similar after PCI and CABG, a result that is consistent with those of randomized trials.

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Background: Effects of prophylactic implantable cardioverter-defibrillator (ICD) on quality-adjusted life years (QALYs) in patients with congestive heart failure are uncertain.
Methods: We developed a decision model for patients at risk of sudden death due to reduced ejection fraction and who had no history of life-threatening ventricular arrhythmias. It estimated the QALYs for ICD strategy as a primary prevention for sudden cardiac death and conventional strategy without antiarrhythmic therapies.
Results: In a 3-year time period, the QALYs for patients with conventional strategy were higher than that of ICD strategy (2.19 years vs. 2.14 years). When the mortality rate of conventional strategy exceeded 8.6%/year and the hazard ratio of death for the ICD strategy was lower than 0.70, the ICD strategy was the superior treatment option.
Conclusions: The QALYs of patients with ICD could be lower than that of conventional strategy. Incorporating quality of life could affect decision making of ICD implantation. (c) 2007 Elsevier Ireland Ltd. All rights reserved.

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Language：English   Publisher：Japanese Heart Rhythm Society  

Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is an uncommon type of cardiomyopathy with fibrofatty tissue replacement. Magnetic resonance imaging (MRI) is a sophisticated method for the diagnosis of ARVD/C. Electroanatomical mapping has been reported to rapidly provide accurate data that facilitates catheter ablation of VT in ARVD/C. In addition, multislice CT (MSCT) is fast, easy to perform, and has a more reliable image quality. MSCT is considered a clinically valuable, noninvasive tool for assessment of myocardial pathology. However, the relationship between MSCT, cardiac MRI and electroanatomical mapping imaging in patients with ARVD/C is unknown. We report two cases diagnosed as ARVD/C by endomyocardial biopsy. In one case MRI imaging revealed marked wall thinning and a decrease in wall motion in the inferior wall and basal interventricular septum of the left ventricle. In another case an electroanatomical map of the RV was created. Endocardial voltage mapping in sinus rhythm revealed a large low voltage area and a focal pattern of activation was documented in activation mapping during VT. In both cases MSCT demonstrated low density areas indicative of focal fatty infiltration and morphological and functional abnormalities which were simultaneously assessed with MRI or electroanatomical mapping.

DOI： 10.4020/jhrs.23.277

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DOI： 10.4020/jhrs.23.277

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症例は30歳、男性。18歳時より動悸を自覚していた。27歳時に症状悪化にて当科を受診し、発作性心房細動(Af)・心房頻拍(AT)を指摘された。家族内に父方の祖父・叔父・父・妹がAfを指摘されている。電気生理学的検査にて冠静脈洞入口部後縁、His束近傍、上大静脈を起源とするATを認め、このうち冠静脈洞入口部後縁起源のATについてはカテーテルアブレーションによる焼灼に成功した。その後は薬物療法にて洞調律を維持していたが、最近になって動悸発作の頻度が増加したため再度カテーテルアブレーション施行目的に入院した。アブレーション直前に心腔内電気的除細動を試みたところ、一度ATを経てから洞調律に復帰した。この傾向はAfに対する電気的除細動の際、必ず認められた。その後、右房を起源とする連結時間の短い心房期外収縮(APC)を頻回に認め、右房後壁と分界稜中部に2種類のAPCの起源を同定し焼灼に成功した。三尖弁峡部にブロックラインを作成し手術を終了したが、ブロックライン作成時にもカテーテル先端の焼灼部位を最早期とするAPCが頻発しAfを生じた。術4日後にもAfが再発し、除細動のあとATを経由して洞調律に復帰した。本症例は、濃厚なAfの家族歴から家族性Afと考えられ、何らかの遺伝子異常を背景として異常自動能を持った細胞が右房内に広範に存在することが示唆された。(著者抄録)

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Other Link： https://search.jamas.or.jp/index.php?module=Default&action=Link&pub_year=2007&ichushi_jid=J00679&link_issn=&doc_id=20071017290006&doc_link_id=%2Fah2sinzd%2F2007%2F003910%2F007%2F0895-0901%26dl%3D0&url=https%3A%2F%2Fwww.medicalonline.jp%2Fjamas.php%3FGoodsID%3D%2Fah2sinzd%2F2007%2F003910%2F007%2F0895-0901%26dl%3D0&type=MedicalOnline&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00004_2.gif

