The Current Status of Development and Implementation of Medical Emergency Response Plan in Schools.

BACKGROUND: Automated external defibrillators (AEDs) have been widely distributed at schools in Japan. We have demonstrated that ventricular fibrillation accounted for 68% of nontraumatic sudden cardiac arrest (SCA) in schools, suggesting that a well-prepared medical emergency response plan (MERP) for schools would improve the outcomes of SCA patients. However, it is uncertain if the MERP has been well developed or implemented in Japanese schools. METHODS AND RESULTS: We conducted a cross-sectional study of schools in Osaka using a postal questionnaire. Survey items included type of school, number of students, school staff and teaching staff, number of AEDs used and the place of installation, cardiopulmonary resuscitation (CPR) training to school staff, MERP development and implementation, and the number of SCA cases they experienced. The response rate to this survey was 44% (764 of 1728 schools). Every school except for 4 have installed at least 1 AED. Thirty-six percent of schools, however, have not yet developed and implemented a MERP for SCA. Moreover, 49% of schools surveyed have not conducted a rehearsal training session for SCA in the previous 3 years, although 95% of schools provided CPR training courses to school staff. A total of 15 schools have experienced 16 presumed or actual SCA cases in the study period. Of the 15 schools, 6 schools reported that bystanders experienced psychological stress. CONCLUSIONS: A MERP for SCA has not yet been fully developed and implemented in the schools surveyed in our study despite widely distributed AEDs and CPR training.

Serological assessment of measles-rubella vaccination catch-up campaign among university students.

BACKGROUND: In Japan, 5000-300,000 persons contracted measles every year until 2001. The measles/rubella-combined (MR) vaccination at age 17-18 years (phase 4 MR vaccination: MR-IV) was launched in 2008 in Japan as a measles-rubella catch-up campaign. A serological assessment of this campaign has not been thoroughly performed. METHODS: Titers of anti-measles and anti-rubella immunoglobulin G antibodies, and past medical history including measles and rubella vaccination and infection were obtained from first-year university students in 2008 and 2009, and the immune status against measles and rubella was compared between students at the target MR-IV age (the target age group) and those 1 year older than the target age (non-target age group). RESULTS: A total of 186 students were in the target age group and 146 were in the non-target age group. The proportion of students with a history of measles and rubella infection was not significantly different between the two groups (8.8% vs. 6.3%, P = 0.41 and 11.0% vs. 9.9%, P = 0.75, respectively). A history of two or more measles and rubella vaccinations was significantly more frequent in the target age group (85.2% and 54.9%, respectively) than in the non-target age group (20.8% and 13.2%, respectively; both P < 0.001). Prevalence of seropositivity for measles and for rubella was also higher in the target age group (98.9% and 97.8%, respectively) than in the non-target age group (91.0% and 87.5%, respectively; both P < 0.001). CONCLUSIONS: The MR-IV catch-up campaign helped achieve herd immunity and will contribute to the elimination of measles and rubella.

Social regulations predispose people to complete vaccination for vaccine-preventable diseases.

Japan experienced measles outbreaks in both 2006 and 2007 mainly among university students. Improvement of vaccine coverage against vaccine-preventable viral infections is the prime task for preventing outbreaks of viral infections. To elucidate the promoting factors for complete vaccination against measles, rubella, mumps, and varicella-zoster viruses, we conducted a case-control study among single university students in Japan. Information on vaccinations and clinico-demographical factors were collected using a self-administered questionnaire and a photocopy of the Maternal and Child Health Handbook. Logistic regression analysis was performed to estimate odds ratios (ORs) and their 95% confidence intervals (CIs) for two-time vaccination against measles and rubella viruses as mandatory vaccinations and at least one-time vaccination against mumps and varicella-zoster viruses as optional vaccinations. A total of 1,370 (744 medical, 508 paramedical, and 118 pharmaceutical) students were invited to participate, 960 (70.1%) of whom were enrolled in the study. Students aged < 20 years had a greater propensity for measles and rubella vaccinations (OR 7.8 [95% CI, 5.1-11.8] and OR 6.1 [95% CI, 3.7-10.0], respectively) compared with those aged ≥ 20 years. Students with a history of living over-seas for 1 month or longer were more likely to complete vaccination for measles (OR 4.4 [95% CI, 1.4-13.5] compared with those without such history. This significantly high vaccination coverage was attributed to the measles-rubella catch-up campaign by the Japanese government and the immunization regulations by foreign countries. These findings suggest that social regulations would predispose people to complete vaccination.

