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Showing 1 - 200 of 1577 Journals sorted alphabetically
Abacus     Hybrid Journal   (Followers: 12, SJR: 0.48, h-index: 22)
About Campus     Hybrid Journal   (Followers: 5)
Academic Emergency Medicine     Hybrid Journal   (Followers: 61, SJR: 1.385, h-index: 91)
Accounting & Finance     Hybrid Journal   (Followers: 45, SJR: 0.547, h-index: 30)
ACEP NOW     Free   (Followers: 1)
Acta Anaesthesiologica Scandinavica     Hybrid Journal   (Followers: 49, SJR: 1.02, h-index: 88)
Acta Archaeologica     Hybrid Journal   (Followers: 145, SJR: 0.101, h-index: 9)
Acta Geologica Sinica (English Edition)     Hybrid Journal   (Followers: 3, SJR: 0.552, h-index: 41)
Acta Neurologica Scandinavica     Hybrid Journal   (Followers: 5, SJR: 1.203, h-index: 74)
Acta Obstetricia et Gynecologica Scandinavica     Hybrid Journal   (Followers: 15, SJR: 1.197, h-index: 81)
Acta Ophthalmologica     Hybrid Journal   (Followers: 5, SJR: 0.112, h-index: 1)
Acta Paediatrica     Hybrid Journal   (Followers: 56, SJR: 0.794, h-index: 88)
Acta Physiologica     Hybrid Journal   (Followers: 6, SJR: 1.69, h-index: 88)
Acta Polymerica     Hybrid Journal   (Followers: 9)
Acta Psychiatrica Scandinavica     Hybrid Journal   (Followers: 35, SJR: 2.518, h-index: 113)
Acta Zoologica     Hybrid Journal   (Followers: 6, SJR: 0.459, h-index: 29)
Acute Medicine & Surgery     Hybrid Journal   (Followers: 3)
Addiction     Hybrid Journal   (Followers: 33, SJR: 2.086, h-index: 143)
Addiction Biology     Hybrid Journal   (Followers: 12, SJR: 2.091, h-index: 57)
Adultspan J.     Hybrid Journal   (SJR: 0.127, h-index: 4)
Advanced Energy Materials     Hybrid Journal   (Followers: 24, SJR: 6.411, h-index: 86)
Advanced Engineering Materials     Hybrid Journal   (Followers: 26, SJR: 0.81, h-index: 81)
Advanced Functional Materials     Hybrid Journal   (Followers: 50, SJR: 5.21, h-index: 203)
Advanced Healthcare Materials     Hybrid Journal   (Followers: 13, SJR: 0.232, h-index: 7)
Advanced Materials     Hybrid Journal   (Followers: 250, SJR: 9.021, h-index: 345)
Advanced Materials Interfaces     Hybrid Journal   (Followers: 6, SJR: 1.177, h-index: 10)
Advanced Optical Materials     Hybrid Journal   (Followers: 5, SJR: 2.488, h-index: 21)
Advanced Science     Open Access   (Followers: 5)
Advanced Synthesis & Catalysis     Hybrid Journal   (Followers: 17, SJR: 2.729, h-index: 121)
Advances in Polymer Technology     Hybrid Journal   (Followers: 13, SJR: 0.344, h-index: 31)
Africa Confidential     Hybrid Journal   (Followers: 19)
Africa Research Bulletin: Economic, Financial and Technical Series     Hybrid Journal   (Followers: 12)
Africa Research Bulletin: Political, Social and Cultural Series     Hybrid Journal   (Followers: 9)
African Development Review     Hybrid Journal   (Followers: 35, SJR: 0.275, h-index: 17)
African J. of Ecology     Hybrid Journal   (Followers: 15, SJR: 0.477, h-index: 39)
Aggressive Behavior     Hybrid Journal   (Followers: 15, SJR: 1.391, h-index: 66)
Aging Cell     Open Access   (Followers: 10, SJR: 4.374, h-index: 95)
Agribusiness : an Intl. J.     Hybrid Journal   (Followers: 6, SJR: 0.627, h-index: 14)
Agricultural and Forest Entomology     Hybrid Journal   (Followers: 14, SJR: 0.925, h-index: 43)
Agricultural Economics     Hybrid Journal   (Followers: 44, SJR: 1.099, h-index: 51)
AIChE J.     Hybrid Journal   (Followers: 30, SJR: 1.122, h-index: 120)
Alcoholism and Drug Abuse Weekly     Hybrid Journal   (Followers: 7)
Alcoholism Clinical and Experimental Research     Hybrid Journal   (Followers: 7, SJR: 1.416, h-index: 125)
Alimentary Pharmacology & Therapeutics     Hybrid Journal   (Followers: 34, SJR: 2.833, h-index: 138)
Alimentary Pharmacology & Therapeutics Symposium Series     Hybrid Journal   (Followers: 3)
Allergy     Hybrid Journal   (Followers: 49, SJR: 3.048, h-index: 129)
Alternatives to the High Cost of Litigation     Hybrid Journal   (Followers: 3)
American Anthropologist     Hybrid Journal   (Followers: 133, SJR: 0.951, h-index: 61)
American Business Law J.     Hybrid Journal   (Followers: 24, SJR: 0.205, h-index: 17)
American Ethnologist     Hybrid Journal   (Followers: 92, SJR: 2.325, h-index: 51)
American J. of Economics and Sociology     Hybrid Journal   (Followers: 27, SJR: 0.211, h-index: 26)
American J. of Hematology     Hybrid Journal   (Followers: 31, SJR: 1.761, h-index: 77)
American J. of Human Biology     Hybrid Journal   (Followers: 12, SJR: 1.018, h-index: 58)
American J. of Industrial Medicine     Hybrid Journal   (Followers: 16, SJR: 0.993, h-index: 85)
American J. of Medical Genetics Part A     Hybrid Journal   (Followers: 15, SJR: 1.115, h-index: 61)
American J. of Medical Genetics Part B: Neuropsychiatric Genetics     Hybrid Journal   (Followers: 3, SJR: 1.771, h-index: 107)
American J. of Medical Genetics Part C: Seminars in Medical Genetics     Partially Free   (Followers: 5, SJR: 2.315, h-index: 79)
American J. of Physical Anthropology     Hybrid Journal   (Followers: 36, SJR: 1.41, h-index: 88)
American J. of Political Science     Hybrid Journal   (Followers: 255, SJR: 5.101, h-index: 114)
American J. of Primatology     Hybrid Journal   (Followers: 15, SJR: 1.197, h-index: 63)
American J. of Reproductive Immunology     Hybrid Journal   (Followers: 3, SJR: 1.347, h-index: 75)
American J. of Transplantation     Hybrid Journal   (Followers: 16, SJR: 2.792, h-index: 140)
American J. on Addictions     Hybrid Journal   (Followers: 9, SJR: 0.843, h-index: 57)
Anaesthesia     Hybrid Journal   (Followers: 126, SJR: 1.404, h-index: 88)
Analyses of Social Issues and Public Policy     Hybrid Journal   (Followers: 10, SJR: 0.397, h-index: 18)
Analytic Philosophy     Hybrid Journal   (Followers: 16)
Anatomia, Histologia, Embryologia: J. of Veterinary Medicine Series C     Hybrid Journal   (Followers: 3, SJR: 0.295, h-index: 27)
Anatomical Sciences Education     Hybrid Journal   (Followers: 1, SJR: 0.633, h-index: 24)
Andrologia     Hybrid Journal   (Followers: 2, SJR: 0.528, h-index: 45)
Andrology     Hybrid Journal   (Followers: 2, SJR: 0.979, h-index: 14)
Angewandte Chemie     Hybrid Journal   (Followers: 160)
Angewandte Chemie Intl. Edition     Hybrid Journal   (Followers: 210, SJR: 6.229, h-index: 397)
Animal Conservation     Hybrid Journal   (Followers: 36, SJR: 1.576, h-index: 62)
Animal Genetics     Hybrid Journal   (Followers: 8, SJR: 0.957, h-index: 67)
Animal Science J.     Hybrid Journal   (Followers: 6, SJR: 0.569, h-index: 24)
Annalen der Physik     Hybrid Journal   (Followers: 5, SJR: 1.46, h-index: 40)
Annals of Anthropological Practice     Partially Free   (Followers: 2, SJR: 0.187, h-index: 5)
Annals of Applied Biology     Hybrid Journal   (Followers: 8, SJR: 0.816, h-index: 56)
Annals of Clinical and Translational Neurology     Open Access   (Followers: 1)
Annals of Human Genetics     Hybrid Journal   (Followers: 9, SJR: 1.191, h-index: 67)
Annals of Neurology     Hybrid Journal   (Followers: 44, SJR: 5.584, h-index: 241)
Annals of Noninvasive Electrocardiology     Hybrid Journal   (Followers: 2, SJR: 0.531, h-index: 38)
Annals of Public and Cooperative Economics     Hybrid Journal   (Followers: 9, SJR: 0.336, h-index: 23)
Annals of the New York Academy of Sciences     Hybrid Journal   (Followers: 5, SJR: 2.389, h-index: 189)
Annual Bulletin of Historical Literature     Hybrid Journal   (Followers: 12)
Annual Review of Information Science and Technology     Hybrid Journal   (Followers: 14)
Anthropology & Education Quarterly     Hybrid Journal   (Followers: 24, SJR: 0.72, h-index: 31)
Anthropology & Humanism     Hybrid Journal   (Followers: 17, SJR: 0.137, h-index: 3)
Anthropology News     Hybrid Journal   (Followers: 15)
Anthropology of Consciousness     Hybrid Journal   (Followers: 11, SJR: 0.172, h-index: 5)
Anthropology of Work Review     Hybrid Journal   (Followers: 11, SJR: 0.256, h-index: 5)
Anthropology Today     Hybrid Journal   (Followers: 93, SJR: 0.545, h-index: 15)
Antipode     Hybrid Journal   (Followers: 45, SJR: 2.212, h-index: 69)
Anz J. of Surgery     Hybrid Journal   (Followers: 6, SJR: 0.432, h-index: 59)
Anzeiger für Schädlingskunde     Hybrid Journal   (Followers: 1)
Apmis     Hybrid Journal   (Followers: 1, SJR: 0.855, h-index: 73)
Applied Cognitive Psychology     Hybrid Journal   (Followers: 69, SJR: 0.754, h-index: 69)
Applied Organometallic Chemistry     Hybrid Journal   (Followers: 7, SJR: 0.632, h-index: 58)
Applied Psychology     Hybrid Journal   (Followers: 141, SJR: 1.023, h-index: 64)
Applied Psychology: Health and Well-Being     Hybrid Journal   (Followers: 48, SJR: 0.868, h-index: 13)
Applied Stochastic Models in Business and Industry     Hybrid Journal   (Followers: 5, SJR: 0.613, h-index: 24)
Aquaculture Nutrition     Hybrid Journal   (Followers: 14, SJR: 1.025, h-index: 55)
Aquaculture Research     Hybrid Journal   (Followers: 31, SJR: 0.807, h-index: 60)
Aquatic Conservation Marine and Freshwater Ecosystems     Hybrid Journal   (Followers: 34, SJR: 1.047, h-index: 57)
Arabian Archaeology and Epigraphy     Hybrid Journal   (Followers: 11, SJR: 0.453, h-index: 11)
Archaeological Prospection     Hybrid Journal   (Followers: 12, SJR: 0.922, h-index: 21)
Archaeology in Oceania     Hybrid Journal   (Followers: 13, SJR: 0.745, h-index: 18)
Archaeometry     Hybrid Journal   (Followers: 27, SJR: 0.809, h-index: 48)
Archeological Papers of The American Anthropological Association     Hybrid Journal   (Followers: 14, SJR: 0.156, h-index: 2)
Architectural Design     Hybrid Journal   (Followers: 25, SJR: 0.261, h-index: 9)