Publishing type：Research paper (scientific journal)  

DOI： 10.1016/j.ejheart.2007.07.015

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Language：Japanese   Publisher：(一社)日本循環器学会  

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Language：Japanese   Publisher：(一社)日本循環器学会  

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Language：English   Publisher：ELSEVIER SCIENCE INC  

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：3  

Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is an uncommon inheritable cardiomyopathy involving predominant right ventricle with progressive fibrofatty tissue replacement. An integrated assessment of electrical, functional and anatomic abnormalities, in addition to personal and family history would be used to diagnose this disease entity. We present the case of a 69-year-old man with a history of sustained ventricular tachycardia. Fatty infiltration and regional wall motion abnormalities over biventricular myocardium were clearly demonstrated by cardiac 64-slice computed tomography (CT), as consistent with magnetic resonance imaging. Thus, multi-slice CT may have a significant role in the assessment and follow-up of patients with ARVD/C by providing excellent structural, functional assessment and tissue characterization. © 2006 Elsevier Ireland Ltd. All rights reserved.

DOI： 10.1016/j.ijcard.2006.08.047

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Other Link： http://orcid.org/0000-0003-3676-0135

Language：Japanese  

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Language：English   Publisher：OXFORD UNIV PRESS  

DOI： 10.1093/eurheartj/ehl026

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Other Link： http://orcid.org/0000-0003-3676-0135

Language：Japanese   Publisher：(一社)日本不整脈心電学会  

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Language：Japanese   Publisher：(一社)日本不整脈心電学会  

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Language：Japanese   Publisher：(一社)日本不整脈心電学会  

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Language：Japanese   Publisher：(一社)日本不整脈心電学会  

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：Japanese Heart Rhythm Society  

Cardiac resynchronization therapy (CRT) improves symptoms and cardiac function in patients with heart failure and prolongs QRS duration on an electrocardiogram. However, additional effects of concomitant CRT in patients who undergo cardiac surgery are unclear. We assessed the clinical efficacy of this therapy when it is performed concomitantly with primary cardiac surgery.&lt;BR&gt;METHODS: We evaluated four patients who underwent primary surgery and CRT between February 2002 and December 2003, and compare clinical data with four patients who underwent conventional primary surgery without CRT.&lt;BR&gt;RESULTS: Primary surgeries were CABG (n=2), aortic valve replacement (n=1), mitral valve plasty (n=1) and mitral annular plication (n=4). After the operation, symptoms associated with congestive heart failure were improved in all patients. The average NYHA class improvement was from 3.3±0.5 before the operation to 1.7±0.6 after the operation. All patients were discharged after surgery. Only one patient needed re-hospitalization for congestive heart failure one month after the operation. The mean QRS duration (190±47.6 ms vs 160±16.3 ms), cardiothoracic ratio (60.7±5.7% vs 58.5±2.9%) and ejection fraction (28.5±8.8% vs 50.0±0.0%) were also improved after surgery.&lt;BR&gt;CONCLUSION: In patients with poor left ventricular function and impaired cardiac conduction, CRT performed concomitantly with primary surgery may improve the postoperative course. Further study on indications for implantation of a CRT device during primary surgery is needed.

DOI： 10.4020/jhrs.21.523

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Language：English   Publisher：Japanese Heart Rhythm Society  

