Association between physician-staffed ambulances and patient prognoses after out-of-hospital cardiac arrests with respect to shockable and non-shockable rhythms: a retrospective observational study in a southern area of Shiga Prefecture Japan.

AIM: Out-of-hospital cardiac arrests (OHCA) are a significant public health problem; to improve patients' prognoses, various interventions, such as providing physician-staffed ambulances, have been implemented. We aimed to examine whether physician-staffed ambulances were associated with patients' prognoses after OHCA with respect to first-monitored rhythms. METHODS: This retrospective observational study was undertaken between 1 September 2011 and 31 December 2015, using data based on Utstein-style guidelines. We extracted data on age, sex, first-monitored rhythm (shockable or non-shockable), presence of a witness, bystander cardiopulmonary resuscitation, time from call to arrival at the scene, out-of-hospital adrenaline administration, out-of-hospital intubation, return of spontaneous circulation before arrival at the hospital, and survival and neurological outcomes 30 days after OHCA, according to cerebral performance categories. We undertook logistic regression analyses to assess the association between physician-staffed ambulances and patients' prognoses. RESULTS: A total of 882 OHCA patients were eligible for this study. Physician-staffed ambulances attended to 164 OHCA patients. Multivariable analysis found that in non-shockable rhythm patients, physician-staffed ambulances significantly improved good neurological outcome (odds ratio, 3.65; 95% confidence interval [CI], 1.28-10.50; P = 0.02), return of spontaneous circulation before arrival at the hospital (odds ratio, 2.68; 95% CI, 1.62-4.42; P < 0.001), and 30-day survival (odds ratio, 2.90; 95% CI, 1.30-6.45; P = 0.009). However, physician-staffed ambulances were not associated with patient prognoses in shockable rhythm patients. CONCLUSION: Despite our study's limitations, physician-staffed ambulances might be associated with good neurological outcomes in non-shockable rhythm patients. Our observations could provide more appropriate prehospital treatment options for OHCA patients.

Biological treatment of selenate-containing saline wastewater by activated sludge under oxygen-limiting conditions.

Selenium often coincides with high salinity in certain industrial wastewaters, which can be a limitation in the practical application of biological treatment. However, there are no studies on the biological treatment of selenate-containing saline wastewater. A sequencing batch reactor inoculated with activated sludge was applied to treat selenate in the presence of 3% (w/v) NaCl. Start-up of the sequencing batch reactor with a 7-day cycle duration and excessive acetate as the sole carbon source succeeded in removing above 98% and 72% soluble and solid selenium, respectively, under oxygen-limiting conditions. Further selenium removal experiments with a shorter cycle duration of 3 days and a stepwise decrease of acetate addition achieved soluble and total selenium removal efficiencies in most batches above 96% and 80%, respectively. Mass balance analysis revealed that selenate was converted into elemental selenium, most of which was accumulated in the sludge. Microscopic analyses also found that elemental selenium particles were primarily present as approximately 2 µm large rods, with some extremely large particles above 10 µm. Although the bacterial populations responsible for selenium removal, especially selenate reduction, could not be identified by microbial community analysis, this study reported for the first time that selenate could be biologically treated in the presence of considerable salinity, offering implications for the practical treatment of selenium in certain industrial wastewaters.

Efficacy of isoproterenol for treating amlodipine overdose resulting in bradycardia.

Case: Amlodipine 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. Outcome: Although 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. Conclusion: Isoproterenol is effective for treating bradycardia after amlodipine overdose.

[Emergency Decompressive Craniotomy in the Emergency Room was Effective in Severe Acute Subdural Hematoma Treatment:Two Case Reports].