Nationwide public-access defibrillation in Japan.

BACKGROUND: It is unclear whether dissemination of automated external defibrillators (AEDs) in public places can improve the rate of survival among patients who have had an out-of-hospital cardiac arrest. METHODS: From January 1, 2005, through December 31, 2007, we conducted a prospective, population-based, observational study involving consecutive patients across Japan who had an out-of-hospital cardiac arrest and in whom resuscitation was attempted by emergency responders. We evaluated the effect of nationwide dissemination of public-access AEDs on the rate of survival after an out-of-hospital cardiac arrest. The primary outcome measure was the 1-month rate of survival with minimal neurologic impairment. A multivariate logistic-regression analysis was performed to assess factors associated with a good neurologic outcome. RESULTS: A total of 312,319 adults who had an out-of-hospital cardiac arrest were included in the study; 12,631 of these patients had ventricular fibrillation and had an arrest that was of cardiac origin and that was witnessed by bystanders. In 462 of these patients (3.7%), shocks were administered by laypersons with the use of public-access AEDs, and the proportion increased, from 1.2% to 6.2%, as the number of public-access AEDs increased (P<0.001 for trend). Among all patients who had a bystander-witnessed arrest of cardiac origin and who had ventricular fibrillation, 14.4% were alive at 1 month with minimal neurologic impairment; among patients who received shocks from public-access AEDs, 31.6% were alive at 1 month with minimal neurologic impairment. Early defibrillation, regardless of the type of provider (bystander or emergency-medical-services personnel), was associated with a good neurologic outcome after a cardiac arrest with ventricular fibrillation (adjusted odds ratio per 1-minute increase in the time to administration of shock, 0.91; 95% confidence interval, 0.89 to 0.92; P<0.001). The mean time to shock was reduced from 3.7 to 2.2 minutes, and the annual number of patients per 10 million population who survived with minimal neurologic impairment increased from 2.4 to 8.9 as the number of public-access AEDs increased from fewer than 1 per square kilometer of inhabited area to 4 or more. CONCLUSIONS: Nationwide dissemination of public-access AEDs in Japan resulted in earlier administration of shocks by laypersons and in an increase in the 1-month rate of survival with minimal neurologic impairment after an out-of-hospital cardiac arrest.

Regional variation in survival following pediatric out-of-hospital cardiac arrest.

BACKGROUND: Although regional variation in outcome after adult out-of-hospital cardiac arrest (OHCA) is known, no clinical studies have assessed this in pediatric OHCA. METHODS AND RESULTS: This nationwide, prospective, population-based observation of the whole of Japan included consecutive OHCA patients with resuscitation attempt from January 2005 through December 2009. Primary outcome was 1-month survival with neurologically favorable outcome. Japan was divided into the following 7 regions as the largest administrative units: Hokkaido-Tohoku, Kanto, Tokai-Hokuriku, Kinki, Chugoku, Shikoku, and Kyushu-Okinawa. The outcome of pediatric OHCA was then compared between the regions. Multiple logistic regression analysis was used to adjust for other factors that were considered to influence the relationship between region and outcome. A total of 8,240 pediatric OHCA patients were registered during the study period. One-month survival with neurologically favorable outcome significantly differed by region: 2.5% (24/967) in Hokkaido-Tohoku (adjusted odds ratio [AOR], 1.65; 95% confidence interval [CI]: 0.94-2.90), 2.9% (47/1614) in Tokai-Hokuriku (AOR, 2.06; 95% CI: 1.28-3.31), 2.1% (26/1239) in Kinki (AOR, 1.45; 95% CI: 0.84-2.51), 3.4% (16/465) in Chugoku (AOR, 3.11; 95% CI: 1.62-6.00), 1.5% (4/259) in Shikoku (AOR, 0.79; 95% CI: 0.26-2.43), and 2.8% (27/974) in Kyushu-Okinawa (AOR, 2.15; 95% CI: 1.24-3.74) referred to Kanto (1.4%, 37/2722). CONCLUSIONS: According to Japanese nationwide OHCA registry data there are significant regional variations in the outcome of pediatric OHCA.

