We reviewed emergency response to bioterrorism, especially for anthrax, smallpox, pulmonary plague, tularemia, and botulism, based on recent publications including information obtained over the Internet. It may be difficult to distinguish earlystage illness from natural or intentional outbreaks, we discuss the importance of the epidemiological information and the incubation period and initial symptoms of bioterrorism-related illness.

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Problems involving tuberculosis in Japan, primarily in its actual treatment, have been brought to light through the results of the “Survey on the Tuberculosis State of Emergency” in 2000 by the Ministry of Health, Labor and Welfare of Japan. Measures that Japan is taking against tuberculosis include issuing notification as required by the Tuberculosis Prevention Law, the registration of patients by the government, the implementation of patient management including the setting of treatment standards, and the set up of a system to ensure proper medical treatment. The survey showed a discrepancy in the number of tuberculosis deaths according to vital statistics and the number of deaths according to notification made as required by the Tuberculosis Prevention Law. Upon close examination of diseases listed by registered patients, it was found that disorders other than tuberculosis make up about 10% of the total. This suggests a problem with the accuracy of notifications and the overall evaluation of tuberculosis in Japan. In treatment provided, certain cases suggest that diagnoses for the option of short-term chemical treatment or sensitivity to drugs that fight the bacteria responsible for tuberculosis are not conducted properly. This presents problems in the promotion of reducing treatment period or preventing drug-resistant bacterium. The survey results also suggested that nonmedical issues greatly influenced the contraction of tuberculosis, including social and economic factors. In particular, when providing medical treatment to the elderly and to those with underlying disease or those with no fixed address, full consideration must be given to early detection and improvement of the completion of treatment.

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The influence of drugs must be excluded before making a diagnosis of brain death. No standard guidelines currently exist for evaluating drug influence, however. We studied 29 drugs influencing brain death diagnosis. The therapeutic range is known in 41% of these drugs. They have potential metabolites in 55%. The duration of efficacy is known in 72%. We term the time during which plasma concentration decreases to one tenth “decilife.” To estimate drug influence elimination time, we propose 3 calculation times: H-time (sum of efficacy duration and elimination half-life), D-time (sum of efficacy duration and decilife), and F-time (4 times the elimination half-life). Plasma drug concentration was measured in 10 cases. We then compared efficacy duration, half-life, and the 3 calculated times. H-time is the most adequate among the 3 calculated times if both efficacy duration and half-life are known. F-time is useful if only the half-life is known. If drug substances have potential metabolites, elimination time should be estimated longer. If neuromuscular blocking agents have been administered, examination with a bedside peripheral nerve stimulator is required. Adequate recovery of neuromuscular function requires the return of the train-of-4 ratio to more than 0.90. We have thus proposed practical guidelines to exclude drug influence before brain death is diagnosed.

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Intestinal ischemia and hypoperfusion appear to play key roles in the pathogenesis of multiple organ dysfunction syndrome (MODS). While various animal models have been used to elucidate what causes MODS, investigators have recently started to use mice since knockout and transgenic technologies emerged. However, definite methods to estimate systemic organ damage, especially endothelial injury, have not well been established in mice. We, therefore, attempted to establish simple methods that enable us to detect intestinal, pulmonary, and hepatic injury in a murine model of intestinal ischemia-reperfusion (I/R). Adult female BALB/c mice underwent 45 minutes of superior mesenteric artery occlusion and subcutaneously received 3ml of saline as fluid resuscitation. Two and 6 hours after reperfusion, whole blood was drawn from the inferior vena cava and the heart. Microvascular permeability and edema formation in the intestine, lung, and liver, were quantitated by Evans blue method (EB) and wet/dry ratio (W/D), respectively. Liver function was also measured by plasma alanine aminotransferase (ALT) and total bilirubin (T-Bil) concentrations. In the second set of experiments, the same methods were employed in C57BL/6 mice after 45 minutes of intestinal ischemia and 2 hours reperfusion. In BALB/c mice, intestinal injury was detected by EB and W/D and increased pulmonary permeability was measured by EB. Liver injury was quantitated by EB, W/D, and T-Bil. In C57BL/6 mice, intestinal injury was estimated by EB and W/D, lung leak by EB, and liver injury by W/D, ALT, and T-Bil. While slight difference was observed between those two strains of mice, the data indicate that intestinal, pulmonary and hepatic injury could be successfully estimated by the combination of EB, W/D, ALT and T-Bil in a murine model of intestinal I/R. These methods may become useful in mice not only to delineate the mechanisms linking intestinal I/R and remote organ injury but also in other fields of shock research.

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Purpose: Coronary artery bypass grafting (CABG) using arterial grafts has been utilized aiming at improvement of the long-term results and its indication has been expanded for emergent CABG. We report here our experience of emergent CABG in the arterial bypass era. Methods: We performed a retrospective study of emergent CABG for acute coronary syndrome to evaluate postoperative and remote results. Among 1997 consecutive patients who underwent isolated CABG between January 1, 1991 and December 31, 2000, a total of 154 were emergent cases. The inhospital and long-term data in these patients were analyzed using appropriate statistical methods. Results: The mean number of grafts performed by emergent CABG was 3.2±1.1. At least one arterial graft was used in 144 patients (93.5%). The patients who underwent emergent CABG required significantly longer intubation period, longer ICU stay and longer hospital stay than elective CABG. Major complications occurred in 73 cases (47.7%), and in-hospital deaths occurred in 11 cases (7.1%). Emergent surgery was one of the significant predictors of inhospital death by both univariate and multivariate analysis (relative risk 23.5 with 95% confidence interval 8.6-61.6). Among the hospital survivors, follow-up was completed in 98% of the patients with a mean follow-up period of 3.5 years. The actuarial 5-year event-free and survival rates after emergent CABG were 78.1% and 90.8%, respectively, which were not significantly different from elective CABG in which the actuarial 5-year event-free rate was 83.6% and the 5-year survival rate was 90.7%. Conclusions: Hospital mortality and morbidity were higher in the emergent surgery. However, once adequate surgical revascularization was completed, the long-term results in the emergent group were not inferior to those in the elective CABG group. Use of arterial grafts may have contributed improvement of its long-term outcomes.

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