Distal radial approach for arterial pressure monitoring with a long catheter provides safe and stable monitoring in the intensive care unit: A single-center retrospective study.

BACKGROUND: To compare the distal radial artery approach (DRA) with a longer catheter to DRA with a shorter catheter in arterial catheter (AC) placement in the intensive care unit (ICU). METHODS: This was a single-center retrospective cohort study of DRA with a long catheter (60 mm) for arterial catheterization in the ICU. DRA with a short catheter (25-30 mm) was used in the control group, and the groups were compared using multivariate regression analysis. The primary study endpoint was the incidence of unplanned AC removal. The secondary endpoint was the incidence of other inappropriate events, namely loss of arterial pressure waveforms, bleeding, catheter-related infection, pressure ulcer, and other complications associated with the AC. RESULTS: In this study, the DRA with a long catheter was used in 50 patients. No unplanned AC removals or other inappropriate events occurred, and there were no complications associated with the DRA. The DRA procedural success rate was 100%. There was no significant difference in hemostasis times between the groups. Loss of arterial waveforms was an early predictor of unplanned AC removal. CONCLUSIONS: The DRA with a long catheter provided stable monitoring and was associated with a low unplanned removal rate. This method has the advantages of fewer complications and shorter hemostasis time compared with the DRA with a short catheter, and may become a new AC option in the ICU.

Economic effects of dietary salt reduction policies for cardiovascular disease prevention in Japan: a simulation study of hypothetical scenarios.

Objective: Reducing dietary salt intake is an essential population strategy for cardiovascular disease (CVD) prevention, but evidence on healthcare costs and outcomes is limited in Japan. We aimed to conduct a pilot economic evaluation under hypothetical scenarios of applying the salt reduction policies of England to Japan. Methods: We examined salt reduction policies in England: media health promotion campaigns, front-of-pack labeling, and voluntary and mandatory reformulation with best-case and worst-case policy cost scenarios. We assumed that these policies were conducted in Japan for 10 years from 2019. We used published data on epidemiology and healthcare expenditures in Japan and the costs and effects of salt reduction policies in England, and defined the benefits as a decrease in national medical expenditures on CVD. We developed a Markov cohort simulation model of the Japanese population. To estimate the annual net benefits of each policy over 10 years, we subtracted monitoring and policy costs from the benefits. We adopted a health sector perspective and a 2% discount rate. Results: The cumulative net benefit over 10 years was largest for mandatory reformulation (best case) at 2,015.1 million USD (with costs of USD 48.3 million and benefits of USD 2063.5 million), followed by voluntary reformulation (net benefit: USD 1,895.1 million, cost: USD 48.1 million, benefit: USD 1,943.2 million), mandatory reformulation (worst case, net benefit: USD 1,447.9 million, cost: USD 1,174.5 million, benefit: USD 2,622.3 million), labeling (net benefit: USD 159.5 million, cost: USD 91.6 million, benefit: USD 251.0 million), and a media campaign (net benefit: USD 140.5 million, cost: USD 110.5 million, benefit: USD 251.0 million). There was no change in the superiority or inferiority of policies when the uncertainty of model parameters was considered. Conclusion: Mandatory reformulation with the best-case cost scenario might be economically preferable to the other alternatives in Japan. In future research, domestic data on costs and effects of salt reduction policies should be incorporated for model refinement.

Reduction of Cardiovascular Events and Related Healthcare Expenditures through Achieving Population-Level Targets of Dietary Salt Intake in Japan: A Simulation Model Based on the National Health and Nutrition Survey.

