Extracorporeal circulation is performed using hemodiafiltration circuits for the purpose of cooling the core temperatures of patients with severe heat stroke. By using the warmer coil instead of the hemofilter, we thus tried to improve the cooling efficiency even further. We investigated the background, admission status, use of extracorporeal circulation and outcomes in patients with severe heat stroke admitted to our hospital during the period from July 2000 to October 2011. Patients who underwent extracorporeal circulation were divided into two groups: those who underwent extracorporeal circulation before (the previous group) and those who underwent extracorporeal circulation after (the late group) improvements were made to the circuits in 2004. The time from admission until the start of extracorporeal circulation, extracorporeal circulation time, cooling efficiency, period of mechanical ventilation and length of hospitalization were compared between the two groups. Twenty-eight patients were evaluated, and the previous and late groups included six and eight cases, respectively. No significant differences in age, sex, body mass index, APACHE II score, SOFA score, DIC score or core temperature on admission were observed between the two groups. The extracorporeal circulation time was 32.5 minutes in the previous group and 27.5 minutes in the late group. The extracorporeal circulation time decreased in the late group, but no significant differences were observed. Cooling efficiency in the late group was significantly higher than that in the previous group (0.112°C/min vs. 0.040°C/min, p<0.01). No significant differences in the period of mechanical ventilation (6.0 days in the previous group vs. 3.5 days in the late group) or the length of hospitalization (10.0 days in the previous group vs. 13.5 days in the late group) were observed between the two groups. The improvement of cooling efficiency was achieved by devising new circuits and devices. The methods of core temperature cooling that we used in the late period (after 2004) are clinically useful.

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Objective: Although simulation-based training has been widely used for resuscitation programs, few studies have so far evaluated its effectiveness. This study measured the rate and time needed to perform tasks in simulation scenarios to assess the effectiveness of resuscitation training.
Methods: This study evaluated 24 newly-hired residents at the National Center for Child Health and Development in 2009 (doctor-in-training 11, pediatrician 11, other 2). The residents had an average of 3.5 years post-graduate years of experience. Twenty-three residents were PALS (pediatric advanced life support) providers and they had completed the PALS an average of 7 months earlier. The residents were divided into two groups (simulation group: SG, control group: CG). The SG members were trained by means of simulation methodology. Twelve courses (two scenarios, 30 minutes, once a week, for three months) were provided. Both groups of residents participated in a 7-minute test with a simulation scenario (using infant ventricular fibrillation) before and after the simulation-training course, and the time for each individual to successfully perform the tasks needed for resuscitation was measured.
Results: 1) The time the residents needed to perform chest compression was shorter (p=0.04) and the total CPR time was longer (p=0.002) in the SG in comparison to the CG. 2) The time needed to perform ventilation (p=0.03) and chest compression (p=0.002) was shorter and the total CPR time was also longer (p=0.005) in the SG, after the course than before.
Conclusion: Repeating the same scenarios and increasing the amount of training improved the effectiveness of the resuscitation training for cardiopulmonary arrest. However, various problems regarding the limited opportunities for in-hospital training and the optimal methodologies for training residents whose performance is found to be insufficient remain to be resolved. In addition, the knowledge and skills acquired by simulation-based training declined over time. Therefore, it is necessary to determine the optimal duration and frequency of such training.

