Prehospital emergency medical care (PEMC) refers to events in which a medical crew, including emergency physicians and nurses, is dispatched to a prehospital scene to provide early treatment for patients. The Japanese HEMS (Helicopter Emergency Medical Service) system, also known "Doctor-Helicopter," has enabled the establishment of a PEMC system. The Hokusoh HEMS has been dispatched on 587 missions, representing 15.6% of all Japanese HEMS dispatches to emergency sites in 2008. Among 151 trauma patients with an Injury Severity Score greater than 15, the Revised Trauma Score at the time of arrival at the emergency department was significantly higher than that before the prehospital treatment provided by HEMS (6.57±1.63 vs. 6.16±1.65; p<0.001). The coronary angiography time was also significantly shorter in the HEMS group than in the ground ambulance group (98.8±29.2 minutes vs. 126.6±48.7 minutes; p<0.05). These results show that the Japanese HEMS system can help improve the emergency medical system, as have similar helicopter services in the United States and Europe. However, a rapid response ground-based system is also needed to compensate for limitations of the HEMS, such those arising from weather and night-time conditions. Furthermore, the PEMC system requires an "early alert" and "over-triage" of the helicopter or ground ambulance dispatch (THESE TERMS ARE STILL UNCLEAR). The HEMS should also be available to transport Disaster Medical Assistance Teams to disaster sites, such as major accidents or earthquakes. Thus, the efficient deployment and networking of the HEMS are needed for the practical use of Doctor Helicopters in disaster situations. The education and training of young physicians dispatched to the scenes of accidents is also essential for establishing the PEMC system. Such physicians must not only be able to treat patients but must also have the discretion and talent to control the accident site and assume a leadership position. Such skills should be fostered through on-the-job training involving actual missions onboard a helicopter or a ground ambulance while accompanied by a senior physician, rather than through lectures or simulations. The PEMC represents proactive, not reactive, medical care and may offer a solution to the present insufficiencies in emergency health care. The Hokusoh HEMS wishes to propose a new model for emergency medical services through the use of a PEMC system incorporating both helicopter and ground-based ambulances.

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Pancreaticoduodenectomy (PD) is the procedure of choice for malignant disorders and certain benign disorders in the pancreaticoduodenal region. Several modifications of the surgical procedure have been proposed for accomplishing radical resection and for improving of quality of life. Pancreatic fistula (PF) is a common, potentially life-threatening postoperative complication of PD. An International Study Group on Pancreatic Fistula defined PF as drain output of any measurable volume of fluid on or after postoperative day 3 with amylase content greater than 3 times the serum amylase activity. This definition grades the severity of PF according to its effect on the clinical course. According to this criterion, about 20% of patients have PF after PD. Of these patients, 10% have grade B or C PF. Soft pancreatic parenchyma, intraoperative blood transfusion, and postoperative bleeding are significant risk factors for PF after PD. Conservative treatment is the treatment of first choice for PF after PD and is extremely effective. However, some patients require additional percutaneous drainage or surgical treatment or both. Uncontrolled sepsis and massive hemorrhage are the main causes of death. Early aggressive interventional embolization allows later conservative management of most patients with intraabdominal hemorrhage and prevents death. Therefore, early recognition of a PF and prompt and appropriate treatment are critical for preventing potentially devastating consequences. On the other hand, little has been done to evaluate the efficacy of tissue engineering for anastomotic healing of pancreaticojejunostomy toward the goal of "Zero PF." We examined the effects of basic fibroblast growth factor incorporated in gelatin hydrogel (bFGF-GH) microspheres on anastomotic healing. Basic FGF-GH administration can promote the rapid completion of pancreaticojejeunal anastomosis and may help improve the quality of healing in granulation tissue by conferring potent angiogenesis and accelerating apoptosis. Basic FGF-GH shows promise as a new technique for preventing PF.