The outcome of severe acute subdural hematoma is unfavorable. In particular, patients with levels of consciousness of Glasgow Coma Scale(GCS)3 or 4 tend to be refractory to treatment. Decompressive craniotomy should be promptly performed to remove hematoma. However, if an operating room is not immediately available, emergency burr hole surgery is sometimes performed in the emergency room(primary care room)prior to craniotomy. A previous study has reported that the interval from injury to surgery influences the outcome of severe acute subdural hematoma. Therefore, emergency decompression is important to effectively treat patients with severe acute subdural hematoma. We present the cases of two patients with acute subdural hematomas. In both cases, emergency decompressive craniotomy(hematoma removal after craniotomy and external decompression)was performed in the emergency room of the Emergency and Critical Care Center. In both cases, the surgery was followed by favorable outcomes. Case 1 was a 36-year-old female. The patient's level of consciousness upon arrival was GCS 3. The interval from injury to diagnosis on the basis of CT findings was 75 minutes. Surgery began 20 minutes after diagnosis. Case 2 was a 25-year-old male. The second patient's level of consciousness upon arrival was GCS 4. The interval from injury to diagnosis on the basis of CT findings was 60 minutes. Surgery was begun 40 minutes after diagnosis. In both patients, we observed anisocoria and the loss of the light reflex. However, the postoperative course was favorable, and both patients were discharged. In summary, to treat severe acute subdural hematomas, early emergency decompressive craniotomy is optimal. Emergency decompressive surgery in the emergency room is independent of operating room or staff. Therefore, emergency decompressive craniotomy may improve the outcome of patients with severe acute subdural hematomas.

[Examination of the Usefulness of Palliative Self-Expanding Metallic Stents in Patients with Malignant Colorectal Obstruction].

Self-expanding metallic stents (SEMS) are a useful palliative option in malignant colorectal obstruction. The aim of this study was to evaluate the clinical outcomes of SEMS used for palliation. Patients with malignant colorectal obstruction who underwent SEMS insertion in our hospital from April 2014 to March 2015 were enrolled in the study. Clinical outcomes and complications of palliative SEMS insertion were retrospectively analyzed. Nine patients were enrolled in the palliative SEMS group. The success rate was 100%, while the complication rate was 11%. Successful SEMS insertion may enable oral intake in a few days, but 3 patients required up to several weeks to resume oral intake. Palliative SEMS are effective and beneficial for malignant colorectal obstruction.

[A Case of Rectal Stenosis For Gastric Cancer Recurrence Effectively Treated with a Colonic Stent].

A man in his 70s underwent distal gastrectomy and D1 dissection with Roux-en-Y reconstruction in March 2009 for advanced gastric cancer with peritoneal metastasis. He was diagnosed with signet-ring cell carcinoma, Stage Ⅳ(T4a, N3a, H0, P1, CY1, M1) and R2. Seventeen cycles of S-1 plus CDDP were administered from April 2009 to December 2010 and 19 cycles of S-1 monotherapy were administered from January 2011 to March 2014. He developed peritoneal recurrence with serum tumor marker elevation in May 2014. Stenosis of the common bile duct, hydronephrosis, and rectal stenosis in Ra-Rs was observed in June 2014. A bile duct stent and a double J catheter was inserted. A colonic stent (NitiTM, 22 mm×6 cm) was also inserted. He could eat after the surgery and was discharged from the hospital. We suggest that a colonic stent is an effective treatment for colon stenosis due to peritoneal metastasis from gastric cancer.

[A Case of Disseminated Carcinomatosis of the Bone Marrow with Disseminated Intravascular Coagulation Caused by Cecal Cancer Successfully Treated with mFOLFOX6].

Disseminated carcinomatosis of the bone marrow is often accompanied by disseminated intravascular coagulation syndrome (DIC). This condition is rarely caused by colorectal cancer, and there are no established therapies. OUR CASE: A 66-year-old woman was admitted to our hospital because of DIC. She had been diagnosed with cecal cancer and multiple metastases of the lymph nodes, liver, and bone. She was diagnosed with disseminated carcinomatosis of the bone marrow and treated with systemic chemotherapy by modified FOLFOX6 (mFOLFOX6). Subsequently, the DIC rapidly resolved, and she was discharged from the hospital.

[A Case of Invasive Ductal Carcinoma in the Fat Replacement of the Pancreatic Body and Tail].

A 56 year-old woman with obesity (BMI3 2) and diabetes mellitus was diagnosed with right renal cell carcinoma. She underwent right nephrectomy 1 year ago. Seven months after surgery, CT revealed a rapidly growing mass near the spleen. The mass showed slight accumulation of FDG (SUVmax=2.4) on PET-CT. Since the lesion grew rapidly and was not enhanced in the early phase of enhanced CT, we diagnosed pancreatic cancer. Distal pancreatectomy and splenectomy were performed. The final pathological diagnosis was invasive ductal carcinoma in the fat replacement of the pancreatic body and tail. Postoperatively, the patient had no complications such as pancreatic fistula or aggravation of glucose intolerance. She received postoperative chemotherapy with gemcitabine. Since she developed pulmonary artery thrombosis, postoperative chemotherapy was interrupted after 8 courses. Thirty-two months after the surgery, she was still living without any recurrence. Acinar cells were absent in the fat replacement of the pancreas, but the pancreatic duct cells were still present. There was carcinoma in situ in the main pancreatic duct surrounding chronic inflammation. Fat replacement itself could be potentially precursor of the pancreatic cancer.

