Investigating age and regional effects on the relation between the incidence of heat-related ambulance transport and daily maximum temperature or WBGT.

BACKGROUND: Although age and regional climate are considered to have effects on the incidence ratio of heat-related illness, quantitative estimation of age or region on the effect of occurring temperature for heat stroke is limited. METHODS: By utilizing data on the number of daily heat-related ambulance transport (HAT) in each of three age groups (7-17, 18-64, 65 years old, or older) and 47 prefectures in Japan, and daily maximum temperature (DMT) or Wet Bulb Globe Temperature (DMW) of each prefecture for the summer season, the effects of age and region on heat-related illness were studied. Two-way ANOVA was used to analyze the significance of the effect of age and 10 regions in Japan on HAT. The population-weighted average of DMT or DMW measured at weather stations in each prefecture was used as DMT or DMW for each prefecture. DMT or DMW when HAT is one in 100,000 people (T1 and W1, respectively) was calculated for each age category and prefecture as an indicator of heat acclimatization. The relation between T1 or W1 and average DMT or DMW of each age category and prefecture were also analyzed. RESULTS: HAT of each age category and prefecture was plotted nearly on the exponential function of corresponding DMT or DMW. Average R2 of the regression function in 47 prefectures in terms of DMW was 0.86, 0.93, and 0.94 for juveniles, adults, and elderly, respectively. The largest regional difference of W1 in 47 prefectures was 4.5 and 4.8 °C for juveniles and adults, respectively between Hokkaido and Tokyo, 3.9 °C for elderly between Hokkaido and Okinawa. Estimated W1 and average DMT or DMW during the summer season for 47 prefectures was linearly related. Regarding age difference, the regression line showed that W1 of the prefecture for DMW at 30 °C of WBGT was 31.1 °C, 32.4 °C, and 29.8 °C for juveniles, adults, and elderly, respectively. CONCLUSIONS: Age and regional differences affected the incidence of HAT. Thus, it is recommended that public prevention measures for heat-related disorders take into consideration age and regional variability.

[Clinical Ethics in Neurological Emergencies and Critical Care].

The author has examined the characteristics of clinical ethics regarding neurological emergencies and critical care. Ethics are involved in areas such as emergency medicine standards, intensive care strategies for brain dead patients who are followed by organ donation as well as those who do not donate their organs, resulting in cardiac deaths, and serious problems about distributing medical resources among the elder in extremely aged society. We must understand not only that we encounter a variety of fluctuating patient emotions in emergency rooms, but also that it is difficult or even impossible for many patients with a disturbance in consciousness to express what is on their minds. Therefore in many cases, we need to consider the patient's dignity be of the ultimate priority and that one of the most important duties for medical personnel is to display autonomy in utilizing the principle of benevolence. Additionally, hospital administrative staff should fully support the autonomy of doctors and other medical personnel.

[The status quo and future prospects of emergency medical service systems in Japan in view of the tight supply-demand situation for medical resources].

Considering the tight supply-demand situation for medical resources contributing to emergency medical service(EMS) systems at present and in the future in Japan, the author has explained the present states and future prospects of EMS systems in our country. EMS in remote places in this country is now consisting of the concentration of limited human resources, and is therefore suggestive of the EMS systems in the future, because we will have to deal with the possible exhaustion of EMS in our superannuated society progressing now and in the future. And also EMS systems will have to be maintained in the future with concerted efforts of all the medical staffs. The transferring the medical doctors' tasks to those of nurses and other staffs, that is to say the task shifting has just authorized by recent laws, and so the task shifting will be useful in the future EMS systems performed by all kinds of medical workers, in whom general physicians will be included as they are to be distributed throughout this country in the future.

Toxic epidermal necrolysis caused by acetaminophen featuring almost 100% skin detachment: Acetaminophen is associated with a risk of severe cutaneous adverse reactions.