Cardiac resynchronization therapy (CRT) improves symptoms and cardiac function in patients with heart failure and prolongs QRS duration on an electrocardiogram. However, additional effects of concomitant CRT in patients who undergo cardiac surgery are unclear. We assessed the clinical efficacy of this therapy when it is performed concomitantly with primary cardiac surgery.<BR>METHODS: We evaluated four patients who underwent primary surgery and CRT between February 2002 and December 2003, and compare clinical data with four patients who underwent conventional primary surgery without CRT.<BR>RESULTS: Primary surgeries were CABG (n=2), aortic valve replacement (n=1), mitral valve plasty (n=1) and mitral annular plication (n=4). After the operation, symptoms associated with congestive heart failure were improved in all patients. The average NYHA class improvement was from 3.3&plusmn;0.5 before the operation to 1.7&plusmn;0.6 after the operation. All patients were discharged after surgery. Only one patient needed re-hospitalization for congestive heart failure one month after the operation. The mean QRS duration (190&plusmn;47.6 ms vs 160&plusmn;16.3 ms), cardiothoracic ratio (60.7&plusmn;5.7% vs 58.5&plusmn;2.9%) and ejection fraction (28.5&plusmn;8.8% vs 50.0&plusmn;0.0%) were also improved after surgery.<BR>CONCLUSION: In patients with poor left ventricular function and impaired cardiac conduction, CRT performed concomitantly with primary surgery may improve the postoperative course. Further study on indications for implantation of a CRT device during primary surgery is needed.

DOI： 10.4020/jhrs.21.523

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Language：Japanese   Publisher：(NPO)日本冠疾患学会  

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Language：Japanese   Publisher：(NPO)日本冠疾患学会  

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Language：Japanese   Publisher：(一社)日本心臓病学会  

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Language：Japanese   Publisher：(一社)日本心臓病学会  

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：3  

In spite of the progress made in acute angiographic evaluation and obtaining durable reperfusion of acute myocardial infarction (AMI) in the past two decades, cardiac free wall rupture (FWR) is still one of the causes of mortality following AMI. In this study, we evaluated the role of thrombolysis in the risk of FWR in AMI patients treated with acute percutaneous coronary intervention (PCI). Among 3,786 consecutive AMI patients seen between 1985 and 2003, 3,066 patients were treated by primary PCI or rescue PCI, with or without additional thrombolysis. FWR occurred in 24 of 3,066 patients (0.8%) treated by PCI
female gender (1.4% vs 0.6%, P = 0.001), age &gt
75 years, (1.4% vs 0.6%, P = 0.001) left main coronary artery (LMCA)-related infarction, (4.5% vs all other arteries, P = 0.015), and thrombolytic use (3.1% vs 0.4%, P &lt
0.001) were all associated with higher rates of FWR by univariate analysis. In patients treated with PCI and thrombolysis, FWR occurred in 2.7% with optimal PCI results but in only 4.9% if PCI was unsuccessful (P = NS). The incidence of FWR in patients with optimal PCI without thrombolysis was 0.4% (P &lt
0.001). Multivariable analysis identified thrombolytic use (odds ratio [OR]: 8.49, 95% confidence interval [CI]: 3.66-19.7, P &lt
0.001), LMCA-related infarction (OR: 7.06, 95% CI: 1.89-26.4, P = 0.004), and female gender (OR: 3.02, 95% CI: 1.27-7.21, P = 0.013) as independent predictors of FWR. Thrombolysis is one of the contributing causes of FWR in AMI patients undergoing PCI, even when PCI is successful.

DOI： 10.1111/j.1540-8183.2005.04110.x

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Other Link： http://orcid.org/0000-0003-3676-0135

Language：English  

DOI： 10.1016/j.ebcm.2005.01.036

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：1  

DOI： 10.1016/j.ebcm.2005.01.036

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Other Link： http://orcid.org/0000-0003-3676-0135

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Language：English   Publisher：International Heart Journal Association  

Ventricular tachycardia (VT), which causes hemodynamic instability, and ventricular fibrillation (VF) sometimes occur in patients with severe underlying cardiovascular disease such as myocardial ischemia or infarction, and are associated with high mortality. This report presents the efficacy of nifekalant hydrochloride (nifekalant), a pure class III antiarrhythmic agent, in treating life-threatening ventricular arrhythmia in such patients.<br> From June 2000, when nifekalant became commercially available in Japan, to May 2003, 30 ischemic heart disease (IHD) patients with VT/VF resistant to direct-current (DC) countershock received nifekalant in our hospital. These 30 patients served as the nifekalant group in this study. As a control group, we also included 33 IHD patients with VT/VF that had been resistant to DC countershock upon or during hospitalization between January 1996 and May 2000 before nifekalant became commercially available.<br> No significant differences were observed in patient background factors and treatments between the two groups. The rates of death within 48 hours of occurrence of VT/VF were significantly lower in the nifekalant group (7%, 2/30) than in the control group (27%, 9/33; <i>P</i> < 0.03). The rates of cardiac death during hospitalization were also significantly lower in the nifekalant group (40%, 12/30) than in the control group (67%, 22/33; <i>P</i> < 0.03). The rates of survival until hospital discharge were significantly higher in the nifekalant group (57%, 17/30) than in the control group (30%, 10/33; <i>P</i> < 0.03). Multivariate analysis of all 63 patients revealed nifekalant administration was the factor that significantly improved the mortality (odds ratio for cardiac death, 0.26; 95% confidence interval (CI), 0.07 to 0.95; <i>P</i> = 0.041).<br> Nifekalant improves the prognosis for life-threatening ventricular arrhythmia in IHD patients. <br>