[A case of metastatic colorectal cancer that reduced in size after re-challenging with an anti-EGFR monoclonal antibody].

A 58-year-old woman was confirmed as having multiple liver metastases after undergoing a high anterior resection for a sigmoid colon tumor. She was administered bevacizumab+FOLFOX as the first regimen and bevacizumab+FOLFIRI and S-1 and irinotecan (IRIS)therapy as the second regimen. During this treatment she also underwent hepatectomy 3 times and radiofrequency ablation once. She was administered panitumumab+irinotecan as the third regimen and, due to the presence of multiple pulmonary metastases, was subsequently considered to have had a partial response (PR). Because she subsequently developed progressive disease (PD), she received the fourth regimen as part of a clinical trial (TAS102) in another hospital. Cetuximab+irinotecan was administered as the fifth regimen after PD and the tumor was found to have reduced in size by 23%upon computed tomography (CT) 2 months later. Although stable disease (SD) was achieved, she was subsequently administered regorafenib for 8 months as a sixth regimen after the disease progressed a second time. In some cases of KRAS wild type metastatic colorectal cancer, re-challenging with an anti-epidermal growth factor receptor (EGFR) monoclonal antibody seems to be an effective strategy for reducing tumor mass.

[A study of laparoscopic stoma creation for patients with malignant bowel obstruction].

UNLABELLED: We evaluated the efficacy of laparoscopic palliative stoma creation for patients with malignant bowel obstruction (MBO). PATIENTS AND METHODS: Twenty-four patients with MBO who underwent laparoscopic stoma creation between January 2009 and December 2012 were studied and their clinical outcome was evaluated retrospectively. RESULTS: Compared to the open approach, the laparoscopic approach led to significantly shorter operation times and a significantly lower incidence of surgical site infection( SSI). The rate of removal of the intestinal tube and intravenous drip after surgery was 100% and 88%, respectively, and the rate of oral intake was 100% after palliative stoma creation. The prognosis was 58% in 3 months and 29% in 1 year, and the median survival time was approximately 4 months. DISCUSSION: The quality of surgery by the laparoscopic approach was better than that by the open approach, and the quality of life( QOL) after stoma creation was better than that before surgery. Given the shorter operation time, lower incidence of SSI, and better QOL, laparoscopic stoma creation is a beneficial choice for palliative treatment in patients with MBO.

The functional interrelationship between gap junctions and fenestrae in endothelial cells of the liver organoid.

Functional intact liver organoid can be reconstructed in a radial-flow bioreactor when human hepatocellular carcinoma (FLC-5), mouse immortalized sinusoidal endothelial M1 (SEC) and A7 (HSC) hepatic stellate cell lines are cocultured. The structural and functional characteristics of the reconstructed organoid closely resemble the in vivo liver situation. Previous liver organoid studies indicated that cell-to-cell communications might be an important factor for the functional and structural integrity of the reconstructed organoid, including the expression of fenestrae. Therefore, we examined the possible relationship between functional intact gap junctional intercellular communication (GJIC) and fenestrae dynamics in M1-SEC cells. The fine morphology of liver organoid was studied in the presence of (1) irsogladine maleate (IM), (2) oleamide and (3) oleamide followed by IM treatment. Fine ultrastructural changes were studied by transmission electron microscopy (TEM) and scanning electron microscopy (SEM) and compared with control liver organoid data. TEM revealed that oleamide affected the integrity of cell-to-cell contacts predominantly in FLC-5 hepatocytes. SEM observation showed the presence of fenestrae on M1-SEC cells; however, oleamide inhibited fenestrae expression on the surface of endothelial cells. Interestingly, fenestrae reappeared when IM was added after initial oleamide exposure. GJIC mediates the number of fenestrae in endothelial cells of the liver organoid.