Association of prehospital advanced airway management with neurologic outcome and survival in patients with out-of-hospital cardiac arrest.

IMPORTANCE: It is unclear whether advanced airway management such as endotracheal intubation or use of supraglottic airway devices in the prehospital setting improves outcomes following out-of-hospital cardiac arrest (OHCA) compared with conventional bag-valve-mask ventilation. OBJECTIVE: To test the hypothesis that prehospital advanced airway management is associated with favorable outcome after adult OHCA. DESIGN, SETTING, AND PARTICIPANTS: Prospective, nationwide, population-based study (All-Japan Utstein Registry) involving 649,654 consecutive adult patients in Japan who had an OHCA and in whom resuscitation was attempted by emergency responders with subsequent transport to medical institutions from January 2005 through December 2010. MAIN OUTCOME MEASURES: Favorable neurological outcome 1 month after an OHCA, defined as cerebral performance category 1 or 2. RESULTS: Of the eligible 649,359 patients with OHCA, 367,837 (57%) underwent bag-valve-mask ventilation and 281,522 (43%) advanced airway management, including 41,972 (6%) with endotracheal intubation and 239,550 (37%) with use of supraglottic airways. In the full cohort, the advanced airway group incurred a lower rate of favorable neurological outcome compared with the bag-valve-mask group (1.1% vs 2.9%; odds ratio [OR], 0.38; 95% CI, 0.36-0.39). In multivariable logistic regression, advanced airway management had an OR for favorable neurological outcome of 0.38 (95% CI, 0.37-0.40) after adjusting for age, sex, etiology of arrest, first documented rhythm, witnessed status, type of bystander cardiopulmonary resuscitation, use of public access automated external defibrillator, epinephrine administration, and time intervals. Similarly, the odds of neurologically favorable survival were significantly lower both for endotracheal intubation (adjusted OR, 0.41; 95% CI, 0.37-0.45) and for supraglottic airways (adjusted OR, 0.38; 95% CI, 0.36-0.40). In a propensity score-matched cohort (357,228 patients), the adjusted odds of neurologically favorable survival were significantly lower both for endotracheal intubation (adjusted OR, 0.45; 95% CI, 0.37-0.55) and for use of supraglottic airways (adjusted OR, 0.36; 95% CI, 0.33-0.39). Both endotracheal intubation and use of supraglottic airways were similarly associated with decreased odds of neurologically favorable survival. CONCLUSION AND RELEVANCE: Among adult patients with OHCA, any type of advanced airway management was independently associated with decreased odds of neurologically favorable survival compared with conventional bag-valve-mask ventilation.

An association between systolic blood pressure and stroke among patients with impaired consciousness in out-of-hospital emergency settings.

BACKGROUND: Stroke is difficult to diagnose when consciousness is disturbed. However few reports have discussed the clinical predictors of stroke in out-of-hospital emergency settings. This study aims to evaluate the association between initial systolic blood pressure (SBP) value measured by emergency medical service (EMS) and diagnosis of stroke among impaired consciousness patients. METHODS: We included all patients aged 18 years or older who were treated and transported by EMS, and had impaired consciousness (Japan Coma Scale ≧ 1) in Osaka City (2.7 million), Japan from January 1, 1998 through December 31, 2007. Data were prospectively collected by EMS personnel using a study-specific case report form. Multiple logistic regressions assessed the relationship between initial SBP and stroke and its subtypes adjusted for possible confounding factors. RESULTS: During these 10 years, a total of 1,840,784 emergency patients who were treated and transported by EMS were documented during the study period in Osaka City. Out of 128,678 with impaired consciousness, 106,706 who had prehospital SBP measurements in the field were eligible for our analyses. The proportion of patients with severe impaired consciousness significantly increased from 14.5% in the <100 mmHg SBP group to 27.6% in the > =200 mmHg SBP group (P for trend <0.001). The occurrence of stroke significantly increased with increasing SBP (adjusted odd ratio [AOR] 1.34, 95% confidence interval [CI] 1.33 to 1.35), and the AOR of the SBP > =200 mmHg group versus the SBP 101-120 mmHg group was 5.26 (95% CI 4.93 to 5.60). The AOR of the SBP > =200 mmHg group versus the SBP 101-120 mmHg group was 9.76 in subarachnoid hemorrhage (SAH), 16.16 in intracranial hemorrhage (ICH), and 1.52 in ischemic stroke (IS), and the AOR of SAH and ICH was greater than that of IS. CONCLUSIONS: Elevated SBP among emergency patients with impaired consciousness in the field was associated with increased diagnosis of stroke.