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Dysphagia and chest pain often occur in adults, and most patients with persistent symptoms initially undergo evaluation to rule out reflux esophagitis, esophageal cancer, and cardiovascular disease. When the findings of these evaluations are normal, esophageal manometry is performed. Esophageal motility disorders, which include achalasia, diffuse esophageal spasm, nutcracker esophagus, hypertensive lower esophageal sphincter, and nonspecific esophageal motility disorder, are often identified in these patients. In our series, 78% of patients with nonobstructive dysphagia or unexplained (noncardiac) chest pain or both have an esophageal motility disorder (achalasia, 44%; diffuse esophageal spasm, 5%; nutcracker esophagus, 2%; and nonspecific esophageal motility disorder, 27%). Therefore, in patients who present with dysphagia or chest pain or both, an esophageal motility disorder should be suspected.

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People 65 years and older can be divided into 2 groups: the young old (those aged 65 to 74 years) and the old old (those 75 years or older). The old old are at greater risk for several common geriatric syndromes, such as depression, cognitive impairment, urinary incontinence, injurious falls, and persistent pain. Comprehensive geriatric assessment programs linking geriatric evaluation with strong long-term management are effective for improving survival and function in older persons. Diastolic blood pressure decreases after 60 years in association with a continual rise in systolic blood pressure. Whether treatment of hypertension for patients 80 years or older is beneficial is still unclear. Epidemiologic population studies have suggested that blood pressure and the risk of death are negatively correlated in people 80 years or older. The Hypertension in the Very Elderly Trial, suggests that antihypertensive treatment in persons 80 years or older is beneficial.

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We introduce a new technique of thoracoscopic esophagectomy with the patient in the prone position. The prone position allows mobilization of the esophagus and lymphadenectomy with only 5 trocars because the deflated lung does not block access. Stomach mobilization and gastric tube creation are performed by means of laparoscopy with the patient in the supine position. The esophagogastric anastomosis is an end-to-side anastomosis performed through a left cervical incision. This technique could reduce postoperative pain and morbidity.

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Immunohistochemistry is concerned with the detection of specific biological substances at the light and electron microscopic levels with antibodies labeled with visible markers, such as horseradish peroxidase and colloidal gold. In particular, the immunohistochemistry of electron microscopy has provided much morphological and biological information. Immunoelectron microscopy can be classified into three methods, i.e., pre-embedding, postembedding, and nonembedding methods, on the basis of the step during which the immunoreaction is applied to the biological specimens. Each method has both advantages and disadvantages, so we should select the method according to the biological purpose. An overview of immunoelectron microscopy is given, and several electron micrographs using immunohistochemical techniques are shown.

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We report on a 70-year-old man with recurrent bloody bowel discharge. We detected angiectasia at the distal ileum at initial capsule endoscopy. The angioectasia was treated with double balloon endoscopy. After treatment, bloody bowel discharge recurred. At a second capsule endoscopy after treatment of the distal ileum with double balloon endoscopy, another angiectasia and a bleeding ulcer were detected on the proximal jejunum. The bleeding ulcer was re-treated with double balloon endoscopy. After re-treatment, bloody bowel discharge again recurred. At a third capsule endoscopy, active bleeding was detected at the proximal jejunum. We were then able to diagnose the angiectasia on the proximal jejunum detected at the second capsule endoscopy and to determine that it was the source of bleeding. The angiectasia was detected and was treated with double balloon endoscopy. After treatment, the bloody bowel discharge has not recurred. We should carefully treat patients with multiple angiectasias, because most angiectasias can be sources of bleeding.

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We describe a case of severe facial burn caused by a heated floor. A 63-year-old man with a history of diabetes mellitus fell asleep on a heated floor in a Japanese sauna after drinking a large quantity of alcohol. He sustained a severe moderate-temperature burn of the nose, upper lip, left cheek, and left earlobe. After the patient's general condition had improved, the affected areas were debrided and reconstructed with flaps. The skin and subcutaneous defect of the upper lip were reconstructed with a submental artery perforator flap. The flap survived completely, and the aesthetic result was good because of a simultaneously reconstructed mustache. The pathogenesis of the moderate-temperature burn is explained by the temperature-time curve and is due mainly to a disorder of blood circulation and the individual's condition. We believe that the number of persons sustaining such burns in saunas will increase because of recent health trends in Japan. Therefore, the danger of such burns should be publicized.

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