Archiv der Pharmazie     Hybrid Journal   (Followers: 4, SJR: 0.628, h-index: 43)
Archives of Drug Information     Hybrid Journal   (Followers: 4)
Archives of Insect Biochemistry and Physiology     Hybrid Journal   (SJR: 0.768, h-index: 54)
Area     Hybrid Journal   (Followers: 12, SJR: 0.938, h-index: 57)
Art History     Hybrid Journal   (Followers: 225, SJR: 0.153, h-index: 13)
Arthritis & Rheumatology     Hybrid Journal   (Followers: 50, SJR: 1.984, h-index: 20)
Arthritis Care & Research     Hybrid Journal   (Followers: 28, SJR: 2.256, h-index: 114)
Artificial Organs     Hybrid Journal   (Followers: 1, SJR: 0.872, h-index: 60)
ASHE Higher Education Reports     Hybrid Journal   (Followers: 14)
Asia & the Pacific Policy Studies     Open Access   (Followers: 14)
Asia Pacific J. of Human Resources     Hybrid Journal   (Followers: 315, SJR: 0.494, h-index: 19)
Asia Pacific Viewpoint     Hybrid Journal   (SJR: 0.616, h-index: 26)
Asia-Pacific J. of Chemical Engineering     Hybrid Journal   (Followers: 7, SJR: 0.345, h-index: 20)
Asia-pacific J. of Clinical Oncology     Hybrid Journal   (Followers: 6, SJR: 0.554, h-index: 14)
Asia-Pacific J. of Financial Studies     Hybrid Journal   (SJR: 0.241, h-index: 7)
Asia-Pacific Psychiatry     Hybrid Journal   (Followers: 3, SJR: 0.377, h-index: 7)
Asian Economic J.     Hybrid Journal   (Followers: 8, SJR: 0.234, h-index: 21)
Asian Economic Policy Review     Hybrid Journal   (Followers: 4, SJR: 0.196, h-index: 12)
Asian J. of Control     Hybrid Journal   (SJR: 0.862, h-index: 34)
Asian J. of Endoscopic Surgery     Hybrid Journal   (SJR: 0.394, h-index: 7)
Asian J. of Organic Chemistry     Hybrid Journal   (Followers: 4, SJR: 1.443, h-index: 19)
Asian J. of Social Psychology     Hybrid Journal   (Followers: 5, SJR: 0.665, h-index: 37)
Asian Politics and Policy     Hybrid Journal   (Followers: 12, SJR: 0.207, h-index: 7)
Asian Social Work and Policy Review     Hybrid Journal   (Followers: 5, SJR: 0.318, h-index: 5)
Asian-pacific Economic Literature     Hybrid Journal   (Followers: 5, SJR: 0.168, h-index: 15)
Assessment Update     Hybrid Journal   (Followers: 4)
Astronomische Nachrichten     Hybrid Journal   (Followers: 2, SJR: 0.701, h-index: 40)
Atmospheric Science Letters     Open Access   (Followers: 29, SJR: 1.332, h-index: 27)
Austral Ecology     Hybrid Journal   (Followers: 13, SJR: 1.095, h-index: 66)
Austral Entomology     Hybrid Journal   (Followers: 10, SJR: 0.524, h-index: 28)
Australasian J. of Dermatology     Hybrid Journal   (Followers: 8, SJR: 0.714, h-index: 40)
Australasian J. On Ageing     Hybrid Journal   (Followers: 7, SJR: 0.39, h-index: 22)
Australian & New Zealand J. of Statistics     Hybrid Journal   (Followers: 13, SJR: 0.275, h-index: 28)
Australian Accounting Review     Hybrid Journal   (Followers: 4, SJR: 0.709, h-index: 14)
Australian and New Zealand J. of Family Therapy (ANZJFT)     Hybrid Journal   (Followers: 3, SJR: 0.382, h-index: 12)
Australian and New Zealand J. of Obstetrics and Gynaecology     Hybrid Journal   (Followers: 43, SJR: 0.814, h-index: 49)
Australian and New Zealand J. of Public Health     Hybrid Journal   (Followers: 11, SJR: 0.82, h-index: 62)
Australian Dental J.     Hybrid Journal   (Followers: 7, SJR: 0.482, h-index: 46)
Australian Economic History Review     Hybrid Journal   (Followers: 4, SJR: 0.171, h-index: 12)
Australian Economic Papers     Hybrid Journal   (Followers: 25, SJR: 0.23, h-index: 9)
Australian Economic Review     Hybrid Journal   (Followers: 6, SJR: 0.357, h-index: 21)
Australian Endodontic J.     Hybrid Journal   (Followers: 3, SJR: 0.513, h-index: 24)
Australian J. of Agricultural and Resource Economics     Hybrid Journal   (Followers: 3, SJR: 0.765, h-index: 36)
Australian J. of Grape and Wine Research     Hybrid Journal   (Followers: 5, SJR: 0.879, h-index: 56)
Australian J. of Politics & History     Hybrid Journal   (Followers: 13, SJR: 0.203, h-index: 14)
Australian J. of Psychology     Hybrid Journal   (Followers: 18, SJR: 0.384, h-index: 30)
Australian J. of Public Administration     Hybrid Journal   (Followers: 399, SJR: 0.418, h-index: 29)
Australian J. of Rural Health     Hybrid Journal   (Followers: 4, SJR: 0.43, h-index: 34)
Australian Occupational Therapy J.     Hybrid Journal   (Followers: 68, SJR: 0.59, h-index: 29)
Australian Psychologist     Hybrid Journal   (Followers: 11, SJR: 0.331, h-index: 31)
Australian Veterinary J.     Hybrid Journal   (Followers: 19, SJR: 0.459, h-index: 45)
Autism Research     Hybrid Journal   (Followers: 31, SJR: 2.126, h-index: 39)
Autonomic & Autacoid Pharmacology     Hybrid Journal   (SJR: 0.371, h-index: 29)
Banks in Insurance Report     Hybrid Journal   (Followers: 1)
Basic & Clinical Pharmacology & Toxicology     Hybrid Journal   (Followers: 10, SJR: 0.539, h-index: 70)
Basic and Applied Pathology     Open Access   (Followers: 2, SJR: 0.113, h-index: 4)
Basin Research     Hybrid Journal   (Followers: 5, SJR: 1.54, h-index: 60)
Bauphysik     Hybrid Journal   (Followers: 2, SJR: 0.194, h-index: 5)
Bauregelliste A, Bauregelliste B Und Liste C     Hybrid Journal  
Bautechnik     Hybrid Journal   (Followers: 1, SJR: 0.321, h-index: 11)
Behavioral Interventions     Hybrid Journal   (Followers: 9, SJR: 0.297, h-index: 23)
Behavioral Sciences & the Law     Hybrid Journal   (Followers: 23, SJR: 0.736, h-index: 57)
Berichte Zur Wissenschaftsgeschichte     Hybrid Journal   (Followers: 9, SJR: 0.11, h-index: 5)
Beton- und Stahlbetonbau     Hybrid Journal   (Followers: 2, SJR: 0.493, h-index: 14)
Biochemistry and Molecular Biology Education     Hybrid Journal   (Followers: 6, SJR: 0.311, h-index: 26)
Bioelectromagnetics     Hybrid Journal   (Followers: 1, SJR: 0.568, h-index: 64)
Bioengineering & Translational Medicine     Open Access  
BioEssays     Hybrid Journal   (Followers: 10, SJR: 3.104, h-index: 155)
Bioethics     Hybrid Journal   (Followers: 14, SJR: 0.686, h-index: 39)
Biofuels, Bioproducts and Biorefining     Hybrid Journal   (Followers: 1, SJR: 1.725, h-index: 56)
Biological J. of the Linnean Society     Hybrid Journal   (Followers: 15, SJR: 1.172, h-index: 90)
Biological Reviews     Hybrid Journal   (Followers: 3, SJR: 6.469, h-index: 114)
Biologie in Unserer Zeit (Biuz)     Hybrid Journal   (Followers: 42, SJR: 0.12, h-index: 1)
Biology of the Cell     Full-text available via subscription   (Followers: 9, SJR: 1.812, h-index: 69)
Biomedical Chromatography     Hybrid Journal   (Followers: 6, SJR: 0.572, h-index: 49)
Biometrical J.     Hybrid Journal   (Followers: 5, SJR: 0.784, h-index: 44)
Biometrics     Hybrid Journal   (Followers: 37, SJR: 1.906, h-index: 96)
Biopharmaceutics and Drug Disposition     Hybrid Journal   (Followers: 10, SJR: 0.715, h-index: 44)
Biopolymers     Hybrid Journal   (Followers: 18, SJR: 1.199, h-index: 104)
Biotechnology and Applied Biochemistry     Hybrid Journal   (Followers: 45, SJR: 0.415, h-index: 55)
Biotechnology and Bioengineering     Hybrid Journal   (Followers: 137, SJR: 1.633, h-index: 146)
Biotechnology J.     Hybrid Journal   (Followers: 13, SJR: 1.185, h-index: 51)
Biotechnology Progress     Hybrid Journal   (Followers: 39, SJR: 0.736, h-index: 101)
Biotropica     Hybrid Journal   (Followers: 18, SJR: 1.374, h-index: 71)
Bipolar Disorders     Hybrid Journal   (Followers: 9, SJR: 2.592, h-index: 100)
Birth     Hybrid Journal   (Followers: 35, SJR: 0.763, h-index: 64)
Birth Defects Research Part A : Clinical and Molecular Teratology     Hybrid Journal   (Followers: 2, SJR: 0.727, h-index: 77)
Birth Defects Research Part B: Developmental and Reproductive Toxicology     Hybrid Journal   (Followers: 5, SJR: 0.468, h-index: 47)
Birth Defects Research Part C : Embryo Today : Reviews     Hybrid Journal   (SJR: 1.513, h-index: 55)
BJOG : An Intl. J. of Obstetrics and Gynaecology     Partially Free   (Followers: 221, SJR: 2.083, h-index: 125)

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Journal Cover Acute Medicine & Surgery
  [3 followers]  Follow
   Hybrid Journal Hybrid journal (It can contain Open Access articles)
   ISSN (Print) 2052-8817
   Published by John Wiley and Sons Homepage  [1577 journals]
  • A case of non-cardiogenic pulmonary edema provoked by intravenous
    • Authors: Yuichiro Ono; Makiko Morifusa, Satoru Ikeda, Chika Kunishige, Yoshiki Tohma
      Abstract: CaseA 61-year-old man was diagnosed with severe chest trauma after a car accident and had had difficulty in weaning from a ventilator because of flail chest and dilated cardiomyopathy. On the 17th day in the intensive care unit, he received i.v. acetazolamide to increase urine output. One hour after the injection, he suddenly developed severe hypoxia. Chest radiography revealed a butterfly shadow. He received other diuretics and a vasodilator, which seemed slowly to resolve the respiratory failure. Five days later, acetazolamide was again given and he experienced the same deterioration.OutcomeWe concluded that the episodes were attributed to pulmonary edema provoked by acetazolamide.ConclusionAcute non-cardiogenic pulmonary edema is an uncommon and lethal adverse effect of acetazolamide. Careful attention may be warranted when administering acetazolamide to critically ill patients.Acetazolamide is a carbonic anhydrase inhibitor that is widely use in various clinical settings, although it is associated with rare episodes of potentially lethal adverse effects, such as non-cardiogenic pulmonary edema. We report our experience with a critically ill patient who experienced two episodes of pulmonary edema after received acetazolamide.