Reducing population dietary salt intake is expected to help prevent cardiovascular disease and thus constrain increasing national healthcare expenditures in Japan's super-aged society. We aimed to estimate the impact of achieving global and national salt-reduction targets (8, <6, and <5 grams/day) on cardiovascular events and national healthcare spending in Japan. Using published data including mean salt intake and systolic blood pressure from the 2019 National Health and Nutrition Survey, we developed a Markov model of a closed cohort of adults aged 40−79 years in 2019 (n = 66,955,000) transitioning among six health states based on the disease course of ischemic heart disease (IHD) and stroke. If mean salt intake were to remain at 2019 levels over 10 years, cumulative incident cases in the cohort would be approximately 2.0 million for IHD and 2.6 million for stroke, costing USD 61.6 billion for IHD and USD 104.6 billion for stroke. Compared with the status quo, reducing mean salt intake towards the targets over 10 years would avert 1−3% of IHD and stroke events and save up to 2% of related national healthcare costs. Attaining dietary salt-reduction goals among adults would yield moderate health economic benefits in Japan.

The Tsukui (Japan) Yamayuri-en Facility Stabbing Mass-Casualty Incident.

INTRODUCTION: In July 2016, a mass-casualty stabbing attack took place at a facility for disabled persons located in Sagamihara City (Kanagawa Prefecture, Japan). The attack resulted in 45 casualties, including 19 deaths. The study hospital dispatched physicians to the field and admitted multiple casualties. This report aimed to review the physicians' experiences and to provide insights for the formulation of response measures for similar incidents in the future. REPORT: This incident involved 30 emergency teams and 12 fire department teams, including those from neighboring fire departments. Five physicians from three medical institutions, including the study hospital, entered the field. The Simple Triage and Rapid Treatment (START) method was used on the field. The final field triage category count was: 20 red, four yellow, two green, and 19 black tags. All the casualties (n = 26) except for the 19 black tag casualties were transported to one of six neighboring medical institutions.The median age of the transported casualties was 41 years (interquartile range [IQR] = 35.5 - 42.0). Three casualties (21.4%) were in hemorrhagic shock on arrival at the hospital. Twelve patients had multiple cervical stab wounds (median four wounds; IQR = 3.75 - 6.0). A total of 91.7% of these stab wounds were in mid-neck Zone II region. Of the 12 patients with cervical stab wounds, four (33.3%) required emergency surgery, and the rest were sutured on an out-patient basis. One patient had already been sutured on the field. All patients requiring emergency surgery had deep wounds, including those of the carotid vein, thyroid gland, nerves, and the trachea. Eight of the casualties were hospitalized at the study institution. Five of them were admitted to the intensive care unit. There were no deaths among the casualties transported to the hospitals. CONCLUSION: Regional core disaster medical hospitals must take on a central role, particularly in the case of local disasters. Horizontal communication and interactions should be reinforced by devising protocols and conducting joint training for effective inter-department collaborations on the field.Maruhashi, T, Takeuchi, I, Hattori, J, Kataoka, Y, Asari, Y. The Tsukui (Japan) Yamayuri-en facility stabbing mass-casualty incident. Prehosp Disaster Med. 2019;34(2):203-208.

The Imbalance in Medical Demand and Supply for Pediatric Victims in an Earthquake.

OBJECTIVES: We quantified an absolute imbalance of the medical risks and the support needs for children at each disaster-based hospital in Kanagawa immediately following the occurrence of a large earthquake by using the risk resource ratio (RRR) and need for medical resources (NMR). METHODS: The RRR and NMR of 33 disaster-based hospitals were estimated through dividing the estimated number of pediatric victims by the number of critically patients. We calculated the ratio of the NMR of each hospital. RESULTS: The total number of pediatric victims in Kanagawa was estimated at 8,391. The total number of vacant beds for pediatric victims was 352. The median RRR and NMR of the total number of pediatric victims were 27 and 224. The median RRR and NMR of the number of critically ill pediatric patients were 27 and 12. CONCLUSIONS: The absolute imbalance of the RRR and NMR for children in Kanagawa was quantified. This suggests that we might embark on preparedness strategies for children in advance. (Disaster Med Public Health Preparedness. 2018;13:672-676).

Creating a new index to evaluate imbalance in medical demand and supply when disasters occur.