Annual improvement trends in resuscitation outcome of patients defibrillated by laypersons after out-of-hospital cardiac arrests and compression-only resuscitation of laypersons.

AIM: We aimed to investigate the effect of compression-only cardiopulmonary resuscitation (CPR) with conventional CPR in patients who were defibrillated by laypersons. METHODS: This is a population-based, nationwide observational study. Adult and children who sustained a witnessed out-of-hospital cardiac arrest and defibrillated by laypersons between 2005 to 2019 were identified on the national database. The study used trend analyses, multivariate logistic regression, and inverse probability weighting using propensity score to explore changes in one-month survival and survival with a good neurological outcome over time and the influence of compression-only CPR compared with conventional CPR. RESULTS: In total, 11,402 patients defibrillated by laypersons were enrolled in this study. The percentages of compression-only resuscitation increased dramatically and more than 50% from 2012 (P < 0.001). The percentages of cases with favorable resuscitation outcomes also increased annually (P < 0.001). By regression analysis, favorable outcomes were associated with recent years, male sex, younger age, and shorter resuscitation start time. In addition, the adjusted odds ratio of compression-only CPR to conventional CPR was 1.23 with a 95% confident interval 1.13-1.34. By inverse probability weighting, compression-only CPR was superior to conventional CPR for the favorable outcomes (P < 0.001). The adjusted outcomes in each year were better in compression-only resuscitation in most of the years. The overall relative risk reduction and the number needed to treat for compression-only resuscitation compared with conventional resuscitation were 7.6% and 22.1, respectively. CONCLUSIONS: In Japan, the outcomes of out-of-hospital cardiac arrest patients who were defibrillated by laypersons were considerably better in compression-only resuscitation of laypersons every year.

Impact of early intravenous epinephrine administration on outcomes following out-of-hospital cardiac arrest.

BACKGROUND: The effectiveness of epinephrine administration for cardiac arrests has been shown in animal models, but the clinical effect is still controversial. METHODS AND RESULTS: A prospective, population-based, observational study in Osaka involved consecutive out-of-hospital cardiac arrest (OHCA) patients from January 2007 through December 2009. We evaluated the outcomes among adult non-traumatic bystander-witnessed OHCA patients for whom the local protocol directed the emergency medical service personnel to administer epinephrine. After stratifying by first documented cardiac rhythm, outcomes were compared among the following groups: non-administration, ≤10, 11-20 and ≥21 min as the time from emergency call to epinephrine administration. A total of 3,161 patients were eligible for our analyses, among whom 1,013 (32.0%) actually received epinephrine. The epinephrine group had a significantly lower rate of neurologically intact 1-month survival than the non-epinephrine group (4.1% vs. 6.1%, P=0.028). In cases of ventricular fibrillation (VF) arrest, patients in the early epinephrine group who received epinephrine administration within 10 min had a significantly higher rate of neurologically intact 1-month survival compared with the non-epinephrine group (66.7% vs. 24.9%), though other epinephrine groups did not. In cases of non-VF arrest, the rate of neurologically intact 1-month survival was low, irrespective of epinephrine administration. CONCLUSIONS: The effectiveness of epinephrine after OHCA depends on the time of administration. When epinephrine is administered in the early phase, there is an improvement in neurological outcome from OHCA with VF.

Medical students' perceptions of emergency medical care before and during the coronavirus disease 2019 pandemic.