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Emergency medical centers play important roles in treating high-energy trauma patients with extremity fractures. However, there have been no reports on the long-term outcome of fractures internally fixated at emergency medical centers in Japan. The purpose of this study was to show the rates of bone union and unexpected re-operations, and to evaluate the risk factors for re-operations. A total of 272 patients with 363 extremity fractures were retrospectively reviewed. Age, mechanism of injury, injury severity score, fracture site, presence of open fracture, and follow-up data were collected using an electronic medical records system. Patients who were followed up at other institutions were investigated by sending letters to the respective orthopaedic directors. The median age of the patients was 37 years old. Mechanisms of injury, in decreasing order, were motorcycle accident, fall from a height, and automobile accident. The most frequent fracture site was femoral shaft followed by tibial shaft. Open fracture was observed in 39.4% of all the fractures. Long-term outcome was shown in 324 fractures (89.3%) with a median follow-up of 19 months. Of those, 90 fractures required unexpected re-operations at a median after internal fixation time of 112 days. The reasons for re-operation were surgical site infection, nonunion, and delayed union in decreasing order. In total, 313 fractures (96.6%) achieved good bone union; however, there were several fractures that were refractory, e.g., arthrodesis in 4, amputation in 3, nonunion in 2, joint replacement in 1, and chronic osteomyelitis in 1. Logistic regression analysis revealed that open fracture, lower extremity fracture, and fractures in multiple trauma patients were statistically significant risk factors for re-operations. In summary, high-energy fractures, especially those with open wounds, located in the lower extremities, or multiple trauma patients tend to have a significant possibility of requiring unexpected re-operations and should be followed up meticulously after internal fixation.

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The first case was a 47-year-old female with diabetes. Left dorsal pain appeared 8 months previously. She became unable to walk, and the previous physician sent her to our hospital by ambulance. A large volume of gas was noted in the left retroperitoneal space over the region around the hip joint. Open drainage and colostomy were performed for retroperitoneal abscess caused by perforation of the descending colon and purulent coxitis directly caused by the abscess. When retroperitoneal infection was controlled, acetabular curettage and femoral head transection were performed for myelitis of the left acetabula and femoral head. The second case was a 52-year-old male with no particular past medical history. He had had right lower back pain for a month and was referred to us by the previous physician. Open drainage was appropriately performed for secondary iliopsoas abscess which may have been caused by perforation of a diverticulum of the ascending colon, but complication by purulent coxitis and myelitis right occurred, and acetabular curettage and femoral head transection were performed. It may be necessary to pay attention to complications caused by purulent coxitis and myelitis when the iliopsoas muscle is the main progression pathway of gastrointestinal perforation-induced retroperitoneal abscess.

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An 84-year-old woman with a nosebleeds was transported to our hospital in an ambulance. We checked her vital signs and found an ST segment elevation in lead II on electrocardiography. She did not have chest pain at presentation, and we packed her right nasal cavity with gauze soaked in epinephrine. A 12-lead electrocardiography revealed ST segment elevations in leads II, III, aVf, and V3-V6. She complained of mild chest pain in the ambulance, and her condition was diagnosed as acute myocardial infarction. Coronary angiography revealed no obstructing lesions, and left ventriculography revealed apical ballooning of the left ventricle. On the basis of these findings, the condition was diagnosed as Takotsubo cardiomyopathy (TCM). TCM is a cardiac condition with clinical symptoms similar to those of myocardial infarction and is usually associated with emotional stress. This is the first report of TCM in an elderly woman with a nosebleeds. The findings of this case indicate the importance of routine examination, including electrocardiography, in the evaluation of the condition of a patient with common complaints.

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Hepatic portal venous gas (HPVG) has been considered an ominous radiologic sign. However, the increased use of high resolution CT has allowed early and highly sensitive detection of not only bowel necrosis, but also non-life-threatening causes of HPVG. Because the prognosis is related to the pathology itself and is not influenced by the presence of HPVG, appropriate treatment depends on the underlying disease. However, it is sometimes difficult to exclude bowel necrosis before deciding whether to perform exploratory laparotomy. To establish the appropriate management of HPVG, we retrospectively reviewed the records of patients seen in our institution from April 2009 to March 2013. Twelve cases of HPVG were detected and 8 cases were excluded because of cardiopulmonary arrest. Four cases showed bowel necrosis, which achieved significance with signs of rebound tenderness (p=0.039), base excess (p=0.039), and C-reactive protein (p=0.025). Neither the findings of HPVG nor the amount of HPVG significantly relate to bowel necrosis. In conclusion, signs of rebound tenderness, base excess, and C-reactive protein were important indicators of bowel necrosis in our study.

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