AIM: This study examines the use of the medical risk/resource ratio (RRR) and need for medical resources (NMR) as new indicators of the imbalance in medical demand and supply in disasters. These indicators are used to quantify the medical demand-supply imbalance per disaster base hospital, examine the demand-supply imbalance in the region, and verify the need for medical support. METHODS: We calculated the RRR of each disaster base hospital by dividing the revised estimate of the number of patients with the number of empty beds. We calculated the required number of hospital beds as the NMR to restore the RRR of each disaster base hospital to two. The RRR and NMR were combined, and prioritization for medical support was classified into three levels. RESULTS: The median RRR was 23 (range, 1-101), and the median NMR was 943 (range, 0-2,124). Fifteen hospitals had a medical support priority of 1, five hospitals had a priority of 2, and 13 hospitals had a priority of 3. CONCLUSION: The medical demand-supply imbalance and amount of medical support needed can be quantified using RRR and NMR, which allows examination of the priority level for medical support.

A case of intestinal obstruction due to inflammatory changes in the small intestine from alkaline ingestion.

CASE: Alkaline ingestion frequently causes corrosive esophagitis but rarely causes lower digestive tract injury. In this case, a 79-year-old man accidentally drank kitchen detergent. After 3 h, lower abdominal pain occurred and gradually worsened. He was taking a proton pump inhibitor after proximal gastrectomy for gastric cancer. He had local tenderness in the left lower abdomen. Abdominal computed tomography showed expansion of the small intestine, thickening of the intestinal wall, and inflammatory changes. Upper gastrointestinal endoscopy showed no obvious injury to the esophagus or stomach. OUTCOME: Conservative treatment with an ileus tube was undertaken for intestinal obstruction caused by alkaline ingestion. There were no complications, such as gastrointestinal perforation, and he was discharged on day 17. CONCLUSION: Alkaline ingestion may cause injuries not only to the upper but also to the lower digestive tract in patients who are taking proton pump inhibitors or have had gastrectomy.

Impact of Doctor Car with Mobile Cloud ECG in reducing door-to- balloon time of Japanese ST-elevation myocardial infarction patients.

Early reperfusion by percutaneous coronary intervention (PCI) is the current standard therapy for ST-elevation myocardial infarction (STEMI). To achieve better prognoses for these patients, reducing the door-to-balloon time is essential. As we reported previously, the Kitasato University Hospital Doctor Car (DC), an ambulance with a physician on board, is equipped with a novel mobile cloud 12-lead ECG system. Between September 2011 and August 2013, there were 260 emergency dispatches of our Doctor Car, of which 55 were for suspected acute myocardial infarction with chest pain and cold sweat. Among these 55 calls, 32 patients received emergent PCI due to STEMI (DC Group). We compared their data with those of 76 STEMI patients who were transported directly to our hospital by ambulance around the same period (Non-DC Group). There were no differences in patient age, gender, underlying diseases, or Killip classification between the two groups. The door-to-balloon time in the DC group was 56.1 ± 13.7 minutes and 74.0 ± 14.1 minutes in the Non-DC Group (P < 0.0001). Maximum levels of CPK were 2899 ± 308 and 2876 ± 269 IU/L (P = 0.703), and those of CK-MB were 292 ± 360 and 295 ± 284 ng/mL (P = 0.423), respectively, in the 2 groups. The Doctor Car system with the Mobile Cloud ECG was useful for reducing the door-to-balloon time.

Refractory status epilepticus, circulatory collapse after cardiac arrest, and acute respiratory distress syndrome caused by severe isolated fluvoxamine poisoning: a case report.

Case: A 30-year-old female ingested 21.75 g fluvoxamine in a suicide attempt. She presented with grand mal seizures and vomiting on admission to our Emergency Center, with a fluvoxamine serum concentration of 4.58 µg/mL. The patient was diagnosed with status epilepticus, which could not be fully suppressed with the maximum dosage of benzodiazepines. The patient also developed circulatory collapse after resuscitation for sudden cardiac arrest and acute respiratory distress syndrome, believed to be secondary to aspiration. Outcome: With venoarterial extracorporeal membrane oxygenation, a massive infusion of propofol successfully suppressed status epilepticus, and both the circulatory collapse and acute respiratory distress syndrome gradually improved; venoarterial extracorporeal membrane oxygenation and propofol treatments were then terminated, and the patient was discharged without further disabilities. Conclusion: Compared to all other reported clinical cases of fluvoxamine poisoning, the patient in this study ingested the highest dose and developed the most severe symptoms, but was successfully treated without any disabilities.