Toxic epidermal necrolysis (TEN) is an adverse reaction that can be induced by various drugs; the associated mortality rate is 20-25%. A previous report showed a weak association between TEN and acetaminophen. Recently, the US Food and Drug Administration declared that acetaminophen is associated with a risk of serious skin reactions, including TEN. Here, we describe the case of a 43-year-old Japanese woman with TEN caused by acetaminophen. She had poorly controlled ulcerative colitis and was treated with high doses of prednisolone, infliximab, acetaminophen and lansoprazole. Nine days after administrating acetaminophen, targetoid erythematous and bullous lesions appeared on the patient's trunk, palms and the soles of her feet. The skin lesions expanded rapidly; within 3 weeks, skin detachment was detected across nearly 100% of the patient's body. However, no mucosal involvement of the eyes, oral cavity or genitalia was found. We performed lymphocyte transformation tests using various drugs; however, a high stimulation index was obtained only with acetaminophen. The patient recovered following treatment with plasmapheresis, i.v. immunoglobulin therapy, topical medication and supportive therapy. Acetaminophen is included in many prescription and over-the-counter products; thus, clinicians should monitor their patients for severe drug reactions, including TEN.

PACAP38 suppresses cortical damage in mice with traumatic brain injury by enhancing antioxidant activity.

The production of reactive oxygen species (ROS) and the resulting oxidative stress in mice in response to a controlled cortical impact (CCI) are typical exacerbating factors associated with traumatic brain injury (TBI). Pituitary adenylate cyclase-activating polypeptide 38 (PACAP38) is a multifunctional peptide that has been shown to exhibit neuroprotective effects in response to a diverse range of injuries to neuronal cells. We recently reported that PACAP38 might regulate oxidative stress in mice. The aim of the present study was to determine whether PACAP38 exerts neuroprotective effects by regulating oxidative stress in mice with TBI. Reactive oxidative metabolites (ROMs) and biological antioxidant potential (BAP) were measured in male C57Bl/6 mice before and 3, 4, and 24 h after CCI. PACAP38 was administered intravenously immediately following CCI, and immunostaining for the oxidative stress indicator nitrotyrosine (NT), and for neuronal death as an indicator of the area affected by TBI, was measured 24 h later. Western blot experiments to determine antioxidant activity [as indicated by superoxide dismutase-2 (SOD-2) and glutathione peroxidase 1 (GPx-1)] in the neocortical region were also performed 3 h post-CCI. Results showed that plasma BAP and ROM levels were dramatically increased 3 h after CCI. PACAP38 suppressed the extent of TBI and NT-positive regions 24 h after CCI, and increased SOD-2 and GPx-1 levels in both hemispheres. Taken together, these results suggest that increasing antioxidant might be involving in the neuroprotective effect of PACAP38 in mice subjected to a CCI.

A retrospective quality assessment of the 7119 call triage system in Tokyo - telephone triage for non-ambulance cases.

Summary We assessed the accuracy of telephone triage at the 7119 telephone consultation centre in Tokyo. We evaluated walk-in patients at primary care facilities in a clinic or hospital. Nurses asked all patients calling 7119 to join the study and gave them a specific identification number (ID no) at the end of the telephone consultation. The outcome of the consultation was defined as discharge to home (home), admittance to hospital (hospitalization), referral, or transfer to another hospital. After matching consultation records and patient data by ID no, emergency medical physicians reviewed the protocol for problems. During the study, consultation nurses issued an ID no in 17,141 cases, and hospitals and clinics sent back the data on 1205 patients. Among these patients, 1119 cases (93%) were home, 59 cases (5%) were hospitalization, 18 cases (2%) were referral and 9 cases (1%) were transfer. Of the 86 cases which had an outcome of hospitalization, referral or transfer, there were 56 cases with matched patient data. Among these 56 cases, review showed no significant problems with 37 cases. However, there were 11 cases with patient refusal to comply with the triage recommendation, 4 cases with 7119 staff education problems and 4 cases with problems with the protocol itself. We were able to evaluate the 7119 telephone triage system in Tokyo. The study identified three types of problems with the triage process: refusal of telephone triage recommendations, problems with staff education and problems with the protocol itself.

[Case of continuous trans-arterial calcium gluconate infusion using a direct arterial sphygmomanometry line that exhibited dramatic improvement of chemical burns on the fingers caused by hydrofluoric acid].