Aim: Understanding how medical students perceive emergency medical care is important in promoting education and recruitment in the field of emergency medicine. This study aimed to clarify the perceptions of undergraduate medical students on emergency medical care with a focus on comparing their perceptions before and during the coronavirus disease 2019 (COVID-19) pandemic. Methods: Fourth-year undergraduate medical students were invited to complete a self-administered questionnaire in 2017 and 2020. Free comments on emergency medical care were analyzed via text mining. The relationships among categorical words were evaluated via correlation matrix and correspondence analysis. Results: The number of written words per student were not significantly different between 2017 (4.9 ± 3.4) and 2020 (5.3 ± 4.1). In 2017, the most frequently used word was "busy," and the words "patients," "life," and "care" were not related to each other significantly. In 2020, the frequency of the word "busy" decreased and the word "patients" was related to "life" (P < 0.01) and "care" (P < 0.01). In the correspondence analysis, seven words including "life" and "care" were associated with "patients," which demonstrates that these words tended to occur together. Conclusions: Although the responses of the medical students regarding emergency medical care before and during the COVID-19 pandemic included similar words, their expressions tended to be related to patient care or patient life during the pandemic. This change in perception might cultivate a sense of mission and responsibility and an interest in emergency medical care among medical students.

Liver Abscess due to Streptococcus intermedius Bacteremia and Its Association with Colonic Carcinoma: Is Bacteremia with Streptococcus intermedius an Alert for Colonic Carcinoma?

Liver abscess caused by some kinds of Streptococcus group such as Streptococcus bovis group has been recognized to associate with colorectal cancer. Streptococcus milleri group with liver abscess has not been received much attention in this point of view. Here, we report the case of a 63-year-old man who developed liver abscess with S. intermedius, which belongs to the S. milleri group. We confirmed that this case was accompanied by cecal carcinoma by colonoscopy. The tumor was a pathological lead point of intussusception of cecum. On the 26th day, open right hemicolectomy was performed. In this case, bacterial endophthalmitis was a complication due to bacteremia. The patient underwent ophthalmic surgery on the 98th day. Research investigating 16S rRNA of the mucosal colon microbiome reported that the S. intermedius gene was upregulated in patients with colorectal carcinoma. It is recommended that liver abscess with S. intermedius bacteremia should alert the clinician about the risks of carcinoma of the colon and abscess formation in distant organs. We here list the case reports of liver abscess caused by Streptococcus other than S. bovis group, which was associated with colonic carcinoma, and suggest the need for further research about S. milleri group.

Bystander-initiated rescue breathing for out-of-hospital cardiac arrests of noncardiac origin.

BACKGROUND: Although chest compression-only cardiopulmonary resuscitation (CPR) is effective for adult out-of-hospital cardiac arrest (OHCA) of cardiac origin, it remains uncertain whether bystander-initiated rescue breathing has an incremental benefit for OHCA of noncardiac origin. METHODS AND RESULTS: A nationwide, prospective, population-based, observational study covering the whole population of Japan and involving consecutive OHCA patients with emergency responder resuscitation attempts was conducted from January 2005 through December 2007. The primary outcome was neurologically intact 1-month survival. Multiple logistic regression analysis was used to assess the contribution of bystander-initiated CPR to better neurological outcomes. Among a total of 43 246 bystander-witnessed OHCAs of noncardiac origin, 8878 (20.5%) received chest compression-only CPR, and 7474 (17.3%) received conventional CPR with rescue breathing. The conventional CPR group (1.8%) had a higher rate of better neurological outcome than both the no CPR group (1.4%; odds ratio, 1.58; 95% confidence interval, 1.28 to 1.96) and the compression-only CPR group (1.5%; odds ratio, 1.32; 95% confidence interval, 1.03 to 1.69). However, the compression-only CPR group did not produce better neurological outcome than the no CPR group (odds ratio, 1.19; 95% confidence interval, 0.96 to 1.47). The number of OHCAs needed to treat with conventional CPR versus compression-only CPR to save a life with favorable neurological outcome after OHCA was 290. CONCLUSIONS: This nationwide observational study indicates that rescue breathing has an incremental benefit for OHCAs of noncardiac origin, but the impact on the overall survival after OHCA was small.