[Clostridium tetani isolated from patients with systemic tetanus].

Clostridium tetani is widely distributed in ground or mud, especially in field and pond-shore surface layers. C. tetani is rarely isolated from specimens of patients with tetanus, and is generally diagnosed based on clinical symptoms such as trismus or general tonic spasms. This means that positive C. tetani infection is rarely diagnosed bacterially. Using gram straing, we identified C. tetani in specimens from patients suspected of C. tetani infection brought to the Kitasato University Hospital emergency center. Rapid gram staining information in the bacteriology laboratory is expected to improve recovery from C. tetani infection. It is therefore necessary to ensure clinical specimen quality control, and to keep standard strains of rare bacteria for isolation and identification.

A case of HELLP syndrome with multiple complications.

Hemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome is a rare complication of pregnancy. The mortality rate associated with HELLP syndrome increases when life-threatening complications occur. A 37-year-old woman at 37 weeks of gestation developed severe cerebral hemorrhage at the beginning of labor induction and was transferred to our hospital, where HELLP syndrome was diagnosed. She developed disseminated intravascular coagulation (DIC), hepatic hematoma, and cerebral infarction after surgery. On day 68, she was transferred to her local hospital. Careful observation and rapid management can save patients with severe complications of HELLP syndrome.

Effects of the Chinese herbal medicines Bupleuri radix, Ginseng radix, and Zingiberis rhizoma on lymphatic vessel activity in rats.

The aim of the present study was to determine the effects of the Chinese herbal medicines Bupleuri radix, Ginseng radix and Zingiberis rhizoma on spontaneous lymphatic vessel activity. The effect of each herbal medicine on in vivo lymphatic flow was examined by injection of dye into the femoral regions of rats after feeding with the herbal medicines. In an in vitro study, spontaneous changes in diameter of the rat thoracic duct were monitored, and each segment was exposed to each herbal medicine. In the in vivo study, 100% of the right iliac lymphatic node were positively stained in the herbal medicine group, whereas only 40% of the node were positively stained in the control group. In the in vitro study, Bupleuri radix and Ginseng radix increased the amplitude of spontaneous activity of lymphatic vessels in a concentration-dependent manner with or without L-NAME, an NO synthase inhibitor. The results indicated that the herbal medicines Bupleuri radix and Ginseng radix activated spontaneous lymphatic vasomotion and lymph flow, and the mechanisms of this effect seem to be independent of endothelial cells.

Inhibitory effects of the anesthetics propofol and sevoflurane on spontaneous lymphatic vessel activity in rats.

BACKGROUND: The effects of propofol and sevoflurane on lymphatic vessel activity are unknown. This study aimed to clarify the effects of these anesthetics on lymphatic vessel activity in rats by the use of a technique for mechanical removal of the endothelium. METHODS: The authors first examined the effects of propofol (8 mg/kg) and sevoflurane (2.0%) on in vivo lymphatic flow by injection of dye into the femoral regions of rats. In the in vitro study, the ends of the vessel segments of rat thoracic duct were connected to a syringe and stopcock, respectively. Spontaneous changes in diameter of each segment were monitored, and the extraluminal side of each segment was exposed to propofol (1 x 10(-6) approximately 3 x 10(-5) M) or sevoflurane (0.5 approximately 2.0%). Endothelial function was eliminated by perfusion of air into the lumen. RESULTS: In the dye uptake study, 80% of iliac lymphatic nodes were positively stained in a control group, whereas only 10% and 20% were positively stained in propofol and sevoflurane groups, respectively. In the in vitro study, both of the anesthetics significantly decreased the amplitude of spontaneous activity of lymphatic vessels with or without endothelial function. Sevoflurane inhibited the frequency of lymphatic vessel activity but propofol had no effect on it. When the endothelial function was eliminated, both anesthetics decreased the frequency of spontaneous activity of lymphatic vessels. CONCLUSIONS: Propofol and sevoflurane seem to have some different effects on endothelial function, which regulates the pacemaking of spontaneous contraction of lymphatic vessels.