Hydrofluoric acid (HFA) is commonly used and many injuries occur on the upper extremities following exposure to HFA. The use of calcium gluconate (CG) -containing gel or local injections of CG are widely used for the initial treatment of HFA exposure. However, severe pain continues in some cases despite the treatment. There was a report that trans-arterial CG infusion could improve HFA burns, however, such treatment is not an established clinical procedure. A 30-year-old male presented at our hospital with severe pain in his left thumb. He had been cleaning tiles with an HFA-containing detergent. We diagnosed him with a chemical burn due to HFA exposure. Local CG injections were tried several times, but his terrible pain continued. Therefore, a direct arterial sphygmomanometry line was inserted from the left radial artery, and continuous transarterial CG injection was performed. His terrible pain dramatically improved. Direct arterial sphygmomanometry systems are widely used in the critical care field to monitor the hemodynamics and ICU staffs are used to dealing with it. Moreover, continuous saline infusion prevents the tube obstruction. Continuous CG infusion from a direct arterial sphygmomanometry line is simple and safe way to administer CG in HFA burns.

Assertive case management versus enhanced usual care for people with mental health problems who had attempted suicide and were admitted to hospital emergency departments in Japan (ACTION-J): a multicentre, randomised controlled trial.

BACKGROUND: Non-fatal suicide attempt is the most important risk factor for later suicide. Emergency department visits for attempted suicide are increasingly recognised as opportunities for intervention. However, no strong evidence exists that any intervention is effective at preventing repeated suicide attempts. We aimed to investigate whether assertive case management can reduce repetition of suicide attempts in people with mental health problems who had attempted suicide and were admitted to emergency departments. METHODS: In this multicentre, randomised controlled trial in 17 hospital emergency departments in Japan, we randomly assigned people aged 20 years and older with mental health problems who had attempted suicide to receive either assertive case management (based on psychiatric diagnoses, social risks, and needs of the patients) or enhanced usual care (control), using an internet-based randomisation system. Interventions were provided until the end of the follow-up period (ie, at least 18 months and up to 5 years). Outcome assessors were masked to group allocation, but patients and case managers who provided the interventions were not. The primary outcome was the incidence of first recurrent suicidal behaviour (attempted suicide or completed suicide); secondary outcomes included completed suicide and all-cause mortality. This study is registered at ClinicalTrials.gov (NCT00736918) and UMIN-CTR (C000000444). FINDINGS: Between July 1, 2006, and Dec 31, 2009, 914 eligible participants were randomly assigned, 460 to the assertive case management group and 456 to the enhanced usual care group. We noted no significant difference in incidence of first recurrent suicidal behaviour between the assertive case management group and the enhanced usual care group over the full study period (log-rank p=0·258). Because the proportional hazards assumption did not hold, we did ad-hoc analyses for cumulative incidence of the primary outcome at months 1, 3, 6, 12, and 18 after randomisation, adjusting for multiplicity with the Bonferroni method. Assertive case management significantly reduced the incidence of first recurrent suicidal behaviour up to the 6-month timepoint (6-month risk ratio 0·50, 95% CI 0·32-0·80; p=0·003), but not at the later timepoints. Prespecified subgroup analyses showed that the intervention had a greater effect in women (up to 18 months), and in participants younger than 40 years and those with a history of previous suicide attempts (up to 6 months). We did not identify any differences between the intervention and control groups for completed suicide (27 [6%] of 460 vs 30 [7%] of 454, log-rank p=0·660) or all-cause mortality (46 [10%] of 460 vs 42 [9%] of 454, log-rank p=0·698). INTERPRETATION: Our results suggest that assertive case management is feasible in real-world clinical settings. Although it was not effective at reducing the incidence of repetition of suicide attempts in the long term, the results of our ad-hoc analyses suggested that it was effective for up to 6 months. This finding should be investigated in future research. FUNDING: The Ministry of Health, Labour, and Welfare of Japan.

Status of systemic oxidative stress during therapeutic hypothermia in patients with post-cardiac arrest syndrome.

Therapeutic hypothermia (TH) is thought to be due to the downregulation of free radical production, although the details of this process remain unclear. Here, we investigate changes in oxidative stress and endogenous biological antioxidant potential during TH in patients with post-cardiac arrest syndrome (PCAS). Nineteen PCAS patients were enrolled in the study. Brain temperature was decreased to the target temperature of 33°C, and it was maintained for 24 h. Patients were rewarmed slowly (0.1°C/h, <1°C/day). The generation of reactive oxygen metabolites (ROMs) was evaluated in plasma samples by d-ROM test. Plasma antioxidant capacity was measured by the biological antioxidant potential (BAP) test. Levels of d-ROMs and BAP levels during the hypothermic stage (33°C) were suppressed significantly compared with pre-TH induction levels (P < 0.05), while both d-ROM and BAP levels increased with rewarming (33-36°C) and were correlated with brain temperature. Clinical monitoring of oxidative stress and antioxidant potential is useful for evaluating the redox state of patients undergoing TH after PCAS. Additional therapy to support the antioxidant potential in the rewarming stage following TH may reduce some of the observed side effects associated with the use of TH.