DOI： 10.1536/ihj.46.647

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Other Link： http://orcid.org/0000-0003-3676-0135

Language：English   Publishing type：Research paper (scientific journal)  

BACKGROUND: Free wall rupture (FWR) is one of the major causes of mortality in acute myocardial infarction (AMI). To what extent coronary angioplasty for AMI would modify the predictors of FWR is not clear. METHODS: In prospective database of consecutive 3,138 AMI patients seen between May 1985 to May 2002, 3,096 patients (98.7%) who underwent emergent coronary angiography were analyzed retrospectively. The incidence of FWR was determined by univariate and multivariate analyses. RESULTS: FWR after admission occurred in 40 (1.3%) patients. A higher rate of FWR was associated with: 1) not having coronary angioplasty (3.2% vs. 0.9%, p< 0.0001); 2) thrombolytic agents usage (2.4% vs. 1.0%, p = 0.004); 3) female gender (2.5% vs. 1.1%, p = 0.0004); 4) failed reperfusion (5.4% vs. 0.9%, p< 0.0001); and 5) LMT-related infarct (4.7% vs. 1.2%, p = 0.02) in univariate analysis. Five conditions were identified as significant protective or predictive factors of FWR in multivariate logistic regression analysis: having coronary angioplasty (odds ratio [OR]: 0.45, 95% confidence interval [95% CI] 0.22-0.94, p = 0.03), failed reperfusion (OR: 4.57, 95% CI: 2.31-9.05, p< 0.0001), LMT-related infarct (OR: 4.96, 95% CI: 1.42-17.34, p = 0.01), female gender (OR: 2.17, 95% CI: 1.11-4.25, p = 0.02) and age (OR: 1.04, 95% CI: 1.00-1.07, p = 0.03). Coronary angioplasty alone resulted in a lower incidence of FWR (0.5%) than thrombolysis alone (1.6%, p = 0.02), coronary angioplasty with thrombolysis (3.3%, p< 0.0001) and without either treatment (6.3%, p< 0.0001). CONCLUSIONS: Angiographic reperfusion success was the most significant protective factor from FWR. Coronary angioplasty reduced FWR complicating AMI and its concomitant fatality.

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：ELSEVIER SCIENCE INC  

Background: Angiographic regression of luminal narrowing occurs 6 months to 3 years poststenting. However, after 4 years lesions progressed gradually and late restenosis was observed in 28% of 179 Palmaz-Schatz-stented lesions during the past 10 years. Elucidating its pathogenesis is pivotal to developing preventive strategies. Methods and Results: Histopathological and immunohistochemical studies were performed in 19 stented coronary arteries obtained from 19 patients autopsied after noncardiac death 2-7 years poststenting. The quality/severity of chronic inflammatory cells (T lymphocytes, macrophages and multinucleated giant cells) infiltration around the stent struts that is observed even in the absence of restenosis depended on the time elapsed from stenting: a) 2 years postprocedure, in spite of angiographic regression during the first year and pathologically expressed as maturation of the neointimal scar, there was chronic inflammatory response evidence: neovascularization and lymphocyte infiltration; b) greater than or equal to 3 years: the neointimal smooth muscle cells were sparse with abundant proliferation of collagen fibers. Presence of slight helper/inducer T lymphocytes and mild macrophage infiltration around the stent struts was evident immunohistochemically; c) greater than or equal to 4 years: prominent infiltration by lipid-laden macrophages with strong collagen-degrading matrix metalloproteinase immunoreactivity was observed around the struts. In two of these arteries, the surface contacting the stent was focally disrupted and covered by nonocclusive mural thrombi. Conclusions: Stainless steel stents evoke a remarkable foreign-body inflammatory reaction to the metal. These persistent peri-strut chronic inflammatory cells may accelerate new indolent atherosclerotic changes and consequent plaque vulnerability. (C) 2004 Elsevier Inc. All rights reserved.

