Proposal for Reforming Prehospital Response to Chemical Terrorism Disasters in Japan: Going Back to the Basics of Saving the Lives of the Injured by Securing the Safety of the Rescue Team.

INTRODUCTION: Having experienced the Tokyo subway sarin attack in 1995, Japan has established extremely strict rules on handling injured victims before they are sent to a hospital. As a result, it takes a long time before rescue actions are taken. This report aims to propose a reform to change the system that focuses on saving lives. METHODS: First, the issues in firefighting on sites that currently present problems in Japan were identified. Then, Japanese guidelines were compared with those that were considered in other countries. Based on this, an ideal way of running rescue operations was examined, and a proposal to save many lives was made. This research was conducted with funding from the Ministry of Health, Labour, and Welfare of Japan (MHLW; Chiyoda, Tokyo, Japan). RESULTS: In addition to preventing secondary injuries, the temporal aspect of rescuing people early with the clear goal of saving many lives was emphasized. Priority was given to measures against nerve agents to prevent secondary injuries, which put the rescuers' lives at risk. Possible decontamination methods were pursued before choosing the one that was most appropriate. A linear algorithm was used to determine which decontamination method could be started immediately, and then the gradual use of equipment was recommended. Even if Level A personal protective equipment (PPE) and other dedicated equipment and materials cannot be procured, the possibility of starting rescue activities under certain condition using regular equipment was pointed out. The need for a system for possible victims who would require support, such as foreigners, the handicapped, and elderly people, was also identified. Japan limits the scope of activities that can be undertaken by emergency medical technicians (EMTs) on-site. The way in which on-site medical care can be provided with future legal revisions in mind was also discussed. CONCLUSION: There is an urgent need to build a framework in which rescue activities can take place so that the number of deaths would not rise, even if sarin and other poisons are scattered.

Preventable trauma deaths after traffic accidents in Chiba Prefecture, Japan, 2011: problems and solutions.

INTRODUCTION: The incidence of preventable trauma death in the current Japanese emergency medical system remains high. The present study aimed to determine rates of clearly preventable and possibly preventable trauma deaths due to traffic accidents in Chiba Prefecture, Japan, and to consider associated problems and solutions. MATERIALS AND METHODS: During 2011, 175 victims died after traffic accidents in Chiba Prefecture. Of these, the deaths of 69 persons who had vital signs at the time of emergency medical service contact were classified as clearly preventable, possibly preventable, or not preventable through the peer review discussion. We also examined problems associated with deaths that were clearly preventable or possibly preventable. RESULTS: Of the 69 deaths, 9 (13%) were classified as clearly preventable, 11 (16%) as possibly preventable, and 49 (71%) as not preventable. Of the 20 clearly or possibly preventable deaths (each death potentially comprising multiple problems), 5 were related to selection of the hospital before hospital arrival, 4 to problems with regional emergency medical systems, and 15 to inappropriate hemodynamic management, including transfusion and delayed (or not attempted) hemostasis in the hospital. DISCUSSION: Problems of these 20 deaths showed that appropriate triage at the scene, centralization of patients with severe trauma, and trauma centers are necessary in Japan. Under-triage before arrival at the hospital was related to clearly and possibly preventable deaths. Upgrading the triage category for victims with torso injury must be considered. Not all emergency critical care centers in Japan are able to provide severe trauma care. Preventable trauma deaths occur even in some emergency critical care centers; therefore, we need centralization of severe trauma patients from wider area to reduce the incidence of preventable trauma death.

A causal relationship between right paraduodenal hernia and superior mesenteric artery syndrome: a case report.

INTRODUCTION: Cases of right paraduodenal hernia and superior mesenteric artery syndrome have been reported separately, but their occurrence in combination has not been reported. CASE PRESENTATION: A 46-year-old Japanese man who had never undergone laparotomy was admitted to our hospital due to an acute abdomen. An enhanced multidetector-row computed tomography scan of our patient showed a cluster of small intestines with ischemic change in his right lateral abdominal cavity. Emergency surgery was subsequently performed, and strangulation of the distal jejunum along with incidental right paraduodenal hernia was found. His necrotic ileum was resected, and the jejunum encapsulated by the sac was repaired manually without reduction.Three days after the operation, however, our patient developed vomiting. An upper gastrointestinal series revealed a straight line cut-off sign on the third portion of his duodenum. A second enhanced multidetector-row computed tomography scan showed that he had a lower aortomesenteric angle and a shorter aortomesenteric distance compared to his condition before his right paraduodenal hernia was surgically repaired. We strongly suspected that the right paraduodenal hernia repair may have induced superior mesenteric artery syndrome. On the 21st post-operative day, duodenojejunostomy was performed because conservative management had failed. CONCLUSIONS: In this case, enhanced multidetector-row computed tomography, which permits reconstructed multiplanar imaging, helped us to visually identify these diseases easily. It is important to recognize that surgical repair of a right paraduodenal hernia may cause superior mesenteric artery syndrome.