Therapeutic time window for edaravone treatment of traumatic brain injury in mice.

Traumatic brain injury (TBI) is a major cause of death and disability in young people. No effective therapy is available to ameliorate its damaging effects. Our aim was to investigate the optimal therapeutic time window of edaravone, a free radical scavenger which is currently used in Japan. We also determined the temporal profile of reactive oxygen species (ROS) production, oxidative stress, and neuronal death. Male C57Bl/6 mice were subjected to a controlled cortical impact (CCI). Edaravone (3.0 mg/kg), or vehicle, was administered intravenously at 0, 3, or 6 hours following CCI. The production of superoxide radicals (O2 (∙-)) as a marker of ROS, of nitrotyrosine (NT) as an indicator of oxidative stress, and neuronal death were measured for 24 hours following CCI. Superoxide radical production was clearly evident 3 hours after CCI, with oxidative stress and neuronal cell death becoming apparent after 6 hours. Edaravone administration after CCI resulted in a significant reduction in the injury volume and oxidative stress, particularly at the 3-hour time point. Moreover, the greatest decrease in O2 (∙-) levels was observed when edaravone was administered 3 hours following CCI. These findings suggest that edaravone could prove clinically useful to ameliorate the devastating effects of TBI.

Edaravone increases regional cerebral blood flow after traumatic brain injury in mice.

Traumatic brain injury (TBI) is a major cause of preventable death and serious morbidity, with subsequent low cerebral blood flow (CBF) considered to be associated with poor prognosis. In the present study, we demonstrated the effect of the free radical scavenger edaravone on regional CBF (rCBF) after TBI. Male mice (C57/BL6) were subjected to TBI using a controlled cortical impactor device. Immediately after TBI, the animals were intravenously administered 3.0 mg/kg of edaravone or a vehicle saline solution. Two-dimensional rCBF images were acquired before and 24 h post-TBI, and were quantified in the ipsilateral and contralateral hemispheres (n = 5 animals per group). CBF in the vehicle-treated animals decreased broadly over the ipsilateral hemisphere, with the region of low rCBF spreading from the frontal cortex to the occipital lobe. The zone of lowest rCBF matched that of the contusion area. The mean rCBF at 24 h for a defined elliptical region between the bregma and lambda was 73.7 ± 5.8 %. In comparison, the reduction of rCBF in edaravone-treated animals was significantly attenuated (93.4 ± 5.7 %, p < 0.05). The edaravone-treated animals also exhibited higher rCBF in the contralateral hemisphere compared with that seen in -vehicle-treated animals. It is suggested that edaravone reduces neuronal damage by scavenging reactive oxygen species (ROS) and by maintaining intact the autoregulation of the cerebral vasculature.

Emergency/disaster medical support in the restoration project for the Fukushima nuclear power plant accident.

The Fukushima Daiichi Nuclear Power Plant (1F) suffered a series of radiation accidents after the Great East Japan Earthquake on 11 March 2011. In a situation where halting or delaying restoration work was thought to translate directly into a very serious risk for the entire country, it was of the utmost importance to strengthen the emergency and disaster medical system in addition to radiation emergency medical care for staff at the frontlines working in an environment that posed a risk of radiation exposure and a large-scale secondary disaster. The Japanese Association for Acute Medicine (JAAM) launched the 'Emergency Task Force on the Fukushima Nuclear Power Plant Accident' and sent physicians to the local response headquarters. Thirty-four physicians were dispatched as disaster medical advisors, response guidelines in the event of multitudinous injury victims were created and revised and, along with execution of drills, coordination and advice was given on transport of patients. Forty-nine physicians acted as directing physicians, taking on the tasks of triage, initial treatment and decontamination. A total of 261 patients were attended to by the dispatched physicians. None of the eight patients with external contamination developed acute radiation syndrome. In an environment where the collaboration between organisations in the framework of a vertically bound government and multiple agencies and institutions was certainly not seamless, the participation of the JAAM as the medical academic organisation in the local system presented the opportunity to laterally integrate the physicians affiliated with the respective organisations from the perspective of specialisation.