      PubDate: 2017-04-24T06:27:47.894088-05:
      DOI: 10.1002/ams2.279
  • Investigation of Japan Disaster Medical Assistance Team response
           guidelines assuming catastrophic damage from a Nankai Trough earthquake
    • Authors: Hideaki Anan; Hisayoshi Kondo, Osamu Akasaka, Kenichi Oshiro, Mitsunobu Nakamura, Tetsuro Kiyozumi, Norihiko Yamada, Masato Homma, Kazuma Morino, Shinichi Nakayama, Yasuhiro Otomo, Yuichi Koido
      Abstract: AimTransporting critically ill patients outside of disaster-affected areas for treatment is an important activity of Japan Disaster Medical Assistance Teams (DMATs). We investigated whether this activity is possible after possible catastrophic damage from a Nankai Trough earthquake.MethodsJapan was divided into three areas based on the level of predicted damage (definitely, possibly, and non-affected areas). A survey of DMATs and the locations of emergency base hospitals and intensive care units (ICUs) in each area was carried out, and the ability to support disaster areas was investigated. Next, a survey of wide-area medical transport by Self-Defense Force aircraft and the medical transport abilities of helicopter ambulances was carried out. The numbers of ICU beds in each area were compared, and the capacity to accept patients was investigated. Finally, subjects for further study were examined.ResultsThe number of DMATs that could be sent from non-affected areas was insufficient. The number of patients that can be transported by Self-Defense Force aircraft and helicopter ambulance during the first 3 days was determined to be 1,443. The number of patients that can be accepted by ICUs in non-affected areas was insufficient. A system needs to be developed to provide medical treatment for critically ill patients within disaster areas during the acute phase. This will require DMAT operational reforms and the creation of logistics systems such as the supply of resources for earthquake-reinforced hospitals.ConclusionIn addition to patient transport, systems to provide medical care inside disaster-affected areas are needed.We investigated the specific medical response capabilities and considered Japan Disaster Medical Assistance Team activity guidelines that should be changed assuming a Nankai Trough earthquake. The investigations indicate an overwhelming shortage in the number of responding Disaster Medical Assistance Teams, aircraft transport capacity, and the number of intensive care unit beds that can accept critically ill patients estimated to need transport out of the affected areas.
      PubDate: 2017-04-24T06:27:40.506439-05:
      DOI: 10.1002/ams2.280
  • Characteristic of the acute drug intoxication conveyed by Kanagawa
           helicopter emergency medical service
    • Authors: Mariko Sugita; Shigeo Higami, Shigeaki Inoue, Seiji Morita, Yoshihide Nakagawa, Sadaki Inokuchi
      Abstract: AimVarious critical cases have been transported since the use of the Kanagawa Helicopter Emergency Medical Service (HEMS) started at Tokai University Hospital (Isehara, Japan) in 2002, including cases of acute poisoning. We analyzed the characteristics of acute poisoning cases conveyed by the HEMS.MethodsKanagawa HEMS conveyed 3,814 cases from July 2002 to March 2013, and acute drug and poison intoxication was diagnosed in 131 of these cases. We undertook a descriptive statistical study of these cases.ResultsThe causative agent was found to be psychiatric prescription drugs in 39.7% of cases, pesticides in 29.7%, alcohol in 8.4%, analgesics in 5.3%, detergent or bleach in 6.1%, oil, natural gas, or thinner in 4.6%, and others in 6.1%. At HEMS contact, systolic blood pressure was less than 90 mmHg in 18.3% of cases, and 40.2% were in coma. Endotracheal intubation was carried out in 44.5% of cases, and 6.9% died within 24 h of hospital admission. The cases of poisoning that we transported in the HEMS were often in shock and/or coma on arrival at the field, and rapid endotracheal intubation was required in nearly half of them, as many were in a serious condition.ConclusionWe believe that outcomes were more likely to be improved by appropriate early treatment by the HEMS. It will be necessary to further compare the ambulance service with the HEMS to evaluate their efficacy in the future.We treat a severely affected patient by Japanese helicopter emergency medical service (HEMS) every day. The acute drug intoxication was one and studied the characteristic of patients with drug intoxication conveyed by Kanagawa HEMS. A lot of severe poisoning mainly on the pesticide was available for the quick start of therapy by the physician.
      PubDate: 2017-04-24T06:27:32.699653-05:
      DOI: 10.1002/ams2.255
  • Two cases of life-threatening arrhythmia induced by risperidone:
           evaluation of risperidone and 9-hydroxy-risperidone concentrations
    • Authors: Asami Ito; Tomoyuki Enokiya, Eiji Kawamoto, Yoshiaki Iwashita, Taichi Takeda, Kenji Ikemura, Masahiro Okuda, Hiroshi Imai
      Abstract: CasesCase 1: A 20-year-old woman suffering a suspected overdose was transported to the hospital. She presented bradycardia with wide QRS waves and QT prolongation, followed by cardiac arrest. Extracorporeal cardiopulmonary resuscitation was implemented, improving circulation. Risperidone and 9OH-RIS levels were 9.6 ng/mL and 127.6 ng/mL, respectively. Case 2: A 54-year-old woman was hospitalized for femoral fracture and underwent surgery. Her electrocardiogram showed bradycardia and complete AV block. Risperidone and 9OH-RIS levels were 3.2 ng/mL and 61.4 ng/mL, respectively.OutcomeIn both cases, only serum concentration of 90H-RIS were elevated.ConclusionArrhythmia related to risperidone has proven rare but sometimes fatal. Serum concentrations of risperidone and the metabolite 9-hydroxy-risperidone (9OH-RIS) during these events are seldom documented. As 9OH-RIS shows pharmacological activity equivalent to risperidone, it may induce life-threatening arrhythmia (regardless of the intake dosage). It is critical to evaluate the serum concentration of 9OH-RIS in suspected risperidone toxicity.Two cases of risperidone-induced arrhythmia reporting the serum concentration of risperidone and its active metabolite 9OH-RIS. Case 1 is a 20-year-old woman who presented with cardiac arrest; case 2 is a 54-year-old woman who presented with complete AV block. In both cases, serum 9OH-RIS concentrations were elevated, whereas serum risperidone concentrations fell within the normal range.
      PubDate: 2017-04-24T06:27:27.129874-05:
      DOI: 10.1002/ams2.277
  • Cardiac arrest caused by rapidly increasing ascites in a patient with
           TAFRO syndrome: a case report
    • Authors: Masatoshi Okumura; Atsushi Ujiro, Yasunori Otsuka, Hiroshi Yamamoto, Sho Wada, Hirofumi Iwata, Toshiaki Kan, Seiji Miyauchi, Atsushi Hashimoto, Yuko Sato, Yoshihito Fujita, Yoshihiro Fujiwara, Hideki Shimaoka
      Abstract: CaseThrombocytopenia, anasarca, fever, renal insufficiency, and organomegaly (TAFRO) syndrome is a newly defined systemic inflammatory disorder with gradual progression of symptoms. A 59-year-old man with fever and ascites of unknown cause developed sudden-onset shock and respiratory failure in the general ward. Cardiac arrest immediately followed. Although he was resuscitated, frequent administration of adrenaline was required to maintain his blood pressure. His circulation was most effectively stabilized by drainage of fluid from his distended abdomen. The volume of discharged ascites reached 4,000 mL at that time, and several liters continued to be discharged for >1 month. The diagnosis of TAFRO syndrome was based on the clinical features and laboratory and histological findings.OutcomeThe ascites volume and concentrations of inflammatory parameters decreased with treatment using several immunosuppressive agents.ConclusionThe newly defined TAFRO syndrome may be life-threatening. Patients should be monitored for progression to shock and cardiac arrest, especially those with rapidly increasing ascites.TAFRO syndrome may be life-threatening. Patients should be monitored for progression to shock and cardiac arrest, especially those with rapidly increasing ascites.
