Hemorrhagic shock-induced mesenteric hypoperfusion causes gut injury, leading to production of inflammatory mediators that activate neutrophils (PMNs) and damage endothelial cells. Previous studies have shown that the ligation of the mesenteric lymph duct prevents hemorrhagic shock-induced lung injury. Mesenteric lymph is thought to be crucial in the pathogenesis of multiple organ dysfunction syndrome (MODS). Our previous data have shown that liposome-encapsulated hemoglobin (LEH) reduces lung permeability in the rat hemorrhagic shock model. We therefore hypothesize that LEH attenuates mesenteric lymph induced PMN activation. Male Sprague-Dawley rats were exposed to hemorrhagic shock (40mmHg, 30min) and resuscitated over 2 hours with shed blood+normal saline (NS) (shed blood×2) (whole blood group) or LEH (=shed blood)+NS (shed blood×2) (LEH group). A sham group underwent identical procedures without hemorrhage and resuscitation. We use dmesenteric lymph collected between 1 and 2 hours in the resuscitation phase and examined rat PMN activation. Superoxide anion production was measured with the superoxide dismutase inhibitable cytochrome c reduction method. In addition, adhesion was measured by the radioactivity of adherent PMNs labeled with ⁵¹Cr to fibrinogen, and CD11b surface expression was determined with flow cytometry. Mesenteric lymph in the whole blood group significantly increased superoxide production compared with the LEH and sham groups. Mesenteric lymph in whole blood group, but not the LEH group, significantly increased rat PMN adherence. Mesenteric lymph in whole blood group significantly up-regulated CD11b surface expression compared with the LEH and sham groups. LEH attenuates mesenteric lymph induced PMN activation following hemorrhagic shock, and may therefore be one of strategies to prevent MODS.

View full abstract

Background: Going to the toilet alters blood circulation. Purpose: To investigate the epidemiology of diseases in which onset occurred while the patient was in a toilet. Methods: Between May 2003 and April 2004, we prospectively collected data from 74 consecutive patients who placed an emergency call in Tokorozawa city after going to a toilet. The gender, age, atmospheric temperature, and diagnosis upon arrival at the hospital of the subjects were analyzed. Results: Forty males and 34 females, with an average age of 68±16 years, were analyzed. Sixty-two patients had been using a Western-style toilet (sitting position), 2 had been using a Japanese-style toilet (squatting position), and two had been using a urinal; the style of toilet was not documented in the remaining 8 cases. Thirty-eight patients had used a toilet to defecate, and 28 patients had used a toilet to urinate; the activities of the remaining 8 patients were not documented. The percentage of patients who used a toilet to defecate and the percentage who used a toilet to urinate were not significantly different. Overall, 23 patients had central nervous diseases, 12 patients had syncope, 11 patients had gastroenteral diseases, 9 patients had cardiac diseases, 6 patients had shock, 4 patients had cardiopulmonary arrest, and 9 patients had other diseases. The incidence of cardiac diseases was higher than that of syncope when the atmospheric conditions were cold. Conclusion: Patients at risk or who have a past history of central nervous disease should be given medication to prevent disease onset while going to the toilet; similarly, patients at risk for syncope or cardiac disease should ensure that the atmosphere in their toilet is kept cool or warm, respectively.

View full abstract

Background: We have suspected that the regional differences in the emergency medical field are due to the lack of the numbers of emergency medical doctors and emergency medical institutions in Japan. Therefore, in this study we investigated the regional distribution of the numbers of emergency medical doctors and institutions. Methods: We compared the numbers of regular members, diplomats of the Board of Japanese Association for Acute Medicine (JAAM), certified training hospitals of JAAM against population size, the numbers of medical doctors, general hospitals, hospital beds in the 47 prefectures and the nine areas recognized by the eight district societies of JAAM. Results: There were significant correlations in all comparisons between population size, the numbers of medical doctors, general hospitals, hospital beds, regular members, diplomats of the Board, and certified training hospitals of JAAM in the 47 prefectures. The average number of regular members of JAAM per 100, 000 population was 6.2. The maximum difference among 47 prefectures (MDP) was 5.4 times. It was largest (9.2) in the Tokyo area and smallest (4.8) in the Kanto area. The average number of diplomats of the Board of JAAM per 100, 000 population was 1.8. MDP was 7.5 times. It was largest (3.1) in the Tokyo area and smallest (1.1) in the Hokuriku area. The Tokyo and Kinki areas had significantly larger numbers. The percentage of regular members of JAAM per medical doctor was 3.0%. MDP was 5.1 times. It was highest (3.6%) in the Hokkaido area and lowest (2.4%) in the Hokuriku area. The percentage of diplomats of the Board of JAAM per medical doctor was 0.9%. MDP was 7.6 times. It was highest (1.2%) in the Tokyo area and lowest (0.6%) in the Hokuriku area. The average number of regular members of JAAM per one general hospital was 0.9. The MDP was 5.8 times. It was largest (1.7) in the Tokyo area and smallest (0.6) in the Chugoku-Shikoku area. The Tokyo and Kinki areas had significantly larger numbers. The average number of diplomats of the Board of JAAM per one general hospital was 0.3. MDP was 10.2 times. It was largest (0.6) in the Tokyo area and smallest (0.1) in the Hokuriku area. The Tokyo and Kinki areas had significantly larger numbers. The average number of regular members of JAAM per 1, 000 hospital beds was 4.8. The MDP was 5.0 times. It was largest (8.7) in the Tokyo area and smallest (3.7) in the Chugoku-Shikoku area. The Tokyo and Kinki areas had significantly larger numbers. The average number of diplomats of the Board of JAAM per 1, 000 hospital beds was 1.4. MDP was 8.2 times. It was largest (2.9) in the Tokyo area and smallest (0.8) in the Hokuriku area. The Tokyo and Kinki areas had the significantly larger numbers. The percentage of certified training hospitals of JAAM per general hospital was 2.9%. MDP was 10.2 times. It was highest (4.8%) in the Tokyo area and lowest (2.1%) in the Kyushu area. Conclusion: These results suggest that there are the regional discrepancies in the numbers of emergency medical doctors in Japan. The Tokyo and Kinki areas have the largest numbers of emergencies medical doctors. We should correct the regional differences in the numbers of emergency medical doctors and emergency medical institutions among the areas in Japan.