Circulating heat-shock protein 70 is associated with postoperative infection and organ dysfunction after liver resection.

BACKGROUND: Although extracellular heat-shock protein 70 (Hsp70) potentially mediates an inflammatory response, the association of circulating Hsp70 with complications after surgery is poorly understood. METHODS: Perioperative plasma concentrations of Hsp70 and interleukin-6 were measured by immunoassays in 64 consecutive patients undergoing liver resection. RESULTS: Plasma concentrations of Hsp70 and interleukin-6 showed a striking increase immediately after surgery, and on postoperative day 1. The Hsp70 levels correlated significantly with operation time, hepatic ischemia time, postoperative alanine aminotransferase levels, and maximum interleukin-6 levels (P <0.01). The Hsp70 and interleukin-6 concentrations were associated significantly with postoperative infection (P <0.05); Hsp70 concentrations and blood loss but not interleukin-6 were associated significantly with postoperative organ dysfunction (P <0.05) in multivariate analyses. CONCLUSIONS: These results suggest that circulating Hsp70 and IL-6 potentially play a pivotal role in pathophysiology of postoperative infection, and that circulating Hsp70 and blood loss may represent a prognostic marker for postoperative organ dysfunction.

Extended hepatic resection and outcomes in intrahepatic cholangiocarcinoma.

BACKGROUND/PURPOSE: The aim of this report was to assess the outcome of aggressive surgical treatment for intrahepatic cholangiocarcinoma. METHODS: From 1984 to 2001, we encountered 64 patients with intrahepatic cholangiocarcinoma. Of the 64 patients, 50 patients who underwent surgical resection with macroscopically curative objectives (78%) were reviewed for surgical procedures and outcomes. RESULTS: Hemi- or more extensive hepatectomy was required for surgical resection in 40 patients (80%). Overall hospital morbidity and mortality rates were 50% and 8%, respectively. Curative resection with pathological free margins was achieved in 34 patients (68%). The 1-, 3-, and 5-year patient survival and tumor-free survival rates were 61.6%, 37.6%, and 22.5%; and 55%, 11%, and 11%, respectively. Among the macroscopic types, all 9 patients with intraductal growth type are alive 11-75 months after surgery. Survival rates among patients who had undergone curative resection were significantly better than those in patients who had undergone noncurative resection, even when patients with the intraductal growth type were excluded. Nodal status did not affect patient survival. CONCLUSIONS: Although the overall survival rate after surgical resection remains unsatisfactory, long-term survival is possible through extended surgical resection with pathological free margins. Patients with the intraductal growth type of intrahepatic cholangiocarcinoma might have the best chance of being cured by surgical treatment.

Fatal infectious mononucleosis with evidence suggestive of the development of B cell lymphoma.

A 4-year-old girl presented to a local hospital in August 1999 with fever and cervical lymphadenopathy. A diagnosis of Epstein-Barr virus (EBV) infection was made and the patient was treated with corticosteroids. One month later she developed dyspnea secondary to tonsilar swelling, and underwent tonsillectomy and adenoidectomy. Her dyspnea increased, however, and by mid September she required mechanical ventilation. Six weeks later, she was transferred to Chiba Children's Hospital (Chiba, Japan). Despite vigorous treatment, she died within four weeks of admission. At autopsy, microscopic examination revealed numerous histiocytes with frequent hemophagocytosis in her lungs, liver, spleen, thymus, and lymph nodes. The tentative diagnosis was EBV-associated hemophagocytic syndrome (EBVAHS). A proliferation of atypical lymphocytes was observed in the lymph nodes, the majority of which stained positive with CD79a antibody. A whitish nodule, 8 mm in diameter, was noted in her right ovary. It consisted of a proliferation of pleomorphic lymphoid cells expressing CD79a antigen. In situ hybridization detected EBV RNA within CD79a antigen-positive cells in the lungs, spleen, thymus, bone marrow, lymph nodes, and the right ovary. Polymerase chain reaction analysis of DNA from the ovarian nodule demonstrated a monoclonal rearrangement of the immunoglobulin heavy chain gene indicating that it consisted of a clone of B lymphocytes. We suggest that EBVAHS develops into polyclonal and monoclonal lymphoproliferative disorder in a short period, and that EBVAHS is a preneoplastic condition that may result in B cell lymphoma.