      PubDate: 2017-04-17T22:00:37.19037-05:0
      DOI: 10.1002/ams2.278
  • A case of cerebral tuberculoma mimicking neurocysticercosis
    • Authors: Hiroko Yuzawa; Yousuke Hirose, Tomonori Kimura, Sho Kimura, Hisanori Sugawara, Asako Yanagisawa, Sono Toi, Takashi Ohashi, Tomohito Sadahiro
      Abstract: CaseA 42-year-old Peruvian woman residing in Japan for 11 years with a family history of neurocysticercosis presented to our intensive care unit with fever and intense headache.Computed tomography indicated multiple micronodular lesions in the brain parenchyma, and cerebral tuberculoma and neurocysticercosis were considered in the differential diagnosis. Neurocysticercosis was initially suspected, and oral praziquantel was initiated. However, because of a high adenosine deaminase level in the cerebrospinal fluid and positive peripheral blood interferon gamma release test result, cerebral tuberculoma was subsequently considered.OutcomeAntituberculous drugs with steroids were initiated on day 10, after which the symptoms gradually resolved; the patient was discharged on day 29. Gadolinium-contrast magnetic resonance imaging 8 months later showed reduced nodular shadows, confirming cerebral tuberculoma.ConclusionImmediate diagnosis and treatment are imperative for cerebral tuberculoma, a lethal infection. Considering the recent increases in immigration worldwide, increased cases of tuberculoma mimicking neurocysticercosis are expected.We encountered a case of cerebral tuberculoma associated with intense headache and fever, which mimicked neurocysticercosis. Both diseases are rare in Japan but prevalent in endemic areas such as Latin America, Sub-Saharan Africa, and Southeast Asia. Considering the recent increases in immigration worldwide, increased cases of tuberculoma mimicking neurocysticercosis are expected.
      PubDate: 2017-04-04T21:40:26.345413-05:
      DOI: 10.1002/ams2.272
  • Performance review of regional emergency medical service pre-arrival
           cardiopulmonary resuscitation with or without dispatcher instruction: a
           population-based observational study
    • Authors: Hidetada Fukushima; Yasuyuki Kawai, Hideki Asai, Tadahiko Seki, Kazunobu Norimoto, Yasuyuki Urisono, Kazuo Okuchi
      Abstract: BackgroundTo investigate variations in emergency medical service (EMS) pre-arrival cardiopulmonary resuscitation (CPR), including both bystander CPR without dispatch assistance and dispatch-assisted CPR (DACPR).MethodsWe carried out an observational study by implementing EMS pre-arrival CPR reports in three fire agencies. We included adult, non-traumatic, and non-EMS witnessed out-of-hospital cardiac arrests. This reporting system comprised the dispatch instruction process and bystander CPR quality based on evaluations by EMS crews who arrived on the scene. Bystander CPR was categorized as “ongoing CPR” if the bystander was performing CPR when the EMS reached the patient's side and “good-quality CPR” if the CPR was performed proficiently. We compared the frequencies of ongoing and good-quality CPR in the bystander CPR already started without dispatch assistance (CPR in progress) group and DACPR group.ResultsOf 688 out-of-hospital cardiac arrests, CPR was already started in 150 cases (CPR in progress group). Dispatcher CPR instruction was provided in 368 cases. Among these, callers started chest compressions in 162 cases (DACPR group). Ongoing CPR was performed in 220 cases and was more frequent in the DACPR group (128/162 [79.0%] versus 92/150 [61.3%], P < 0.001). Good-quality CPR was more frequent in the CPR in progress group, but the difference was not statistically significant (36/92 [39.1%] versus 42/128 [29.0%], P = 0.888).ConclusionsOngoing CPR and good-quality CPR were not frequent in EMS pre-arrival CPR. Detailed analysis of dispatch instructions and bystander CPR can contribute to improvement in EMS pre-arrival CPR.We implemented EMS pre-arrival CPR reporting in regional fire departments and investigated the performance of EMS pre-arrival CPR including dispatch-assisted CPR and CPR without dispatch assistance.
      PubDate: 2017-04-02T19:35:23.481855-05:
      DOI: 10.1002/ams2.273
  • Do not attempt resuscitation order in Japan
    • Authors: Yoshihide Nakagawa; Sadaki Inokuchi, Nobuo Kobayashi, Yoshinobu Ohkubo
      Abstract: AimIn Japan, the do not attempt resuscitation (DNAR) order is practised routinely even though no related laws or guidelines exist. This study aimed to clarify the current status of DNAR, reveal existing DNAR-related issues, and improve the application of DNAR.MethodsA questionnaire survey of medical institutions in Kanagawa Prefecture (total population, 9,120,000) about the current status of DNAR was carried out.ResultsThe results showed that DNAR has been practised at approximately 90% of the hospitals surveyed, but only about 30% have developed in-hospital DNAR guidelines. Approximately 80% of the hospitals do not involve patients in the decision on their own DNAR orders. Because the DNAR order has not been legislated, it is often unclear whether to resuscitate patients when a request for an ambulance is made for a cardiac arrest at home.ConclusionIt is necessary for prefectures, municipalities, and local medical control authorities to take the initiative in establishing an ordinance on DNAR orders and developing guidelines.A questionnaire survey of medical institutions in Kanagawa Prefecture about the current status of do not attempt resuscitation was conducted. It showed various problems in clinical settings. There is an urgent need for prefectures or municipalities to establish relevant laws and for local medical control authorities to develop guidelines.
      PubDate: 2017-04-02T19:20:26.891404-05:
      DOI: 10.1002/ams2.271
  • Early administration of fibrinogen concentrates improves the short-term
           outcomes of severe pelvic fracture patients
    • Authors: Koichi Inokuchi; Makoto Sawano, Koji Yamamoto, Atsushi Yamaguchi, Satoru Sugiyama
      Abstract: AimHemorrhage from pelvic fracture is a major cause of mortality after blunt trauma. Several studies have suggested that early fibrinogen supplementation improves outcomes of traumatic hemorrhage. Thus, we revised our massive transfusion protocol (MTP) in April 2013 to include early off-label administration of fibrinogen concentrate. The objective of this study was to evaluate the impact of the revision on the short-term outcomes of pelvic fracture patients.MethodsThis was a single-center, retrospective, cohort study. A total of 224 consecutive pelvic fracture patients hospitalized in Saitama Medical Center (Saitama, Japan), 115 before the revision (Group E) and 109 after (Group L), were enrolled. Characteristics of the patients were compared between the groups. Impacts of the revision were evaluated by hazard ratios adjusted for characteristics, injury severity, and coagulation status using Cox's multivariate proportional hazard model. The impact was also evaluated by log–rank test and relative risk of 28-day mortality between the groups.ResultsThe characteristics were equivalent between the groups. The multivariate analysis revealed that the revision of MTP was significantly related to improved survival with an adjusted hazard ratio (95% confidence interval) of 0.45 (0.07–0.97). The log–rank test gave χ2-test values of 5.2 (P = 0.022) and 6.7 (P = 0.009), and the relative risks were 0.37 (0.15–0.91) and 0.33 (0.13–0.84), in patients with all Injury Severity Scores and Injury Severity Score ≥21, respectively.ConclusionThe revision of MTP to include aggressive off-label treatment with fibrinogen concentrate was related to improved short-term outcomes of severe pelvic fracture patients. However, due to the limitations of the study, the improvement could not be attributed totally to the revision.Twenty-eight-day survival curves of pelvic fracture patients compared between treatment groups. Broken lines represent the curve of Group E (those hospitalized before April 2013) and solid lines represent that of Group L (those hospitalized in April 2013 and later). The curves of patients with all Injury Severity Scores (top) and those of patients with Injury Severity Score ≥21 (bottom) are shown.
      PubDate: 2017-04-02T19:15:23.998737-05:
      DOI: 10.1002/ams2.268
  • Microsurgical replantation of an amputated ear
    • Authors: Tomoya Sato; Shigeru Ichioka
      Abstract: We report a case of successful microsurgical reattachment of an amputated ear. Microsurgical reattachment should be considered whenever possible.
      PubDate: 2017-03-30T23:10:51.511909-05:
      DOI: 10.1002/ams2.274
  • Cardiac arrest caused by sibutramine obtained over the Internet: a case of
           a young woman without pre-existing cardiovascular disease successfully
           resuscitated using extracorporeal membrane oxygenation
    • Authors: Naofumi Bunya; Keigo Sawamoto, Shuji Uemura, Ryoko Kyan, Hiroyuki Inoue, Junichi Nishida, Hidemichi Kouzu, Nobuaki Kokubu, Tetsuji Miura, Eichi Narimatsu
      Abstract: CaseSibutramine is a weight loss agent that was withdrawn from the market in the USA and European Union because it increases adverse events in patients with cardiovascular diseases. However, non-prescription weight loss pills containing sibutramine can be still easily purchased over the Internet.A 21-year-old woman without history of cardiovascular diseases developed cardiac arrest. She was a user of a weight loss pills, containing sibutramine and hypokalemia-inducing agents, imported from Thailand over the Internet.OutcomeShe was successfully resuscitated without any neurological deficits by using extracorporeal membrane oxygenation for refractory ventricular fibrillation.ConclusionThis case indicates that sibutramine can cause cardiac arrest even in subjects without pre-existing cardiovascular disease when combined with agents that promote QT prolongation.Even banned high risk agents are readily accessible for the general population over the Internet, and emergency physicians need to be aware of the potential toxicities of weight loss agents. Sibutramine is one such agent that potentially causes cardiac arrest even in subjects without pre-existing cardiovascular disease, particularly when combined with drugs that lead to QT prolongation.