View full abstract

It has been generally considered that the incidence of pulmonary thromboembolism (PTE) is small in Japan. However, recently the condition has been increasing due to the change to a western life-style. In 2002, a work group from Eastern Association for the Surgery of Trauma (EAST) published treatment guidelines for traumatic patients, in which those for vein thromboembolism (VTE) prevention pointed out the necessity of low molecular weight heparin (LMWH) administration for all trauma patients that can tolerate a bleeding risk, except for head injury patients. The aim of the present study was to elucidate the present situation regarding the prevention of deep vein thrombosis (DVT) in Japan, for which we utilized a questionnaire that was sent to 175 critical care medical centers and certified training hospitals. The questionnaire items were intended to be answered by staff of institutions both with and without experience in treating DVT/PTE patients, and focussed on whether the EAST criteria were being used for the prevention of DVT/PTE and which patients were targeted for such care. The overall response rate was 39% and the response rate of institutions with DVT/PTE experience was 57.4%, with 44.1% of those answering that prevention of DVT/PTE was conducted using the established criteria. In hospitals with no experience of DVT/PTE, 37.5% noted that prevention methods had been established, while 47.1% of the hospitals with such experience had prevention methods in place. As for high-risk clinical states of DVT/PTE, the conditions of bedridden without postural rotation, maintenance of artificial ventilation with muscle relaxants, and traction of lower limbs were noted in 82.1%, 64.3%, and 53.6%, respectively, on the responses. Further, a foot pump was the most common method of prevention used (75%), and heparin administration the second most common (25%). In contrast, LMWH was infrequently mentioned as used to prevent DVT/PTE in trauma patients. Guidelines for VTE prevention are becoming established in Japan. However, an understanding of the risk of DVT/PTE in trauma patients remains inadequate in many critical care medical centers and certified training hospitals. The present results showed that the greatest risks associated with DVT/PTE are a pelvic fracture and multiple trauma, apart from whether the guidelines have been adapted. Additionally, for DVT/PTE prevention, it is considered vital to establish the use of anticoagulants including LMWH in Japan.

View full abstract

We report a rare case of progressive severe pulmonary failure due to exposure to dimethyl sulfate vapor. The patient is a 48-year-old man who carried four bottles of dimethyl sulfate on the carrier of a truck and one of them was broken. After he had been cleaning up the carrier for an hour while covering his nose and mouth with a dry towel, he had felt pain of his eyes, pharyngolarynx and nose. He went to an emergency hospital on foot 3 hours after exposure, because he felt obstruction of the pharyngolarynx, hoarseness and dyspnea. He was immediately intubated due to severe hypoxia and was immediately administered hydrocortisone intravenously, and methylprednisolone inhalation therapy was prescribed for ten days. Tracheostomy was performed the 5th day following the onset of symptoms because of severe laryngeal edema. Sputum and strider continued after steroid therapy was suspended because of Pseudomonas aeruginosa infection. The steroid therapy was resumed as transbronchial lung biopsy suggested peribronchiolar inflammation with granulation change, and he improved promptly. However, he had another bout of pneumonitis thereafter, and dyspnea and hypoxia gradually developed. Home oxygen treatment was introduced the 5th year after onset, and then roentgenogram showed severe emphysematous change, and now he is listed for lung transplantation. We ewcommend a high dose of steroid in the acute phase and a low dose of erythromycin for a long term in case of lung injury due to exposure to dimethyl sulfate.

View full abstract

Nifekalant hydrochloride is a novel class III antiarrythmic agent used especially for malignant VT/VF, which is resistant to electrical defibrillation and lidocaine. We previously reported that this agent restored the sinus rhythm from ventricular fibrillation more successfully than lidocaine. A 60-year-old female was transferred to the Emergency Medical Center of Tokai University Hospital because of cardiac arrest due to ventricular fibrillation. After several unsuccessful attempts at electrical defibrillation at the scene and the emergency room, we administrated nifekalant hydrochloride before lidocaine. With the infusion of nifekalant, the patient was successfully defibrillated. A 57-year-old female also admitted to our hospital with recurrent ventricular fibrillation that was resistant to electrical defibrillation. In situations of VT/VF resistance to electrical defibrillation, lidocaine has been used prior to nifekalant. However, we selected nifekalant first, with which the patient was successfully defibrillated. After the infusion of nifekalant hydrochloride, the sinus rhythm was restored. We concluded that nifekalant hydrochloride is especially effective for recurrent ventricular fibrillation and it should be administrated as early as possible.

View full abstract