Pediatric emergency care in Japan is in danger of failure, and will be bankrupt sooner or later if appropriate measures are not taken immediately. One major reason is that too many children and their parents rush to regional core hospitals for routine first aid and that most pediatricians in these hospitals suffer from overwork. The other reason is the unprofitablity of pediatric medicine and the shortage of pediatricians. We also found that many parents are anxious about child-rearing. Medical policy must renovate pediatric emergency care and make it adaptable to an age of low birthrates and nuclear families. Appropriate measures in pediatric emergency care are needed to (1) establish a pediatric emergency care center for each 1 million residents, (2) cooperate more with pediatricians in families and hospitals, (3) make better functional use of comedical staffs to help make up for the pediatrician shortage, and (4) set up general pediatric emergency care centers for surgery.

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We evaluated pediatric emergency care based on 28 years of experience at an emergency clinic set up in cooperation with medical staff in a local community. Status: Pediatric emergency care facilities involve Osaka Medical College Hospital and secondary emergency care organizations including 1 that provides pediatric care and 3 hospitals participating in rotation. The pediatric population is 48, 972 (13.7% of the total population). Those annually undergoing emergency care number 8, 020 or 42% of all annual hospital visits. The clinic is staffed by local physicians and members of the Osaka Medical College Hospital around the clock throughout the year. A total of 435 pediatricians were on duty, i.e., 273 as staff members of the pediatric department of the College 4 days a week and 162 by local physicians 2 days a week. On Sundays and national holidays and during the New Year vacation, the clinic is staffed by a 2- or 3-person combination of local physicians and college staff members. Patients transported to a secondary medical facility numbered 187, of whom slightly less than 50% were admitted to Osaka Medical College. Few patients were transferred out of the medical department. Problems The clinic has been staffed since its establishment by local physicians with the spirit that participation in the service is a duty that should be shared equally by all members of the medical society. As local physicians age and specialization in contem-porary medical care grows, doctors able to work at the clinic have markedly decreased. This decrease has been compensated for by members of the College medical staff. For this reason, these physicians are overworked and have difficulty handling routine practice. The total number of days of service provided by the college staff is 1, 404 annually. This has increased due to the prevailing idea that pediatric patients must be treated by pediatricians. Conclusions: Although we are in a privileged environment, problems that may challenge the feasibility of service have emerged in the last 28 years. Local emergency pediatric care is managed adequately, and maintenance of the present system is important. Reconsideration is urgently needed on behalf of patients and cooperation among parties involved, including the administration and medical society are indispensable.

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We evaluated blood coagulation fibrinolysis and platelet function using Sonoclot^TM in hypothermia in vitro. Methods: Whole blood samples were obtained from volunteers. Sonoclot analysis was conducted in vitro at 37°C, 36°C, 35°C, 34°C, 33°C, and 32°C. Results: 1) son-ACT at 32°C was significantly higher than at 37°C. 2) Clotting at 37°C was significantly lower than at 32°C or 33°C. 3) The time to peak at 37°C did not differ significantly from other groups but was slower than at 32°C. 4) The peak signal at 37°C did not differ significantly from other groups. 5) The peak angle at 37°C was significantly higher than at 33°C, and tended to be higher than at 32°C. 6) The bottom signal at 37°C did not differ significantly from other groups. Conclusion: These results on enzyme activity and platelet function decreased, particularly below 34.0°C, suggesting that Sonoclot^TM is useful in trauma patients with demonstrated hypothermic coagulopathy and for brain trauma patients undergoing therapeutic hypothermia.

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We report 5 patients with severe Aeromonas hydrophila infection, 3 of whom died quite rapidly after admission to our emergency room and thought to be in immunocompromised conditions such as liver dysfunction and multiple surgeries against malignancy. We studied the incidence of clinically colonized A. hydrophila at our hospital and compared to the report of Aeromonas food poisoning in Japan. The systemic infection of A. hydrophila showed high mortality and high morbidity in immunocompromized patients and patients with chronic renal failure and severe burns. We emphasize the clinical importance of the severe systemic infection of A. hydrophila, not as food poisoning, in the emergency department.

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Embolism of the internal carotid artery (ICA) is associated with high mortality. At present, local thrombolytic therapy is performed against the occlusion of the proximal ICA but clinical outcome is worse than that against the occlusions of the middle cerebral artery (MCA) and basilar artery (BA). There are no alternative effective treatments for proximal ICA occlusion. In this study we applied the novel technique of thrombotransfer, designed to scrape out proximal ICA thrombus into the external carotid artery (ECA) using a percutaneous transcatheter angioplasty (PTA) balloon. We applied this treatment to two patients with proximal ICA embolism associated with atrial fibrillation. Both conformed to Rankin's stroke scale (RSS) grade V. The second patient also had a MCA embolism. We used 3-mm diameter PTA balloons in both patients. We also subsequently applied super-selective thrombolytic therapy to the second patient for an M1 occlusion. Within one week following the treatment, both patients showed marked improvement and recovery to RSS grade 0. Thrombotransfer therapy was applied in two patients with acute phase embolic brain ischemia due to proximal ICA occlusion. This treatment requires no thrombolytic agents, and the procedure is technically easy, quick and safe, making it suitable for the treatment of proximal ICA occlusion.

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