      PubDate: 2017-03-29T20:40:23.446487-05:
      DOI: 10.1002/ams2.275
  • Differences in coagulofibrinolytic changes between post-cardiac arrest
           syndrome of cardiac causes and hypoxic insults: a pilot study
    • Authors: Takeshi Wada; Satoshi Gando, Asumi Mizugaki, Akira Kodate, Yoshihiro Sadamoto, Hiromoto Murakami, Kunihiko Maekawa, Kenichi Katabami, Yuichi Ono, Mineji Hayakawa, Atsushi Sawamura, Subrina Jesmin, Masahiro Ieko
      PubDate: 2017-03-27T20:10:21.64085-05:0
      DOI: 10.1002/ams2.270
  • Delayed autonomic neuropathy in a patient with diethylene glycol
           poisoning: a case report
    • Authors: Hiroki Kamada; Hideaki Suzuki, Saori Yamamoto, Ryosuke Nomura, Shigeki Kushimoto
      Abstract: CaseA 72-year-old man presented to our hospital after ingesting insecticide containing approximately 2 mL/kg diethylene glycol, which exceeded the lethal dose of 1 mL/kg. The patient recovered from critical symptoms on acute phase until day 3, but received artificial ventilation for muscle weakness secondary to sensorimotor neuropathy on days 11–54.OutcomeEven after marked improvement from sensorimotor neuropathy, the patient continued to complain of orthostatic hypotension. Autonomic neuropathy was identified by positive result of a head-up tilt test, and reduction in coefficient of variation of R-R intervals and cardiac iodine-123-metaiodobenzylguanidine uptake for the assessment of cardiac sympathetic activity. The patient's symptoms fully recovered 2 years after the exposure to diethylene glycol.ConclusionThis case shows the first report of delayed autonomic neuropathy after recovery from severe sensorimotor neuropathy, and suggests the importance of continuous monitoring for late-onset neurological complications.A 72-year-old man ingested insecticide containing approximately 2 mL/kg diethylene glycol, which exceeded the lethal dose of 1 mL/kg. The patient presented with autonomic neuropathy represented by orthostatic hypotension (Figure) after recovery from severe sensorimotor neuropathy. Continuous monitoring is important for the late onset of neurological complications of diethylene glycol poisoning.
      PubDate: 2017-03-27T19:30:25.092633-05:
      DOI: 10.1002/ams2.267
  • A study of the effect of introduction of JTAS in the emergency room
    • Authors: Toru Koyama; Takeshi Kashima, Motoyoshi Yamamoto, Kenjiro Ouchi, Takayuki Kotoku, Yuta Mizuno
      Abstract: AimThe purpose of this study was to better understand the effects of introducing the Japan Triage and Acuity Scale (JTAS) in the emergency room for walk-in patients.MethodsA simple triage was used in Term A (from April 2006 to December 2010, 4 years and 9 months) and the JTAS was introduced in Term B (from January 2011 to September 2015, 4 years and 9 months). The number of patients who had a sudden turn for the worse after arrival in the emergency room and the time between attendance and emergency catheterization (TBAEC) due to acute coronary syndrome were reviewed.ResultsThere were 653 patients in Term A and 626 patients in Term B who were finally diagnosed as having serious causes. There was no significant difference in the frequency of a sudden turn for the worse between the two terms. There were 182 patients in Term A and 167 patients in Term B who underwent emergency catheterization due to acute coronary syndrome. When ST elevation was recognized in the first electrocardiogram, the median time between attendance and medical attention during Term B improved significantly, by 4.5 min. However, there was no significant difference in medians for TBAEC. When ST elevation was not recognized, there was no significant difference between the two terms, neither in terms of median time between attendance and medical attention, nor TBAEC.ConclusionThe data suggests that the effects of introducing the JTAS in the emergency room were restrictive in these two aspects.There was no significant difference in the frequency of a sudden turn for the worse between the two terms. When ST elevation was recognized in the first electrocardiogram, median time between attendance and medical attention of Term B improved significantly, by 4.5 min. The data suggests that the effects of introducing the JTAS in the emergency room were restrictive.
      PubDate: 2017-03-13T04:20:24.585588-05:
      DOI: 10.1002/ams2.266
  • Indications of early intubation for patients with inhalation injury
    • Authors: Shinya Onishi; Akinori Osuka, Yuichi Kuroki, Masashi Ueyama
      Abstract: AimFor patients with inhalation injury, the indications for early intubation are diverse. The purpose of this study was to identify the most reliable symptoms, physical findings, and medical examinations with which to determine the indications for early intubation in patients with inhalation injury.MethodsWe retrospectively collected patient data from medical records. Collected data included age, sex, burn size, symptoms, physical findings, carboxyhemoglobin levels (COHb), and bronchial wall thickness (BWT) determined from chest computed tomography images. We analyzed the relationships between these findings and the early intubation. We performed fiberoptic bronchoscopy in all patients, and analyzed the relationships between bronchoscopic severity and other findings.ResultsOf the 205 patients, 80 patients were diagnosed as having inhalation injury, and 34 patients were intubated. Burn size, facial burns, neck burns, use of accessory respiratory muscles, and COHb seemed to be related with intubation, whereas singed nasal hair was not. If the patients suffered ≥27% total body surface area burn and BWT ≥3.5 mm, the positive predictive value for early intubation was 1.00. If the patients suffered smaller cutaneous burn without neck burn, and their COHb
      PubDate: 2017-03-06T03:31:17.400106-05:
      DOI: 10.1002/ams2.269
  • Serum levels of interleukin-6 may predict organ dysfunction earlier than
           SOFA score
    • Authors: Takashi Shimazui; Yosuke Matsumura, Taka-aki Nakada, Shigeto Oda
      Abstract: AimTo investigate the clinical utility of interleukin-6 (IL-6), procalcitonin (PCT), and C-reactive protein (CRP) as predictive markers in consideration of the time-course changes in critically ill patients with organ dysfunction.MethodsSerum levels of IL-6, PCT, CRP, and Sequential Organ Failure Assessment (SOFA) scores were measured sequentially in 92 patients during their initial 5 days following admission to the intensive care unit. Maximum values were analyzed. Patients were assigned to a low ( ≤ 8), intermediate ( > 8 and ≤ 16), or high ( > 16 and ≤ 24) SOFA score group.ResultsThere were significant differences in the maximum serum levels of IL-6 and PCT among the three SOFA score groups (IL-6, P < 0.0001; PCT, P = 0.0004). Specifically, comparisons between the groups revealed significant differences in IL-6 levels (low versus intermediate, P = 0.0007; intermediate versus high, P = 0.0010). The probability of patients with the maximum value was greatest on day 1 (56.5%) for IL-6, on day 1 (39.1%) or day 2 (38.0%) for PCT, on day 3 (39.1%) for CRP, and on day 1 (43.5%) for SOFA score. The median (interquartile range) peak day of IL-6 was day 1 (1–2), which was significantly earlier than that of SOFA score at day 2 (1–3) (P = 0.018).ConclusionSerum levels of IL-6 reflected the severity of organ dysfunction in critically ill patients most accurately compared to PCT and CRP. Interleukin-6 elevated soonest from the insult and reached its peak earlier than SOFA score.IL-6 reflected SOFA score more accurately and increased earlier than PCT or CRP. IL-6 is useful to assess severity in the early phase of critical illness.
      PubDate: 2017-03-06T03:20:25.629393-05:
      DOI: 10.1002/ams2.263
  • A case of circumferential type A aortic dissection with intimal
           intussusception diagnosed using repeat transthoracic echocardiography
    • Authors: Toshinobu Yamagishi; Masahiro Kashiura, Kazuya Nakata, Kazuki Miyazaki, Takahiro Yukawa, Takahiro Tanabe, Kazuhiro Sugiyama, Akiko Akashi, Yuichi Hamabe
      Abstract: CaseSometimes it is difficult to diagnose circumferential aortic dissection with enhanced computed tomography alone. A 58-year-old woman presented with sudden-onset chest discomfort and loss of consciousness. Transthoracic echocardiogram showed mild aortic regurgitation. Enhanced computed tomography scans showed no obvious intimal tear or flap at the proximal ascending aorta, but an intimal flap was observed from the aortic arch to both common iliac arteries. Stanford type B dissection was tentatively diagnosed. Repeat detailed transthoracic echocardiography examination showed an intimal tear and flap at the ascending aorta; prolapse into the left ventricle caused severe aortic regurgitation. Type A aortic dissection was definitively diagnosed; emergent operation showed a circumferential intimal tear originating from the ascending aorta.OutcomeThe ascending aorta was replaced; aortic regurgitation disappeared. The patient was discharged in a good condition 58 days postoperatively.ConclusionDynamic evaluations with transthoracic echocardiography should be carried out to diagnose circumferential aortic dissection.Sometimes it is difficult to diagnose circumferential aortic dissection by only enhanced computed tomography. Dynamic evaluations with transthoracic echocardiography should be performed to diagnose this.
      PubDate: 2017-03-02T00:06:26.157185-05:
      DOI: 10.1002/ams2.262
  • Comparison of quality of human serum albumin preparations in two
           pharmaceutical products
    • Authors: Hajime Nakae; Kouki Tomida, Yoshihiro Kikuya, Manabu Okuyama, Toshiko Igarashi
      Abstract: AimHuman serum albumin (HSA) is known for its multiple functions, such as maintenance of colloid osmotic pressure, transport of endogenous and exogenous substances, and antioxidation. The aim of this study was to measure the redox state and concentrations of β-d-glucan and endotoxin to compare the quality of 5% HSA preparations from two different manufacturers.MethodsThe quality of 5% HSA preparations in two different pharmaceutical products (groups A and B) was compared in terms of the percentage of reduced and oxidized albumin and the contaminant level of β-d-glucan and endotoxin.ResultsThe percentage of human mercaptoalbumin in group A was significantly higher than that in group B (P < 0.01), whereas that of human non-mercaptoalbumin-2 in group A was significantly lower (P < 0.01). The concentration of β-d-glucan in group A was significantly lower than in group B (P < 0.01).ConclusionsThe present findings indicate the need for quality control of HSA preparations in applications involving the use of large volumes.Representative chromatograms and comparison of redox status of human serum albumin preparations according to the manufacturer. The percentage of human mercaptoalbumin (HMA) in group A was significantly higher than that in group B. The percentage of human non-mercaptoalbumin (HNA)-2 in group A was significantly lower than that in group B.