Differential pressor response to intravenous ephedrine during recovery from deliberate hypotension.

STUDY OBJECTIVE: To determine whether nitroglycerin or trimethaphan alters pressor response to intravenous (i.v.) ephedrine. DESIGN: Prospective, randomized study. SETTING: Operating room of a university hospital. PATIENTS: 60 ASA physical status I female patients scheduled for mastectomy. INTERVENTIONS: Patients were assigned to one of six groups (n = 10 in each). Group 1: nitroglycerin + normal saline (NS) i.v., Group 2: nitroglycerin + ephedrine 0.1 mg/kg i.v., Group 3: nitroglycerin + ephedrine 0.15 mg/kg i.v., Group 4: trimethaphan + NS i.v., Group 5: trimethaphan + ephedrine 0.1 mg/kg i.v., and Group 6: trimethaphan + ephedrine 0.15 mg/kg i.v. MEASUREMENTS: Hemodynamic responses to ephedrine following withdrawal of vasodilators were observed for 15 minutes. MAIN RESULTS: Ephedrine increased heart rate and mean blood pressure. After ephedrine 0.1 mg/kg i.v., the maximum pressor response in the trimethaphan group was approximately twofold that of the nitroglycerin group (p = 0.038). CONCLUSIONS: Ephedrine restored BP more easily in those patients who had received trimethaphan compared with those who had received nitroglycerin for deliberate hypotension.

Role of endothelium-derived hyperpolarizing factor in phenylephrine-induced oscillatory vasomotion in rat small mesenteric artery.

BACKGROUND: In small mesenteric arteries, endothelium-derived hyperpolarizing factor (EDHF) in addition to endothelium-derived relaxing factors (EDRFs) including NO plays an important role in acetylcholine-induced vasodilation. It has been reported that EDRFs play an important role in alpha(1)-adrenoceptor agonist-induced oscillatory vasomotion and in limiting vasoconstrictor response to the agonists; however, contribution of EDHF to the alpha(1)-agonist-induced oscillation is unknown. METHODS: Rat small mesenteric arteries were isolated and cannulated at each end with a glass micropipette. The vessels were immersed in a bath (37 degrees C) containing physiologic saline solution. Changes in vessel diameter were measured using an optical density video detection system. RESULTS: Denudation of the endothelium and inhibition of NO synthesis caused a leftward shift in the concentration-response relation for phenylephrine in the mesenteric arteries, whereas inhibition of cyclooxygenase by indomethacin had no effect. Blockade of Ca2+-activated K+ (K(Ca)) channels by charybdotoxin and apamin caused a further leftward shift in the concentration-response relation in the vessels pretreated with Nomega-nitro-l-arginine methylester and indomethacin. Phenylephrine at concentrations higher than 10(-6) m caused endothelium-dependent oscillatory vasomotion, which was reduced but not abolished after combined inhibition of the cyclooxygenase and NO synthase pathways. However, the K(Ca) channel blockers completely abolished the remaining component of oscillation. CONCLUSIONS: Endothelially-derived NO is an important modulator of sustained agonist-induced vasoconstriction. NO, as well as endothelially-derived cyclooxygenase products and EDHF, also contribute significantly to phenylephrine-induced oscillatory vasomotion.

Bronchospasm induced by propofol in a patient with sick house syndrome.

IMPLICATIONS: Propofol is often used in patients with asthma, but it can induce bronchospasm. We report a patient with sick house syndrome (nonspecific complaints of mucosal irritation, headache, nausea, and chest symptoms) who suffered bronchospasm. This case suggests that propofol is not always a safe anesthetic for patients with asthma, especially drug-induced asthma.