Impact of Extra-Corporeal Membrane Oxygenation and Blood Purification Therapy on Early Mobilization in the Intensive Care Unit: Retrospective Cohort Study

Objective@#To investigate the effect on early mobilization in patients undergoing extra-corporeal membrane oxygenation (ECMO) and acute blood purification therapy in the intensive care unit (ICU). @*Methods@#We conducted this multicenter retrospective cohort study by collecting data from six ICUs in Japan. Consecutive patients who were admitted to the ICU, aged ≥18 years, and received mechanical ventilation for >48 hours were eligible. The analyzed were divided into two groups: ECMO/blood purification or control group. Clinical outcomes; time to first mobilization, number of total ICU rehabilitations, mean and highest ICU mobility scale (IMS); and daily barrier changes were also investigated. @*Results@#A total of 204 patients were included in the analysis, 43 in the ECMO/blood purification group and 161 in the control group. In comparison of clinical outcome, the ECMO/blood purification group had a significantly longer time to first mobilization: ECMO/blood purification group 6 vs. control group 4 (p=0.003), higher number of total ICU rehabilitations: 6 vs. 5 (p=0.042), lower mean: 0 vs. 1 (p=0.043) and highest IMS: 2 vs. 3 (p=0.039) during ICU stay. Circulatory factor were most frequently described as barriers to early mobilization on days 1 (51%), 2 (47%), and 3 (26%). On days 4 to 7, the most frequently described barrier was consciousness factors (21%, 16%, 19%, and 21%, respectively) @*Conclusion@#The results of this study comparing the ECMO/blood purification group and the untreated group in the ICU showed that the ECMO/blood purification group had significantly longer days to mobilization and significantly lower mean and highest IMS.

A Survey on Current Activities and Issues of Pharmacists at Facilities Calculating Fees for the Implementation of Antimicrobial Stewardship in Ehime / 社会薬学

Although the fees for the implementation of antimicrobial stewardship (AS addition) were newly established in the 2018 revision of medical fees, more detailed activities and issues of pharmacists at facilities calculating AS addition have not been clarified so far. Therefore, to understand the current status of AS activities and problems, we conducted a questionnaire survey of facilities that calculate the additional fee for infection prevention measures 1 and investigated whether there are differences in AS activities between facilities where pharmacists are full-time employees and facilities where non-pharmacists are full-time employees. The results showed that the number of antimicrobial agents used by full-time pharmacists was larger than that by non-pharmacists. In addition, the frequency of AS was lower for non-full-time workers than for full-time workers, with most full-time workers performing AS every day, while non-full-time workers performing AS two to three days a week. In addition, non-full-time workers lacked human resources and work time, and did not have sufficient work materials. The survey revealed that AS activities’ current status and problems differ between full-time and non-full-time employees.

<b>Steps in Developing a Database of Drug Use-Result Surveillance: As an Example of Anti-Hyperlipidemia Drugs </b> / 薬剤疫学

The spontaneous reporting system for adverse drug reactions(ADRs), through which information is collected on patients who experience ADRs, can lead to hypotheses on causal relationships between drugs and ADRs; however, lack of information on patient characteristics or patients who have not experienced ADRs makes quantitative, relative comparison of risks difficult. From the viewpoint of adapting pharmacoepidemiology to supplement spontaneous reporting of ADRs, RAD-AR Council Japan(RCJ) has been promoting development of a database assembling drug use-results surveillance(DURS) data under the re-examination system for secondary use. RCJ received observational DURS data on antihypertensive drug users from pharmaceutical companies and integrated to develop a database of over 100,000 patients and 19 antihypertensives in 2003. RCJ maintains the database, expanding it to 143,509 patients and 21 antihypertensives in 2007, and also developed a database of antihyperlipidemics with approximately 34,000 patients in 2011. Researchers study these databases through an application and protocol review process stipulated by RCJ, and their results have been presented at conferences and published in articles. This report summarizes DURS data collection and its underpinning regulated systems in terms of data assembly and database maintenance at RCJ. The report also introduces the example for constructing the antihyperlipidemics DURS database and summarizes its patient characteristics. The database is characterized by ADR information and treatment-related laboratory values in addition to patient backgrounds and drug use information. However, it is too small to study rare ADRs and has limited longitudinal observational data. Therefore, RCJ worked to expand the antihypertensives DURS database in 2012 by adding data that include long-term surveillance results. (Jpn J Pharmacoepidemiol 2012; 17(2): 87-97)

PROGNOSTIC SIGNIFICANCE OF HEART RATE RESPONSE TO EXERCISE FOR 20-YEAR SURVIVAL IN PATIENTS WITH CORONARY HEART DISEASE / 体力科学