      PubDate: 2017-03-01T00:16:18.869563-05:
      DOI: 10.1002/ams2.259
  • Unexpected complications immediately after cranioplasty
    • Authors: Akihito Kato; Hiroyuki Morishima, Goro Nagashima
      Abstract: CaseAn 84-year-old man with subarachnoid hemorrhage underwent craniotomy and clipping with external decompression. Perfusion magnetic resonance imaging showed subclinical sinking skin flap syndrome, and he underwent cranioplasty on postoperative day 58. No problems occurred during the operation, but cerebral edema and hemorrhage were recognized on immediate postoperative computed tomography. Edema continued to progress, but edema and bleeding eventually improved without additional surgery.OutcomeNeurological symptoms improved to presurgical baseline and stabilized.ConclusionCauses of cerebral edema and hemorrhage immediately after cranioplasty include reperfusion, reduction of automatic adjustment function, sinking skin flap syndrome, negative pressure due to s.c. drain, venous stasis, vascular damage following restoration of midline shift, and allergic reaction. Although cranioplasty itself is a relatively minor surgery, the fatality rate for this complication is high. Most complications are due to infection, convulsions, or epidural hematoma, but brain edema and hemorrhage also occur. It is necessary to elucidate the etiology before corrective surgery.Unexpected complications.
      PubDate: 2017-02-22T22:15:27.057982-05:
      DOI: 10.1002/ams2.260
  • Effectiveness of dispatcher training in increasing bystander chest
           compression for out-of-hospital cardiac arrest patients in Japan
    • Abstract: AimThe Japanese government has developed a standardized training program for emergency call dispatchers to improve their skills in providing oral guidance on chest compression to bystanders who have witnessed out-of-hospital cardiac arrests (OHCAs). This study evaluated the effects of such a training program for emergency call dispatchers in Japan.MethodsThe analysis included all consecutive non-traumatic OHCA patients transported to hospital by eight emergency medical services, where the program was implemented as a pilot project. We compared the provision of oral guidance and the incidence of chest compression applications by bystanders in the 1-month period before and after the program. Data collection was undertaken from October 2014 to March 2015.ResultsThe 532 non-traumatic OHCA cases were used for analysis: these included 249 cases before and 283 after the guidance intervention. Most patients were over 75 years old and were men. After the program, provision of oral guidance to callers slightly increased from 63% of cases to 69% (P = 0.13) and implementation of chest compression on patients by bystanders significantly increased from 40% to 52% (P = 0.01). Appropriate chest compression also increased from 34% to 47% (P = 0.01). In analysis stratified by the provision of oral guidance, increased chest compressions were observed only under oral guidance.ConclusionsWe found increased provision of oral guidance by dispatchers and increased appropriate chest compressions by bystanders after the training program for dispatchers had been rolled out. Long-term observation and further data analysis, including patient outcomes, are needed.After the standardized training program for dispatchers, cases of implementation of chest compressions by bystanders and appropriate chest compressions significantly increased. Cases of chest compressions and appropriate chest compressions increased only under oral guidance.
  • Comparison of registry and government evaluation data to ascertain severe
           trauma cases in Japan
    • Abstract: AimsAccurate evaluation of health care quality requires high-quality data, and case ascertainment (confirming eligible cases and deaths) is a foundation for accurate data collection. This study examined the accuracy of case ascertainment from two Japanese data sources.MethodsUsing hospital-level data, we investigated the concordance in ascertaining trauma cases between a nationwide trauma registry (the Japan Trauma Data Bank) and annual government evaluations of tertiary hospitals between April 2012 and March 2013. We compared the median values for trauma case volumes, numbers of deaths, and case fatality rates from both data sources, and also evaluated the variability in discrepancies for the intrahospital differences of these outcomes.ResultsThe analyses included 136 hospitals. In the registry and annual evaluation data, the median case volumes were 120.5 cases and 180.5 cases, respectively; the median numbers of deaths were 11 and 12, respectively; and the median case fatality rates were 8.1% and 6.4%, respectively. There was broad variability in the intrahospital differences in these outcomes.ConclusionsThe observed discordance between the two data sources implies that these data sources may have inaccuracies in case ascertainment. Measures are needed to evaluate and improve the accuracy of data from these sources.We compared case ascertainment in the Japan Trauma Data Bank and the annual government evaluation of tertiary hospitals. There was considerable discordance between the two data sources. Measures are needed to improve data quality in these data sources
  • Basi-parallel anatomical scanning–magnetic resonance imaging for the
           diagnosis of reversible cerebral vasoconstriction syndrome of the basilar
           artery: a case report
    • Abstract: CaseReversible cerebral vasoconstriction syndrome (RCVS) is an increasingly recognized and important cause of thunderclap headache. Delays in diagnosis may cause deterioration of symptoms and concomitant unnecessary investigations. However, the diagnosis of RCVS in the acute stage remains difficult.A 41-year-old man was admitted to the emergency department for severe, recurrent occipital headaches. The results of initial computed tomography and magnetic resonance imaging (MRI) of the brain and cerebrospinal fluid analysis were normal. Magnetic resonance angiography (MRA) showed multisegmental luminal stenosis of the basilar artery. Basi-parallel anatomical scanning (BPAS)-MRI, illustrating the outer contour of the vertebrobasilar artery, also showed multisegmental stenosis.OutcomeThe patient was speculated as having RCVS and was treated with oral lomerizine hydrochloride. Repeat MRA and BPAS-MRI 2 months later showed resolution, confirming RCVS.ConclusionCombined with MRA, BPAS-MRI is an effective and non-invasive imaging method for diagnosis of RCVS of the basilar artery.Early and accurate diagnosis of RCVS is of utmost important for appropriate management and prognosis. BPAS-MRI may have a supplementary role to MRA in the diagnosis of RCVS of the basilar artery.
  • Early evaluation of severity in patients with severe sepsis: a comparison
           with “septic shock” — subgroup analysis of the Japanese Association
           for Acute Medicine Sepsis Registry (JAAM-SR)
    • Abstract: AimThe purpose of this subgroup analysis of a Japanese multicenter registry, the Japanese Association for Acute Medicine Sepsis Registry Advanced (JAAM-SR-Advanced), was to identify early outcome indicators for severe sepsis that are useful and more objective than “septic shock.”MethodsAmong 624 patients with severe sepsis registered in JAAM-SR-Advanced, 554 with valid serum lactate data were retrospectively studied. Hypotension before and after fluid resuscitation and the highest lactate values over the initial 24 h were compared for their ability to predict in-hospital mortality.ResultsOf the study group, 155 (28.0%) patients were non-survivors and had significantly lower systolic blood pressures and higher lactate peaks. The mortality of 364 patients with initial hypotension was higher than those patients without it (32.7% versus 19.1%, P 
  • Influence of body position during Heimlich maneuver to relieve
           supralaryngeal obstruction: a manikin study
    • Abstract: AimTo study the most effective body position for Heimlich maneuver.MethodsA choking simulation manikin was connected to a laryngeal model of a child or an adult, and a differential pressure transducer recorded the airway pressure and waveform during the maneuver. A konjac jelly was placed on the larynx to mimic complete supralaryngeal obstruction. The maneuver (five successive compressions) was carried out six times each in standing, prone, and supine positions. For cases of children, we added a supine position with a pillow under the back.ResultsIn the adult model, airway obstruction was more frequently relieved in the supine and prone positions than in the standing position (P < 0.001). In the child model, airway obstruction was more frequently relieved in the supine position, with a pillow, and in the prone position, than in the standing position (P < 0.001). Without relief, successive Heimlich maneuvers made the airway pressure increasingly negative (adult, from −21.9 ± 6.5 cmH2O to −31.5 ± 9.1 cmH2O in the standing position [P < 0.001]; child, from −15.0 ± 9.5 cmH2O to −30.0 ± 9.2 cmH2O in the standing position [P < 0.001] and from −35.0 ± 17.4 cmH2O to −47.3 ± 25.1 cmH2O in the supine position without a pillow [P = 0.002]).ConclusionsThe Heimlich maneuver was more effective in the supine and prone positions. In children, the prone position may be most effective. Successive Heimlich maneuvers may be harmful when the airway is not relieved after the first compression.When there was no foreign body in the airway, there was little change in the airway pressure (top panel). In the case of an obstructed airway, the airway pressure showed a transient positive wave followed by a large negative wave (middle panel). Thus, airway pressure can be used to determine whether the airway is obstructed.
  • Respiratory extracorporeal membrane oxygenation for severe sepsis and
           septic shock in adults: a propensity score analysis in a multicenter
           retrospective observational study
    • Abstract: AimThis multicenter retrospective observational study aimed to evaluate the efficacy of extracorporeal membrane oxygenation (ECMO) support for septic patients with severe respiratory failure using propensity score analyses.MethodsThe data of severe sepsis patients from 42 intensive care units between January 2011 and December 2013 were retrospectively collected. Propensity score matching analyses were undertaken for severe respiratory failure patients with/without veno-venous ECMO support. The main outcome was in-hospital all-cause mortality.ResultsOf 3195 patients with severe sepsis, 570 had severe respiratory failure. Forty patients in the ECMO group were matched with 150 patients in the control group. A survival time analysis revealed no difference in the in-hospital survival (hazard ratio, 0.854; 95% confidence interval, 0.531–1.373; P = 0.515). Two-hundred and eighty-five patients had severe respiratory failure induced by lung infection. Twenty-five ECMO group patients were matched with 89 patients in the control group. In the ECMO group, the survival time was longer than in the control group (hazard ratio, 0.498; 95% confidence interval, 0.279–0.889; P = 0.018). The number of renal replacement therapy- and vasopressor-free days improved. The ECMO group received more red blood cells transfused than the control group, but there was no significant difference in the rate of severe bleeding complications between the groups.ConclusionsThere was no difference in the in-hospital survival between the ECMO group and control group among overall septic patients with severe respiratory failure. However, in sepsis patients with severe respiratory failure induced by lung infection, ECMO support may improve their survival time.Among septic patients with severe respiratory failure induced by lung infection, the survival time in the extracorporeal membrane oxygenation (ECMO) group was significantly longer than in the control group. Therefore, in sepsis patients with severe respiratory failure induced by lung infection, ECMO support may improve their survival time.