DOI： 10.1016/s1054-8807(03)00132-7

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Other Link： http://orcid.org/0000-0003-3676-0135

Language：Japanese   Publisher：医学図書出版(株)  

Acute coronary syndromeは,不安的狭心症と急性心筋梗塞に分けられる.両者とも造影上の所見では冠血栓が非常に多いことが特徴である.近年,血栓溶解剤を使用しないPrimary PTCAが導入され,成功率が上がり,死亡率は低くなってきている.ただ,末梢塞栓を起こす危険性があるために,AngiojetやPercusergeなどの血栓吸引剤を使用することにより,なお良好な成績を上げている.末梢塞栓予防措置としては,今後更に新しい器具の開発が予測される

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Language：Japanese   Publisher：(一社)日本循環器学会  

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Language：Japanese   Publisher：(NPO)日本不整脈学会  

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Language：Japanese   Publisher：West-Japanese Society of Orthopedics & Traumatology  

We report a case of femoral bone fracture with a history of pulmonary embolism, which was successfully treated by hemiarthroplasty with the insertion of an IVC filter. A 70-year old woman with a past history of pulmonary embolism was admitted to our hospital, suffering from femoral bone fracture. The hemiarthroplasty was performed under preoperative insertion of an IVC filter. 6 days later her leg swelled, and deep venous thrombosis caught by the IVC filter was found when CT scanning. Warfarin and heparin were administered. 52 days after the operation, she was discharged from the hospital without recurrence. The preoperative insertion of an IVC filter is a useful method for the prevention of pulmonary embolism in patients that have a previous history of it.

DOI： 10.5035/nishiseisai.50.526

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Language：Japanese   Publisher：(一社)日本循環器学会  

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Language：Japanese   Publisher：(一社)日本循環器学会  

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Language：Japanese  

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Other Link： http://orcid.org/0000-0003-3676-0135

Language：Japanese   Publisher：(有)医学の世界社  

Br治療中にPRL値の著増と腫瘍の増大をきたしたマクロプロラクチノーマの1例を経験し,同様の報告について文献的な考察を加えた.ドーパミン(D2)受容体の解析から,ドーパミン抵抗性には受容体以降の機構が関与している可能性が考えられた

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Language：Japanese  

J-GLOBAL

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Publishing type：Research paper (scientific journal)  

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Other Link： http://orcid.org/0000-0003-3676-0135

Language：Japanese Book type：Scholarly book

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：Japanese   Publisher：(一社)日本航空医療学会  

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Language：Japanese   Publisher：(一社)日本航空医療学会  

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Language：Japanese   Publisher：(一社)日本航空医療学会  

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Language：Japanese   Publisher：(一社)日本航空医療学会  

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Language：Japanese   Publisher：(一社)日本航空医療学会  

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Language：Japanese   Publisher：(一社)日本航空医療学会  

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Language：Japanese   Publisher：(一社)日本航空医療学会  

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Language：Japanese   Publisher：(一社)日本航空医療学会  

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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Language：Japanese   Publisher：東北救急医学会  

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

J-GLOBAL

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：Japanese   Publisher：(一社)日本救急医学会  

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Language：Japanese   Publisher：(NPO)日本脳神経血管内治療学会  

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Language：Japanese   Publisher：(一社)日本移植学会  

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Language：Japanese   Publisher：(一社)日本移植学会  

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Language：Japanese   Publisher：(一社)日本臨床救急医学会  

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Language：Japanese   Publisher：(一社)日本臨床救急医学会  

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Language：English   Publisher：日本脳低温療法・体温管理学会  

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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Language：English   Publisher：日本脳低温療法・体温管理学会  

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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Language：Japanese   Publisher：(一社)日本集中治療医学会