The purpose of this study was to investigate the prognostic value of change in heart rate (HR) response to oxygen uptake (VO₂) during exercise in patients with coronary heart disease (CHD).We retrospectively studied 204 patients with CHD who were sent to our exercise testing laboratory between August 1983 and February 1985. The following equation was used to determine the relation between VO₂ and HR during a graded treadmill exercise test: HR= A・exp ^B･VO2, where the constant b was defined as the inclination of the exponential curve-fitting model for oxygen uptake and heart rate during graded treadmill exercise (I-ECOH). Data on mortality were determined in May 2006 by examining medical records from the outpatient clinic and/or conducting telephone interviews with the patients or their families. Among the 204 study subjects, there were 54 cardiac deaths during the entire 20-year follow-up period. Kaplan-Meier survival curves for 20 years of follow-up demonstrated a survival rate of 81.3% for patients with a lower I-ECOH (＜35) and 56.0% for those with a higher I-ECOH (≧35), showing a significant difference in survival (p＜0.001). Multivariate Cox proportional hazards analysis revealed left ventricular ejection fraction (LVEF), peak oxygen uptake (VO₂ peak) and I-ECOH as independent predictors of survival. In this analysis, the prognostic power of minutes ventilation/carbon dioxide output (VE/VCO₂)slope was insignificant. The patients were divided into two groups with (＜45%) and without (≧60%) LV dysfunction using LVEF for more detailed analysis. The VO₂ peak and VE/VCO₂ slope were significant independent predictors of survival in patients with LV dysfunction. However, the I-ECOH was a significant independent predictor of survival in patients with and without LV dysfunction. Our data indicate that I-ECOH provides independent prognostic information on CHD patients with and without LV dysfunction.

Microvascular decompression in trigeminal neuralgia

Trigeminal neuralgia, like other rhizopathies, has defied categorization, clarification in pathology and effective treatment, despite several efforts, in several disciplines. The different rhizopathies like trigeminal neuralgia, hemifacial spasm, glossopharyngeal neuralgia, tinnitus, spasmodic torticollis, etc., all share a common pathology i.e., a vascular compression of the cranial nerve at the root entry zone. A comprehensive description of the features of trigeminal neuralgia and the surgical management with microvascular decompression is detailed in this article. Microvascular decompression is a relatively safe surgery and complications are very unlikely in dexterous hands

INCLINATION OF EXPONENTIAL CURVE-FITTING MODEL FOR OXYGEN UPTAKE AND HEART RATE DURING INCREMENTAL EXERCISE AS INDEX OF CARDIO-PULMONARY FUNCTIONAL RESERVE / 体力科学

A study was conducted to clarify the validity and availability of inclination of exponential curve-fitting model for oxygen uptake (VO<SUB>2</SUB>) and heart rate (HR) during incremental exercise (IECOH) as an index of cardio-pulmonary functional reserve in healthy subjects. A treadmill exercise test was used to measure the VO<SUB>2</SUB> (L/kg/min) and HR (beat /min) during incremental exercise of all subjects. The IECOH was derived from the following equation : HR=A⋅exp<SUP>B·VO<SUB>2</SUB></SUP>. The constant “B” represents the IECOH. The following three identifications were made : 1) the relationship between maximal oxygen uptake (VO<SUB>2</SUB>max) and IECOH in 82 healthy males ; 2) the relationship between IECOH and age in 428 healthy males and females ; 3) the effect of physical training in 8 healthy males.<BR>There was inverse correlation between IECOH and VO<SUB>2</SUB>max (r= -0.824) . And also, there were inverse correlations between IECOH detected from submaximal tests and VO<SUB>2</SUB>max (above r=-0.6) . There were no differences in the IECOH detected from maximal and submaximal tests. In Bland-Altman plot method, accuracy of measurment in the IECOH detected from submaximal exercise test was precise. There was a significant relationship between IECOH and age in male and female subjects (r=0.499 and r=0.310, respectively) . Physical training increased VO<SUB>2</SUB>max and decreased IECOH significantly. The VO<SUB>2</SUB>max before and after physical training correlated inversely with the IECOH before and after physical training (r=-0.514) .<BR>In conclusion, these results suggest that IECOH is adequate and useful as an index of cardio-pulmonary functional reserve which can be measured by the submaximal exercise test in healthy subjects.

Effects of physical training on the ventilatory response to exercise in patients on chronic hemodialysis / 体力科学

This study examined the effects of physical training on exercise hyperpnea (EH) in patients on hemodialysis (HD) . In baseline, 17 (trained group) and 12 (control group) patients on HD performed symptom limited exercise test using a treadmill. Trained group, but not control group, exercised 2 to 3 times weekly on non-dialysis days under medical supervision. Exercise testing was repeated 20 weeks after the baseline. Ventilatory response to exercise was evaluated using the regression slope relating minute ventilation (VE) to carbon dioxide output (VCO<SUB>2</SUB> ) during incremental exercise (VE/VCO<SUB>2</SUB> slope) below the point of respiratory compensation. In trained group, VE, oxygen uptake ( VO<SUB>2</SUB>) and VCO<SUB>2</SUB> at peak exercise increased and VE/VO<SUB>2</SUB> and VE/VCO<SUB>2</SUB> decreased after physical training, respectively. No change was observed in control group. VO<SUB>2</SUB> at the anaerobic threshold increased in trained group, but not in control group. The post training VE/VCO<SUB>2</SUB> slope (33.9±5.0) was significantly (p<0.05) lower than the pre-training slope (38.0± 4.8) and remained constant in control group. In trained group, changes in the VE/VCO<SUB>2</SUB> slope correlated with those in peak VO<SUB>2</SUB> (p<0.05) . These results suggest that physical training decreases EH in patients on HD and that it correlates with changes in exercise tolerance.