  • Endoscopic hematoma evacuation for acute subdural hematoma in a young
           patient: a case report
    • Abstract: CaseThe standard treatment for acute subdural hematoma (ASDH) is large craniotomy; decompressive craniectomy may also be carried out, if needed, to prevent secondary brain damage. Recently, an endoscopic procedure for elderly patients with ASDH was carried out and reported; its safety and effectiveness were emphasized because of minimal invasiveness. We report a young case and discuss its difficulties and tips.A 31-year-old man was found to be in a state of general convulsion. At the time of admission, we observed severe consciousness disturbance, anisocoria, and left hemiparesis. Computed tomography showed a massive subdural hematoma with marked midline shift.OutcomeOsmotherapy and emergency trepanation improved anisocoria. An endoscopic procedure under local anesthesia was sequentially selected. After surgery, the patient's symptoms clearly improved.ConclusionAlthough the standard treatment for ASDH is craniotomy, endoscopic surgery may be useful in some cases.Although endoscopic procedure for young patients with acute subdural hematoma has not been previously reported, we report an experience of endoscopic hematoma evacuation for acute subdural hematoma in a 31 year-old male patient and describe advantages and some tips for the endoscopic procedure.
  • A review of the history of the origin of triage from a disaster medicine
    • Abstract: We usually associate triage with the Simple Triage and Rapid Treatment method, but much of its origin is still unknown. Therefore, French studies and the origin of triage shown in domestic and foreign published works have been investigated and its significance reaffirmed. The etymology of the word “triage” means “to break into three pieces.” It was suggested by a literature review that the rise of Napoleon led to military tactical changes, and that the prototype of triage arose from the experience gained in the difficult campaign in Egypt and Syria. Subsequently, triage was refined by Napoleon's military surgeon, D. J. Larrey, who created the ambulance transport system. Although there is a clash between the ruthless and philanthropic aspects of triage, triage is in accordance with the primary purpose of evacuation or treatment. We should choose the triage method that is consistent with the purpose of each disaster situation.French studies and the origin of triage shown in domestic and foreign published works have been investigated and its significance reaffirmed. It was suggested by a literature review that the rise of Napoleon led to military tactical changes, and that the prototype of triage arose from the experience gained in the difficult campaign in Egypt and Syria. We should choose the triage method that is consistent with the purpose of each disaster situation.
  • Delayed sensorimotor neuropathy and renal failure: an additional report in
           a patient with diethylene glycol poisoning
  • Two cases with intra-aortic balloon pumping use for severe septic
    • Abstract: CasesSeptic cardiomyopathy is defined as a reversible left ventricular systolic dysfunction. Patients with severe septic cardiomyopathy have a high mortality rate, even if they receive conventional therapy. For those patients, previous reports showed intra-aortic balloon pump (IABP) efficacy. We report two rare cases with IABP introduction leading them to drastic improvement, and survival from severe septic cardiomyopathy. Case 1 is a 78-year-old woman diagnosed with renal calculus pyelonephritis, septic shock, and septic cardiomyopathy. Case 2 is a 62-year-old man diagnosed with pneumonia, septic shock, and septic cardiomyopathy.OutcomeIn both cases, despite conventional therapy for cardiomyopathy, including high-dose catecholamine therapy, shock was not reversed, and the IABP was inserted. Circulatory status was improved after the introduction of the IABP.ConclusionOur findings suggest that an IABP can be useful for salvaging patients with septic cardiomyopathy who do not respond to conventional therapy.The intra-aortic balloon pump was a highly effective mechanic device in our two patients with severe septic cardiomyopathy. The clinical course of these two cases indicated that the intra-aortic balloon pump could be useful for managing septic cardiomyopathy that does not response sufficiently to conventional therapy.
  • A case of disseminated cryptococcosis with necrotizing fasciitis in a
           non-HIV patient
    • Abstract: CaseDisseminated cryptococcosis is a well-recognized condition among HIV patients, but it also occurs in non-HIV patients. Necrotizing fasciitis caused by cryptococcus is rare. An 81-year-old man who had received steroid therapy presented with erythema and pain in his right thigh. After the rapid progression of symptoms and a failure to respond to antibiotic therapy, a clinical diagnosis of necrotizing fasciitis was made. We performed debridement, and yeasts were detected using a Gram stain of the fascia. We treated the patient with liposomal amphotericin B. On day 3, he developed meningitis. Cryptococcus neoformans was detected in the blood, fascia, and cerebrospinal fluid. Flucytosine was added to liposomal amphotericin B.OutcomeDespite the antifungal treatment, new regions of dissemination to the skin developed, and the patient died of multiple organ failure.ConclusionA diagnosis of disseminated cryptococcosis should be considered in a differential diagnosis of necrotizing fasciitis among immunocompromised patients, regardless of their HIV status.Necrotizing fasciitis is very rare form of cryptococcosis and the prognosis is poor. Early diagnosis and early debridement with antifungal therapy are necessary to improve the outcome.
  • Issue Information
  • The qSOFA requires validation as a promptly applicable clinical criterion
  • A case of omental herniation through the esophageal hiatus successfully
           treated by laparoscopic surgery
    • Abstract: CaseWe report a rare case of omental herniation through the esophageal hiatus. A 46-year-old man visited our emergency department complaining of epigastralgia. Abdominal examination revealed muscular defense and rebound tenderness in his upper abdomen. A computed tomography scan showed a fat density mass in the posterior mediastinum. A laparoscopic operation was carried out under the diagnosis of omental herniation through the esophageal hiatus.OutcomeAbdominal pain disappeared dramatically after the operation. The postoperative course was uneventful.ConclusionAlthough a fat density mass in the posterior mediastinum is likely to be diagnosed as a lipomatous tumor, omental herniation through the esophageal hiatus should be taken into consideration as a possible diagnosis for acute abdominal pain in the emergency department.We report a rare case of omental herniation through the esophageal hiatus. Omental herniation through the esophageal hiatus should be taken into consideration as a possible diagnosis for acute abdominal pain in the emergency department.
  • A case of panspinal epidural abscess that presented with meningeal
    • Abstract: CaseIn rare cases, spinal epidural abscess involves the entire spine and can lead to neurological deficits and sepsis if treatment is delayed or suboptimal. A 65-year-old man was admitted with a diagnosis of bacterial meningitis. After admission, magnetic resonance imaging showed a spinal epidural abscess from the cervical to lumbar spine. Blood culture revealed Staphylococcus aureus. The patient was initially treated medically because he had no neurological deficits. Repeat blood culture remained positive and abscesses were found in the mediastinum and bilateral psoas muscles.OutcomeSurgery was carried out and the patient's postoperative course was satisfactory.ConclusionSpinal epidural abscess can extensively affect the spine and may present with the symptoms of bacterial meningitis. It is essential to examine the entire spine and paraspinal regions and to treat early in cases of spinal epidural abscess.Spinal epidural abscess can extensively affect the spine and may present with the symptom of bacterial meningitis. Examining the whole spine and paraspinal abscesses is essential in cases of spinal epidural abscess.
  • Better documentation in electronic medical records would lead to an
           increased use of lower extremity venous ultrasound in the inpatient
           setting: a retrospective study
    • Abstract: AimWe hypothesized that the quality of the assessment of abnormal laboratory data in the emergency department (ED) could affect the hospital-attending physicians’ decision-making after a patient's hospitalization. To test this hypothesis, we investigated how patients with a positive D-dimer result were reported by ED physicians in electronic medical records, and measured whether lower extremity venous ultrasonography examination was undertaken during hospitalization by the hospital-attending physicians.MethodsIn an urban tertiary acute care general hospital in Japan, between January 2012 and December 2013, we included patients hospitalized after a positive D-dimer measurement (≥1.0 μg/mL) that was taken in the emergency department. We retrospectively measured the quality of ED physician assessments. Then we examined whether that affected the decisions of attending physicians to order lower extremity venous ultrasonography examinations during hospitalization. The exposure variable was the quality of the ED physicians’ assessment of patients with positive D-dimer results. The outcome was whether a lower extremity venous ultrasonography examination was ordered by the attending physician during hospitalization.ResultsWhen assessments were described by ED physicians for patients with positive D-dimer results, the attending physicians frequently ordered lower extremity venous ultrasonography (odds ratio, 10.74; 95% confidence interval, 5.92–19.50), even if the assessments only contained “copied and pasted” laboratory data (odds ratio, 1.68; 95% confidence interval, 2.10–2.40).ConclusionsBetter documentation by ED physicians, regarding patients with positive D-dimer results, strongly affected the decisions made by attending physicians to order lower extremity venous ultrasonography examination.Several cross-sectional studies have reported on the quality of electronic medical records (EMRs) in the clinical setting, whereas a study has shown the ease with which copy and paste can be used in EMRs. However, none of these studies could answer how much copied-and-pasted documentation was transmitted between physicians by the EMRs, and none investigated the influence of the assessment quality by the EMRs in a cohort setting, even retrospectively. Better documentation by emergency department physicians, regarding patients with positive D-dimer results, strongly affected the decisions made by attending physicians to order lower extremity venous ultrasonography examination.
  • Venous thromboembolism in major trauma patients: a single-center
           retrospective cohort study of the epidemiology and utility of D-dimer for
    • Abstract: AimVenous thromboembolism (VTE) can be a life-threatening complication after major trauma. The aim of this study was to investigate the epidemiology of VTE and to assess the usefulness of D-dimer for screening for VTE in major trauma cases among the Japanese population.MethodsWe examined a single-center retrospective cohort of severely injured trauma patients who had been admitted to the emergency intensive care unit at Okayama University Hospital (Okayama, Japan) from April 2013 through to March 2016. Venous thromboembolism was confirmed by computed tomography angiography and computed tomography venography, which was determined based on the attending physician monitoring daily D-dimer levels. Independent risk factors for VTE were determined by multiple logistic regression analysis. D-dimer levels were evaluated using area under the receiver operating characteristic curve (AUROC) to predict VTE.ResultsThe study cohort consisted of 204 trauma patients (median Injury Severity Score, 20). Of the 204 patients, 65 (32%) developed VTE. The median time from admission to VTE diagnosis was 10 days. In multiple logistic regression analysis, higher Injury Severity Score and the presence of lower extremity fractures were revealed to be a risk factor for VTE. D-dimer levels at day 10 showed moderate accuracy, of which the AUROC was 0.785 (95% confidence interval, 0.704–0.866; P < 0.001). The cut-off that maximized the Youden index was 12.45 μg/mL.ConclusionsAt least one of every three major trauma patients had potential development of VTE at a median of 10 days following admission to the intensive care unit. D-dimer levels on day 10 can be a useful predictor of VTE.This is the first investigation regarding venous thromboembolism (VTE) in major trauma among Japanese patients. At least one of every three major trauma patients developed VTE at a median of 10 days following admission to the intensive care unit. D-dimer levels on day 10 can be a useful predictor of VTE.
