We describe the epidemiological and etiological features of out-of-hospital cardiac arrest (OHCA) in children using the Utstein style. Among 5, 047 consecutive cases of OHCA reported between May 1998 and April 1999, 147 were under 16 years of age. The annual incidence of OHCA was 10.3/10⁵ and was significantly lower compared with adults (66.1/10⁵). However the incidence of OHCA in infants reached 79/10⁵ and was significantly higher compared with adults. The percentage of arrests of cardiac etiology was lower compared with that in adult cases. The frequency of bystander-witnessed cardiac arrests was also lower in children than in adults. The percentage of bystander-CPR was higher in children than that in adults. The 1-month survival rate was higher in children than in adults. Of 147 cases, 68 cases were infants (0 years), 43 cases were preschool children (1-6 years), and 36 cases were school children (7-15 years). In infants, there was no significant history related to the event in the majority of cases. We speculated that the number of sudden infant death syndrome (SIDS) might have reached 41 cases, based on our results, whereas the current mortality statistics reported 17. The current number of SIDS cases might therefore be underestimated. In school children the major cause of arrests was non-cardiac in origin, such as traffic trauma and falls. In preschool children causes of cardiac and non-cardiac origin were roughly equal. The features of OHCA was clearly different among infant, preschool and school children. This is important when we investigate pediatric OHCA data.

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Purpose: Patients with subarachnoid hemorrhage (SAH) as a result of a ruptured aneurysm often have experienced a recent episode of a sudden-onset, severe headache because of minor leakage; such headaches can be interpreted as a warning or the first sign of SAH. The aim of this study was to investigate the clinical course and necessary conditions for initiating early treatment after a patient has experienced a warning headache. Materials and Methods: A total of 194 consecutive patients suffering from SAH as a result of a ruptured aneurysm were included in the study. The medical history of each patient up until the time of admission was recorded after interviewing the patients' families or the paramedics, retrospectively. A warning headache was defined as a recent, unexplained severe headache with an abrupt onset. Patients were divided into two groups according to whether or not they had experienced a warning headache. Results: A total of 49 patients (25.3%) had experienced warning headaches. The WFNS classification grade of these patients was grade IV or V. Thirty-four patients (69.4%) were only observed at rest soon after onset. A total of 15 patients (30.6%) visited a clinic. Attending physicians could not make an accurate diagnosis in 4 patients, resulting in no or delayed treatment. The peak time of major bleeding was within 2 hours of onset (65.3%), and the incidence of bleeding between 24 hours and 1 week after a warning headache was 20.4%. A significantly high incidence (81.6%) of death was observed in patients who experienced a warning headache compared to grade I-III (9.1%; p<0.001) or grade IV, V (56.1%; p<0.01) patients who did not experience a warning headache. Discussion and Conclusion: Two major problems were the low rate of clinic visits and the high incidence of death after experiencing a warning headache. Thus, individuals should be encouraged to visit a clinic after experiencing a warning headache. Patients, families and attending physicians should be aware that a warning headache may be an early sign of a ruptured Intracranial aneurysm.

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We investigated patients admitted to the main hospital critical care and emergency center of the Nippon Medical School after attempting to commit suicide during the 3-year period from January 1, 1998, to December 31, 2000. All patients were examined by psychiatrists. The most common psychiatric diagnosis among these patients was class F4, and the most frequent method of attempted to commit suicide was the consumption of drugs or toxic substances. The number of patients readmitted to the psychiatric units of our hospital in 1999 was 4 times higher than the number in 1998, while the number in 2000 was 5 times higher than in 1998. Furthermore, the number of patients hospitalized in the psychiatric departments of other hospitals is increasing year by year. Only 36% of the patients who were advised to consult psychiatric outpatient clinics after their discharge actually did so at our hospital. The consultation rates of patients who had been diagnosed as F3 or F2 was high, while the consultation rates of patients diagnosed as F4 or F6 was low. On the other hand, 98% of the patients who were transferred to the psychiatric units of our hospital and 78% of the patients who were transferred to hospitals where psychopathological treatment by psychiatrists was available willingly received such treatment. The consultation rate of patients who were diagnosed as F4 and F6 was high, although they reported that continuing psychiatric treatment was difficult. Hospitalization in the psychiatric unit after discharge from the emergency center was an effective method for motivating patients to continue treatment in the outpatients clinic. Patients who have attempted to commit suicide may need to continue psychiatric treatment to prevent further suicide attempts, even if their symptoms are not severe. Active observation of such patients should be an important role of psychiatric departments in general hospitals, and such efforts are likely to improve the prognosis of patients.

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A 69-year-old female was found unconscious after nearly drowning (submersion) in a hot spring spa (Tamagawa spa, Akita prefecture) on June, 2001. The near drowning was associated with acid aspiration. She developed acute respiratory distress syndrome and shock after arrival at our emergency room. She was immediately treated using mechanical ventilation and percutaneous cardiopulmonary support. However, she died on the fourth hospital day as a result of a rapidly progressive lung injury induced by acid aspiration. Lung CT images demonstrated heterogeneous pulmonary infiltrations with irregularly fused cavities. An autopsy showed marked degeneration of the alveolar epithelium and abnormal deposits within the alveoli.

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A 50-year-old man visited a local clinic at 8:40 am complaining of continuous chest discomfort since 7:00 am. Acute myocardial infarction was strongly suspected, and the patient lost consciousness while being transported to a critical care medical center. An ECG showed VF; rescue personnel repeatedly applied DC cardioversion, but the patient experienced cardiac arrest immediately before arrival at the hospital. During CPR, percutaneous cardiopulmonary support (PCPS) was introduced. A CAG showed a 75-90% narrowing of the right coronary artery and poor distal flow; the left coronary artery was normal. Upon admission to the ICU, the patient developed decerebrate rigidity. He died at 2:30 pm. An autopsy was performed, but both of the coronary arteries showed no signs of significant stenosis. This case of sudden cardiac death was suspected to have been caused by coronary vasospasm.

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We report the case of a fistula between a left internal iliac artery aneurysm and the left ureter. An 86-year-old man with no history of laparotomy was hospitalized after collapsing because of sudden massive hematuria. Abdominal computed tomography (CT) showed an abdominal aortic aneurysm and bilateral internal iliac artery aneurysms, necessitating emergency laparotomy under a presumptive diagnosis of urinary bladder hemorrhage. No evidence was seen of active bleeding from the ureter or bladder and massive hematuria was not seen until postoperative day (POD) 52. A second laparotomy and ureterectomy with repair of the fistula was undertaken after cystoscopy led to a diagnosis of left ureteroarterial fistula. Postoperatively, the right internal iliac artery aneurysm spontaneously rupturted into the intraperitoneum on POD 43 and the third operation was successful. The man died of acute heart and renal failure and severe bronchial asthma on POD 45 after the last operation. Ureteroarterial fistula caused by spontaneous rupture of an aneurysm is extremely rare. Only 2 cases have been described through 2001 and to the best of our knowledge this is the first such report in the Japanese literature. Preoperative diagnosis is difficult, but heavy hematuria in a patient with or without prior surgery or ureteral stenting may suggest to the clinician the possibility of ureteroarterial fistula.

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