Conventional and chest-compression-only cardiopulmonary resuscitation by bystanders for children who have out-of-hospital cardiac arrests: a prospective, nationwide, population-based cohort study.

BACKGROUND: The American Heart Association recommends cardiopulmonary resuscitation (CPR) by bystanders with chest compression only for adults who have cardiac arrests, but not for children. We assessed the effect of CPR (conventional with rescue breathing or chest compression only) by bystanders on outcomes after out-of-hospital cardiac arrests in children. METHODS: In a nationwide, prospective, population-based, observational study, we enrolled 5170 children aged 17 years and younger who had an out-of-hospital cardiac arrest from Jan 1, 2005, to Dec 31, 2007. Data collected included age, cause, and presence and type of CPR by bystander. The primary endpoint was favourable neurological outcome 1 month after an out-of-hospital cardiac arrest, defined as Glasgow-Pittsburgh cerebral performance category 1 or 2. FINDINGS: 3675 (71%) children had arrests of non-cardiac causes and 1495 (29%) cardiac causes. 1551 (30%) received conventional CPR and 888 (17%) compression-only CPR. Data for type of CPR by bystander were not available for 12 children. Children who were given CPR by a bystander had a significantly higher rate of favourable neurological outcome than did those not given CPR (4.5% [110/2439] vs 1.9% [53/2719]; adjusted odds ratio [OR] 2.59, 95% CI 1.81-3.71). In children aged 1-17 years who had arrests of non-cardiac causes, favourable neurological outcome was more common after bystander CPR than no CPR (5.1% [51/1004] vs 1.5% [20/1293]; OR 4.17, 2.37-7.32). However, conventional CPR produced more favourable neurological outcome than did compression-only CPR (7.2% [45/624] vs 1.6% [six of 380]; OR 5.54, 2.52-16.99). In children aged 1-17 years who had arrests of cardiac causes, favourable neurological outcome was more common after bystander CPR than no CPR (9.5% [42/440] vs 4.1% [14/339]; OR 2.21, 1.08-4.54), and did not differ between conventional and compression-only CPR (9.9% [28/282] vs 8.9% [14/158]; OR 1.20, 0.55-2.66). In infants (aged <1 year), outcomes were uniformly poor (1.7% [36/2082] with favourable neurological outcome). INTERPRETATION: For children who have out-of-hospital cardiac arrests from non-cardiac causes, conventional CPR (with rescue breathing) by bystander is the preferable approach to resuscitation. For arrests of cardiac causes, either conventional or compression-only CPR is similarly effective. FUNDING: Fire and Disaster Management Agency and the Ministry of Education, Culture, Sports, Science and Technology (Japan).

Incidence of adverse drug events and medication errors in Japan: the JADE study.

BACKGROUND: The epidemiology of adverse drug events (ADEs) and medication errors has received little evaluation outside the U.S. and Europe, and extrapolating from these data might not be valid, especially regarding selecting and prioritizing solutions. OBJECTIVE: To assess the incidence and preventability of ADEs and medication errors in Japan. DESIGN: The Japan Adverse Drug Events (JADE) study was a prospective cohort study. PATIENTS: A cohort of 3,459 adults admitted to a stratified random sample of seven medical and eight surgical wards and three intensive care units in three tertiary care hospitals over 6 months. MAIN MEASURES: We measured ADE and medication error rates from daily reviews of charts, laboratories, incident reports, and prescription queries by on-site reviewers; presence of a signal was considered an incident. Two independent physicians reviewed incidents to determine whether they were ADEs or medication errors and to assess severity and preventability. KEY RESULTS: We identified 1,010 ADEs and 514 medication errors (incidence: 17.0 and 8.7 per 1,000 patient-days, respectively) during the study period. Among ADEs, 1.6%, 4.9% and 33% were fatal, life-threatening and serious, respectively. Among ADEs, 14% were preventable. The rate per admission was 29 per 100 admissions, higher than in U.S. studies because associated with of the long length of hospital stay in Japan (mean, 17 days). CONCLUSIONS: The epidemiology and nature of ADEs and medication errors in Japan were similar to other countries, although more frequent per admission. Solutions that worked in these countries might thus improve medication safety in Japan, as could shortening hospital length of stay.