  • Evaluation of factors associated with the difficulty in finding receiving
           hospitals for traffic accident patients at the scene treated by emergency
           medical services: a population-based study in Osaka City, Japan
    • Abstract: AimAlthough the prolongation of the time between injury and hospital arrival of traffic accident patients can influence their prognosis, factors associated with the difficulty in hospital acceptance of these patients have not been sufficiently evaluated in Japan.MethodsWe retrospectively analyzed the population-based ambulance records of all traffic accident patients for whom the Osaka Municipal Fire Department (Osaka City, Japan) dispatched an ambulance in 2013. We defined “cases with difficulty in hospital acceptance” as cases that required ≥4 calls by emergency medical service personnel at the scene before receiving hospital acceptance. We included patient characteristics (age, sex, coma status, and trauma severity judged by emergency medical service personnel), time factors (day/night or weekday/holiday and weekends), and accident location for multivariable logistic regression analysis to assess factors associated with the difficulty in hospital acceptance.ResultsAmong 13,427 traffic accident patients, 2,033 (15.1%) were cases with difficulty in hospital acceptance. Pediatric patients (adjusted odds ratio [OR], 1.265; 95% confidence interval [CI], 1.060–1.509), male sex (adjusted OR, 1.260; 95% CI, 1.135–1.398), moderate-grade trauma (adjusted OR, 2.241; 95% CI, 1.972–2.547), severe-grade trauma (adjusted OR, 2.057; 95% CI, 1.249–3.388), holidays and weekends (adjusted OR, 1.702; 95% CI, 1.539–1.882), and night-time (adjusted OR, 2.720; 95% CI, 2.443–3.027) were positively associated with difficulty in hospital acceptance.ConclusionsUsing population-based ambulance records from a large urban community in Japan, we showed that the difficulty in hospital acceptance of patients at the scene of traffic accidents was positively associated with several prehospital factors.We assessed the relationship between the difficulties in hospital acceptance of patients at the scene of traffic accidents by using population-based ambulance records from a large urban community in Japan. We showed that the difficulty in hospital acceptance of patients at the scene of traffic accidents was positively associated with several prehospital factors, such as night-time and severity of trauma.
  • A case series of pelvic fracture patients who developed lower urinary
           tract symptoms after transarterial embolization of bilateral internal
           iliac arteries
    • Abstract: CasesTransarterial embolization of bilateral internal iliac arteries (TAE) is a useful hemostatic method for the management of pelvic fracture patients, but its effects on urinary functions remain unclear. In this study, we evaluated the impact of TAE on lower urinary tract symptoms (LUTS) in 10 pelvic fracture patients.OutcomesLower urinary tract symptoms before and after hospitalization were evaluated by International Prostate Symptoms Score, Overactive Bladder Symptoms Score, and Quality Of Life score. All scores showed significant worsening. The changes did not correlate with sex, age, injury severity score, or durations of unstable hemodynamics or urethral catheterization. Changes of International Prostate Symptoms Score and Quality Of Life score showed significant positive correlations with intervals between the evaluations.ConclusionPelvic fracture patients treated with TAE showed significant worsening of LUTS. Risk for exacerbation of LUTS should be taken into consideration when deciding to use TAE.Lower urinary tract symptoms before and after transarterial embolization of bilateral internal iliac arteries (TAE) in pelvic fracture patients were evaluated by International Prostate Symptoms Score (IPSS), Overactive Bladder Symptoms Score (OABSS), and Quality Of Life (QOL) score. All scores showed significant worsening after TAE.
  • Sudden cerebral depression detected by bispectral index monitoring in
           cryptococcal meningitis with elevated near-fatal cerebrospinal fluid
    • Abstract: CaseAn increase in cerebrospinal fluid pressure (CSFP) is usually prominent in cryptococcal meningitis, which has a high mortality rate, so aggressive management to control CSFP is crucial. In this case, a 40-year-old-man survived cryptococcal meningitis treated with continuous spinal drainage under bispectral index (BIS) monitoring. He unexpectedly showed hypertension, went into a coma, and even loss his light reflexes due to CSFP elevation. His BIS values had abruptly dropped before developing these symptoms, but dramatically recovered after lumbar puncture drainage, suggesting that BIS monitoring could reflect cerebral function changes due to CSFP alternations.OutcomeInducing continuous spinal drainage to control CSFP provided stable control of blood pressure and brain activity, which was continuously monitored by BIS, enabling us to provide prompt treatment.ConclusionCerebral depressions due to elevated CSFP may suddenly develop, so continuous spinal drainage is needed for preventing catastrophic events. Bispectral index could be useful for detecting early changes from CSFP elevation in meningitis cases with intracranial hypertension.Sudden cerebral depression with elevated near-fatal CSFP and the effect of treatment were detected by BIS monitoring.
  • Efficacy of isoproterenol for treating amlodipine overdose resulting in
    • Abstract: CaseAmlodipine predominantly affects vascular smooth muscle cells. Amlodipine overdose usually presents with vasodilatory shock, accompanied by reflex tachycardia rather than bradycardia.An 81-year-old woman presented with impaired consciousness 8 h after ingesting 50 5-mg amlodipine tablets with suicidal intent. On admission, her blood pressure was 50/40 mmHg and her heart rate was 45 b.p.m. Serum amlodipine level was extremely high (474.4 ng/mL), causing refractory bradycardia. She remained hypotensive despite fluid resuscitation, and therefore was administered dopamine and norepinephrine. She was also administered glucagon and calcium gluconate, and underwent high-dose insulin euglycemic therapy.OutcomeAlthough her blood pressure improved, bradycardia progressively worsened and isoproterenol infusion was initiated, which resulted in an improvement in her heart rate. The patient discharged on day 14 without any complications.ConclusionIsoproterenol is effective for treating bradycardia after amlodipine overdose.Extremely high serum amlodipine level could cause refractory bradycardia. Isoproterenol infusion is a promising treatment for hypotension with bradycardia caused by amlodipine overdose and calcium infusion.
  • Cardiocerebral and cardiopulmonary resuscitation – 2017 update
    • Abstract: Sudden cardiac arrest is a major public health problem in the industrialized nations of the world. Yet, in spite of recurrent updates of the guidelines for cardiopulmonary resuscitation and emergency cardiac care, many areas have suboptimal survival rates. Cardiocerebral resuscitation, a non-guidelines approach to therapy of primary cardiac arrest based on our animal research, was instituted in Tucson (AZ, USA) in 2002 and subsequently adopted in other areas of the USA. Survival rates of patients with primary cardiac arrest and a shockable rhythm significantly improved wherever it was adopted. Cardiocerebral resuscitation has three components: the community, the pre-hospital, and the hospital. The community component emphasizes bystander recognition and chest compression only resuscitation. Its pre-hospital or emergency medical services component emphasizes: (i) urgent initiation of 200 uninterrupted chest compressions before and after each indicated single defibrillation shock, (ii) delayed endotracheal intubation in favor of passive delivery of oxygen by a non-rebreather mask, (iii) early adrenaline administration. The hospital component was added later. The national and international guidelines for cardiopulmonary resuscitation and emergency medical services are still not optimal, for several reasons, including the fact that they continue to recommend the same approach for two entirely different etiologies of cardiac arrest: primary cardiac arrest, often caused by ventricular fibrillation, where the arterial blood oxygenation is little changed at the time of the arrest, and secondary cardiac arrest from severe respiratory insufficiency, where the arterial blood is severely desaturated at the time of cardiac arrest. These different etiologies need different approaches to therapy.Sudden cardiac arrest is a major public health problem in industrialized nations of the world. Yet, in spite of recurrent updates of guidelines, many areas have suboptimal survival rates. Cardiocerebral Resuscitation, a non-guidelines approach to therapy of primary cardiac arrest has improved survival in patients with a shockable rhythm in every area where it has been instituted.
  • Drug-induced anaphylaxis in the emergency room
    • Abstract: Anaphylaxis is a life-threatening, systemic allergic reaction that presents unique challenges for emergency care practitioners. Anaphylaxis occurs more frequently than previously believed. Therefore, proper knowledge regarding the epidemiology, mechanisms, symptoms, diagnosis, and treatment of anaphylaxis is essential. In particular, the initial treatment strategy, followed by correct diagnosis, in the emergency room is critical for preventing fatal anaphylaxis, although making a diagnosis is not easy because of the broad and often atypical presentation of anaphylaxis. To this end, the clinical criteria proposed by the National Institute of Allergy and Infectious Diseases and the Food Allergy and Anaphylaxis Network are useful, which, together with a differential diagnosis, could enable a more accurate diagnosis. Additional in vitro tests, such as plasma histamine and tryptase measurements, are also helpful. It should be emphasized that adrenaline is the only drug recommended as first-line therapy in all published national anaphylaxis guidelines. Most international anaphylaxis guidelines recommend injecting adrenaline by the intramuscular route in the mid-anterolateral thigh, whereas i.v. adrenaline is an option for patients with severe hypotension or cardiac arrest unresponsive to intramuscular adrenaline and fluid resuscitation. In addition to the route of administration, choosing the appropriate dose of adrenaline is essential, because serious adverse effects can potentially occur after an overdose of adrenaline. Furthermore, to avoid future recurrence of anaphylaxis, providing adrenaline auto-injectors and making an etiological diagnosis, including confirmation of the offending trigger, are recommended for patients at risk of anaphylaxis before their discharge from the emergency room.The initial treatment strategy, followed by correct diagnosis, in the emergency room (ER) is critical for preventing fatal anaphylaxis. Despite therapeutic benefits of adrenaline and the recommendations for its use, adrenaline injection rates to treat anaphylaxis remain low in many ERs. ER physicians should have proper knowledge regarding the diagnosis and treatment of anaphylaxis.
  • Superior mesenteric artery syndrome leading to reversible mucosal gangrene
    • Abstract: We describe a case in which gastrointestinal distention due to superior mesenteric artery syndrome (SMAS) developed into membranous gangrene, which in turn led to septic shock in a 60-year-old woman with cerebral palsy and cachexia. The association with SMAS and septic shock is considered extremely rare, it is important to consider this combination especially in cachectic patients with gastric distension accompanying refractory shock unknown etiology.
School of Mathematical and Computer Sciences
Heriot-Watt University
Edinburgh, EH14 4AS, UK
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Fax: +00 44 (0)131 4513327
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