Background: It is unclear what on-site treatment is given to people suffering airway obstruction. This study attempted to clarify actual initial responses at the scene to patients suffering a foreign body airway obstruction witnessed by someone else.
Method: From January 2003 until December 2006 we interviewed bystanders and emergency workers involved with 50 patients who suffered an airway obstruction and were transported to our critical care centre. We asked them what the obstructing body was and what treatment had been given at the scene in order to examine their impact on the outcome. The patients were divided into two groups according to whether they survived or died. Within these groups they were examined according to: 1) age, 2) gender, 3) whether an effort was made to remove the foreign body after the patient became unresponsive, 4) presence/absence of bystander cardiopulmonary resuscitation (CPR), 5) time elapsed from the emergency call to scene, 6) time elapsed from the emergency call to emergency room (ER) admission, 7) variety of the foreign body (whether a solid mass or not), and 8) index of independence in activities of daily living (ADLs) regarding feeding (dependent/independent).
Results: In each of the 50 cases the patient was unresponsive when the emergency team arrived. Prior to loss of responsiveness, bystanders had not done anything to clear the foreign body from the airway. Once the patient became unresponsive, the sole action taken in 50% of cases was to remove the obstruction, while in 38% of cases it was to call an ambulance. External cardiac massage was performed in just 12% of cases. There was no significant difference between the survival group (n=16) and the group of patients dead at the point of hospital discharge after becoming comatose following foreign body airway obstruction (n=34). A significantly shorter time from the emergency call to ER arrival was observed in the survival group.
Conclusion: Prior to the patients' loss of responsiveness, the bystanders had not done anything to clear the foreign body from the airway. Only 12% of patients unresponsive after airway obstruction received CPR. Recently, educational programs for basic life support (BLS) have been conducted on several occasions in the area. It is possible that there is a lower prevalence of BLS programs for lay rescuers or health care providers that include training for life-threatening conditions such as airway obstruction. It is therefore important to record the prevalence of BLS programs that include such life-threatening scenarios and further educational movement required to improve patient outcome by examining the initial response to patients who suffered a foreign body airway obstruction witnessed by a third party.

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It has been reported that some psychiatric disorders show seasonal remission/exacerbation. In particular, seasonal variations of mood disorder are commonly known. Several studies have presented data on seasonal variations in patients attempting suicide and inpatients. However, studies regarding patients who consulted emergency outpatient units have not been adequately conducted. We investigated 3,877 patients who consulted the Department of Emergency/Intensive Care, Shiga Medical University Hospital between September 2005 and August 2006 (including 2,066 who were brought by ambulance). Of these, 299 patients (7.7%) had psychiatric disorders. In 158 patients, the disease category was evaluated as F4 (neurotic, stress-related, and somatoform disorders), showing the highest percentage. The number of patients who consulted our department with psychiatric disorders reached a peak in June to July and September to October, and was the lowest in January. There was no association between the number of these patients and day length/precipitation. However, the number of patients who consulted our department with psychiatric disorders increased with a rise in the atmospheric temperature. These results clarified the characteristics of psychiatric disorder patients who consulted the emergency outpatient unit, and may contribute to the early detection of psychiatric disorders in this unit in the future.

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Clinical efficacy of biapenem (BIPM) administered at increased dosing frequency for sepsis was compared with that of conventional twice-daily dosing. Twenty-six adult patients with sepsis (mean age, 56.5 years; 19 males) were randomly assigned to two groups for intravenous infusion of BIPM: a twice-daily group (n=14), 600 mg twice daily, or four-times-daily group (n=12), 300 mg four times daily. Patients meeting all three clinical response criteria (body temperature, WBC count, and CRP) were considered complete responders, while those meeting two were considered responders. Although clinical response rates were almost the same (71.4% in twice-daily group and 66.7% in four-times-daily group), complete response rate was higher in the four-times-daily group (50.0% vs. 35.7%). On laboratory culture of foci of infection, more patients in the twice-daily group were positive for BIPM-susceptible (five vs. one) and BIPM-resistant bacteria (five vs. one) after treatment. No significant increases in liver or renal function test values during treatment were noted in either group. Results suggested that the four-times-daily regimen of BIPM might exhibit greater clinical efficacy than the conventional regimen.

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We experienced a case of calcium chloride poisoning complicated by small intestinal necrosis. A 79-year-old woman with dementia who had undergone total gastrectomy for gastric cancer erroneously ingested 100 ml of a liquid suspension of calcium chloride desiccant grains in aqueous calcium chloride solution while alone at home. Two and one-half hours later, she presented to our hospital's emergency department free of symptoms and was hospitalized for acute calcium chloride poisoning. The following evening, she complained of abdominal pain and exhibited tenderness and muscular guarding of the entire abdomen, with melena and hypotension. Since abdominal ultrasonography and CT demonstrated peritoneal effusion and abdominal tap yielded turbid ascitic fluid with an unusual odor, gastrointestinal perforation was suspected and emergency laparotomy performed. Extensive necrosis of the small intestine was observed but without apparent perforation. After partial resection of the small intestine and peritoneal cavity lavage/drainage, she was transferred to the ICU. She survived disseminated intravascular coagulation and renal dysfunction, and was transferred to the general ward on hospital day 8 and discharged from the hospital on hospital day 33. Although calcium chloride is considered relatively harmless, calcium chloride poisoning due to ingestion can cause severe gastrointestinal injury and may cause death.

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The first patient was a 68-year-old woman with urinary calculus. She experienced sudden chest pain and dyspnea. Hypotension with hypokinesis was observed in the echocardiogram along with increased myocardial enzyme. We suspected cardiogenic shock due to acute myocardial infarction, but coronary angiography demonstrated no coronary stenosis. The patient's vital signs improved with urinary drainage. Our diagnosis was takotsubo cardiomyopathy as a result of urosepsis. The second patient was a 63-year-old woman with abdominal pain, diarrhea and vomiting. Hypotension, drowsiness, ascites and intestinal edema in computed tomography were observed. While we suspected panperitonitis due to intestinal perforation, our diagnosis was urosepsis from acute pyelonephritis and kidney abscess based on necrotomy findings. The final patient was an 82-year-old woman with drowsiness and abdominal pain. Hypotension and dilatation of the right renal pelvis, and intrahepatic bile duct with choledocholith were observed in CT. We suspected septic shock due to pyogenic cholangitis based on the abdominal symptoms, but we diagnosed the case as urosepsis with pyelonephritis based on culture findings. In all cases, fatal diseases were suspected by the symptoms and findings, while urosepsis was not strongly suspected. In the differential diagnosis of septic shock, even if symptoms and findings do not strongly indicate urosepsis, we should consider drainage of the urinary tract for diagnosis and treatment.

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Association is not causation. This is a well-known statement. In this connection, there is a definition: “Biases are present when there is a difference between association and causation”. The counterfactual model and directed acyclic graph (DAG), presented during Lesson 3, provide very useful tools for understanding and arranging biases. It is advisable to view confounding biases as those arising from common causes in DAG and selection biases as those arising from adjustment of common results in DAG. So far as information biases are concerned, understanding of non-differential misclassification is useful. When results are to be interpreted, it is essential to know the direction and extent to which a given bias causes deviation of the “estimated value” from the “true value”, that is, to examine whether a given bias involves overestimation (away from the null) or underestimation (toward the null), making use of 2 × 2 cross-tables.

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