Incidence and outcome of out-of-hospital cardiac arrest with public-access defibrillation. A descriptive epidemiological study in a large urban community.

BACKGROUND: Detailed characteristics of those who experience an out-of-hospital cardiac arrest (OHCA) with public-access defibrillation (PAD) are unknown. METHODS AND RESULTS: A prospective, population-based observational study involving consecutive OHCA patients with emergency responder resuscitation attempts was conducted from July 1, 2004 through December 31, 2008 in Osaka City. We extracted data for OHCA patients shocked by a public-access automated external defibrillator (AED) and evaluated the patients' and rescuers' characteristics. The main outcome measure was neurologically favorable 1-month survival. During the study period, 10,375 OHCA patients were registered and of 908 patients suffering ventricular fibrillation arrest, 53 (6%) received public-access AED shocks by lay-rescuers, with the proportion increasing from 0% in 2004 to 11% in 2008 (P for trend<0.001). Railway stations (34%) were the places where PAD shocks were most frequently delivered, followed by nursing homes (11%), medical facilities (9%), and fitness facilities (7%). In 57% of cases, the subject received public-access AED shocks delivered by non-medical persons, including employees of railway companies (13%), school teachers (6%), employees of fitness facilities (6%), and security guards (6%). The proportion of neurologically favorable 1-month survival tended to increase from 0% in 2005 to 58% in 2008 (P for trend=0.081). CONCLUSIONS: Railway stations are the most common places where shocks by public-access AEDs were delivered in large urban communities of Japan, and among lay-rescuers railway station workers use AEDs more frequently.

Comparison of supraglottic airway versus endotracheal intubation for the pre-hospital treatment of out-of-hospital cardiac arrest.

INTRODUCTION: Both supraglottic airway devices (SGA) and endotracheal intubation (ETI) have been used by emergency life-saving technicians (ELST) in Japan to treat out-of-hospital cardiac arrests (OHCAs). Despite traditional emphasis on airway management during cardiac arrest, its impact on survival from OHCA and time dependent effectiveness remains unclear. METHODS: All adults with witnessed, non-traumatic OHCA, from 1 January 2005 to 31 December 2008, treated by the emergency medical services (EMS) with an advanced airway in Osaka, Japan were studied in a prospective Utstein-style population cohort database. The primary outcome measure was one-month survival with neurologically favorable outcome. The association between type of advanced airway (ETI/SGA), timing of device placement and neurological outcome was assessed by multiple logistic regression. RESULTS: Of 7,517 witnessed non-traumatic OHCAs, 5,377 cases were treated with advanced airways. Of these, 1,679 were ETI while 3,698 were SGA. Favorable neurological outcome was similar between ETI and SGA (3.6% versus 3.6%, P = 0.95). The time interval from collapse to ETI placement was significantly longer than for SGA (17.2 minutes versus 15.8 minutes, P < 0.001). From multivariate analysis, early placement of an advanced airway was significantly associated with better neurological outcome (Adjusted Odds Ratio (AOR) for one minute delay, 0.91, 95% confidence interval (CI) 0.88 to 0.95). ETI was not a significant predictor (AOR 0.71, 95% CI 0.39 to 1.30) but the presence of an ETI certified ELST (AOR, 1.86, 95% CI 1.04 to 3.34) was a significant predictor for favorable neurological outcome. CONCLUSIONS: There was no difference in neurologically favorable outcome from witnessed OHCA for ETI versus SGA. Early airway management with advanced airway regardless of type and rhythm was associated with improved outcomes.

Epidemiology of potentially inappropriate medication use in elderly patients in Japanese acute care hospitals.