[Pathophysiology of heat illness].

Human core temperature is strictly controlled by mechanism of radiation, conduction, convection, and evaporation from skin surface. Serial hot and humid climate induces dehydration which interferes heat pump-out from the body. Heart dysfunction is the third factor to rise body temperature. Hyperthermia and hypo-perfusion caused by dehydration and heart failure deteriorate specific organ functions, i.e. central nervous system, liver and renal functions and coagulation system. Disseminated intravascular coagulopathy is one of the standard indicators of severity and mortality of heat stroke.

[Sports and heat stroke].

We described Characteristic of the heat stroke in the sports activity in Japan. It was common in teenage men, and 15 years old had a peak with a man, the woman. Most patients did not need specific treatment. Many happened from the end of July on the outdoors around 3:00 p.m. in mid-August. There are many in order of baseball, football, tennis, and a basketball. Running and cycling had high severity of illness. Probably, grasp of an environmental condition, suitable sportswear, suitable hydration, and condition management are the best things as preventive measures.

[Medical ethics in terminal stage viewed from emergency and critical care in Japan].

In Japan, several types of the proposal for terminal care have been published by Medical Association, Ministry of Health, Labor and Welfare, etc. Among them, the guidelines proposed by Japanese Association for Acute Medicine (JAAM) are appreciated as most concretely expressed ethically as well as practically regarding the judgment of terminal stages, the medical ethics needed through the processes thereafter and the methods on withdrawal or withholding in terminal care. The author explained and considered the terminal care provided by medical professionals for the absolutely desperate including the brain dead following post-cardiac arrest syndrome for instance, according to the guidelines by JAAM. The best practice selected for the terminally ill ought to be reasonable and suitable from the aspects of both medical science and ethics.

Expression and localization of the orexin-1 receptor (OX1R) after traumatic brain injury in mice.

Orexins are neuropeptides that have a wide range of physiological effects, and recent studies have suggested that the orexin system may be involved in traumatic brain injury. However, the expression and localization of orexin receptors have not been examined yet under brain injury conditions. In the present study, we used immunohistochemical techniques to investigate the expression of orexin-1 receptor (OX1R) and its time-dependent changes in the mouse brain after controlled cortical impact (CCI) injury. OX1R-like immunoreactivity was first detected 6 h after injury in the surrounding penumbra of the injury. The intensity of this immunoreactivity was increased at 12 h, peaked at day 1, and then decreased from day 2 to day 7. To identify the cellular localization of OX1R, we also performed double-immunohistochemical staining with OX1R and several cell marker antibodies. OX1R-like immunopositive cells were clearly co-localized with immunoreactivity for the neuronal marker NeuN at day 7. It was also expressed on the periphery of cells immunopositive for CD11b, a microglial cell marker, at days 1 and 7. These results suggest that orexin and its receptor may play roles in traumatic brain injury, and that OX1R is induced in neurons and microglial cells after traumatic brain injury.

The impact of an emergency telephone consultation service on the use of ambulances in Tokyo.

INTRODUCTION: The increasing demands made on emergency ambulance services contribute to inefficient, clinically inappropriate health care, and may delay the provision of emergency care to life-threatening cases. The hypothesis of this study was that the activity for the first year of operation of an emergency telephone consultation service contributed to a reduction in ambulance use in non-urgent cases and a decrease in the cost associated with despatching ambulances. METHODS: The numbers of ambulance use and the emergency hospitalisation of ambulance cases were compared before and after the introduction of the Tokyo Emergency Telephone Consultation Centre (the #7119 centre). Public awareness of the #7119 centre in each region of Tokyo and the cost related to despatching ambulances were also investigated. RESULTS: A total of 26,138 consultations was performed in the initial year. Compared with the previous year, the number of ambulance uses per 1 million people decreased (before 46,846, after 44,689, p<0.0001). The emergency hospitalisation rate (EHR) of ambulance cases increased significantly because of the decreased proportion of non-urgent cases (before 36.5%, after 37.8%, p<0.0001). There was a statistical correlation between the awareness rate in each region and the change of after-hours EHR in adults (R=0.333, p=0.025). The total cost related to despatching ambulances was reduced by approximately ¥678,000,000 (£4,520,000) in the initial year. CONCLUSION: To date, the emergency telephone consultation service has contributed to the appropriate use of ambulances and a reduction of its cost in Tokyo.