PURPOSE: The elderly receive many medications which may have adverse effects. Little evidence is available about the epidemiology of potentially inappropriate medications being prescribed to the elderly in Japan as defined by the Beers criteria, or whether or not these medications result in harm when used in this population. METHODS: We conducted a prospective cohort study of patients aged ≥65 years who were admitted to three acute care hospitals in Japan. Trained research nurses followed up patients from randomly selected wards and collected data about their medications and all potential adverse drug events (ADEs). Two independent reviewers evaluated all the data. The use of potentially inappropriate medications and their effects on patients were identified using the updated Beers criteria. RESULTS: A total of 2155 elderly patients were eligible; 56.1% received at least one drug listed in the Beers criteria (BL drug). The rates of BL drug prescriptions were 103.8 per 100 admissions and 53.6 [DOSAGE ERROR CORRECTED] per 1000 patient-days, and the incidence rate of ADEs related to BL drugs was 1.7 per 100 BL drug prescriptions. Among patients aged ≥65 years, relatively younger patients (p = 0.0002) and those with less complications (p = 0.04) were likely to be prescribed BL drugs. CONCLUSIONS: Although BL drugs were frequently prescribed to elderly Japanese inpatients, the incidence of related ADEs appeared infrequent. These data suggest that re-evaluation of the appropriateness of the Beers criteria is needed before they are used in Japan and other nations to assess quality or for decision support.

Reduction in incidence and fatality of out-of-hospital cardiac arrest in females of the reproductive age.

AIMS: The aim of this study was to determine relative risk (RR) of incidence and fatality of out-of-hospital cardiac arrest (OHCA) by gender and oestrogen status. METHODS AND RESULTS: In a prospective, population-based observational study from 1998 through 2007, incidence and neurologically intact 1-month survival after OHCA were compared by gender after grouping: 0-12 years, 13-49 years, and > or =50 years according to menarche and menopause age. Among 26 940 cardiac arrests, there were 11 179 females and 15 701 males. Age-adjusted RR of females for OHCA incidence compared with males was 0.72 [95% confidence interval (CI), 0.58-0.91] in age 0-12 years, 0.39 (95% CI, 0.37-0.43) in age 13-49 years, and 0.54 (95% CI, 0.52-0.55) in age > or =50 years. Females aged 13-49 years had a significantly higher good neurological outcome than males [adjusted odds ratio (OR), 2.00 (95% CI 1.21-3.32)]. This sex difference was larger than that in the other age groups [adjusted OR, 0.82 (95% CI, 0.06-12.02) in age 0-12 years and 1.23 (95% CI, 0.98-1.54) in age > or =50 years]. CONCLUSION: Reproductive females had a lower incidence and a better outcome of OHCA than females of other ages and males, which might be explained by cardioprotective effects of endogenous oestrogen on OHCA.

[Current situation and future scope of the cardiopulmonary cerebral resuscitation in Japan].

New guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) were released in October 2010. The 2010 Guidelines changed a core concept of basic life support from traditional A-B-C (Airway, Breathing, Chest compressions) procedure to C-A-B (Chest compressions, Airway, Breathing) procedure. In the change of concept, it is emphasized that rescuer should start CPR with chest compression immediately. Japanese researchers contributed to the revision of the guidelines from a stage of establishment of a CoSTR(2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations) which gives the guidelines theoretical evidences. It is expected for us to promote resuscitation science even in traditional theoretical field but also in the field of education, implementation, and team approach.

A case of black esophagus with duodenal involvement.

Black esophagus is a rare condition referred from acute necrosis of the esophagus, with characteristic endoscopic finings of circumferential black appearance of the mucosa. Black esophagus is associated with systemic dysfunction, such as massive bleeding, or severe dehydration. Although the duodenal mucosa is also susceptible to ischemia, reports of black esophagus with duodenal involvement, such as bleeding or perforation, are limited. Here, we present the case of a 61-year-old male who developed the typical black esophagus with duodenal involvement following severe dehydration. The patient was treated conservatively and recovered from the acute phase. In the chronic stage, transthoracic esophagectomy was performed because of esophageal stricture, and the patient then returned to his daily life. Although the etiological mechanism of acute esophageal necrosis is unknown, it is thought to be associated with the presence of an underlying severe systemic condition. Our case is not exceptional for these systemic conditions demonstrating extreme dehydration. However, it remains unclear why our case showed duodenal involvement. Although the reason is unknown, the presence of a celiac aneurysm located near the bifurcation to duodenal blood flow might explain the impaired blood flow to the duodenum.