Establishment of gemcitabine-resistant human pancreatic cancer cells and effect of brefeldin-a on the resistant cell line.

To date, no therapy has been found to which pancreatic cancer responds with the exception of surgical resection in early stages. Recently, gemcitabine has become the standard of care for chemotherapy in those patients with advanced disease. Most pancreatic tumors however, develop resistance to gemcitabine. The aim of this study is to clarify the mechanism of resistance to gemcitabine in human pancreatic cells. Using a cell selection method, a human pancreatic cancer cell line resistant to gemcitabine was established. Cellular proliferation and viability were determined by MTT assay. The cell line with acquired resistance was also found to have cross resistance to fluorouracil. Brefeldin-A (BFA) has been used as a tool for studies of intracellular protein traffic, rather than as an anticancer drug. BFA displays the same effects on wild type cells and those with acquired resistance. Gemcitabine combined with BFA in low doses is significantly more effective than gemcitabine alone against MIA PaCa-2 cell line. Our data suggest that the gemcitabine-resistant and 5-FU-resistant pathways may partially overlap each other. In short, BFA may be used as a modulator of gemcitabine.

Partial splenic embolization for the treatment of hereditary spherocytosis.

OBJECTIVE: Splenectomy is the standard surgical treatment for hereditary spherocytosis, but partial splenic embolization is another potential option. We retrospectively studied the therapeutic effects of partial splenic embolization as a treatment for hereditary spherocytosis. CONCLUSION: Partial splenic embolization is a safe and effective alternative to splenectomy or partial splenectomy in the treatment of hereditary spherocytosis.

Ki-67 expression and prognosis for smokers with resected stage I non-small cell lung cancer.

BACKGROUND: The cigarette smoking status of patients before surgery is an important prognostic factor in evaluation of stage I non-small cell lung cancer, and the proliferative activity of lung tumors is also related to the patient's prognosis. This study evaluates relationships between various clinicopathologic factors, including tumor proliferative activity and smoking status, and the patient's prognosis in stage I non-small cell lung cancer. METHODS: One hundred eighty-seven stage I adenocarcinoma and squamous cell carcinoma cases were evaluated. The patients underwent complete resection between 1988 and 1993 at Chiba University Hospital. Expression levels of Ki-67 nuclear antigen, p53 protein, and retinoblastoma protein were determined immunohistochemically, and postoperative survival rates for patients in the categories of clinicopathologic factors were estimated. RESULTS: The mean Ki-67 labeling index (LI) for all cases was 19.3%. Labeling index values were significantly higher in squamous cell carcinoma than in adenocarcinoma (p < 0.0001). Postoperative survival of adenocarcinoma patients was significantly related to the LI values and to the patient's smoking status (p = 0.0164 and 0.0268, respectively). The LI values were also related to smoking status and the extent of histologic differentiation (p = 0.0112 and p < 0.0001, respectively). For non-smoking adenocarcinoma patients, higher LI values were associated with abnormalities in p53 expression (p = 0.0048). Retinoblastoma protein abnormalities were not related to LI values. CONCLUSIONS: In smokers with stage I pulmonary adenocarcinoma, tumor proliferative activity and smoking status before surgery were important prognostic determinants. The LI values were related to several clinicopathologic factors.

Pulmonary large cell carcinoma with rhabdoid phenotype.

A 70-year-old woman presented with a coin lesion in her left lung. The tumor was well circumscribed and had a large area of central necrosis with a thin rim of viable tumor cells. It showed a solid growth pattern of polygonal cells with eosinophilic intracytoplasmic inclusion bodies. Immunohistochemically, the tumor cells were positive for vimentin, neural cell adhesion molecule, neuron-specific enolase, and vascular endothelial growth factor. Electron microscopy revealed intracytoplasmic inclusion bodies consisting of whorled intermediate filaments. Based on histological and immunohistochemical findings, the patient was diagnosed as having pulmonary large cell carcinoma with rhabdoid phenotype (LCCRP). The patient was in stage IA, and the histological findings may be the prototype of pure LCCRP. The tumor recurred after 6 years, and the second tumor had more apparent intracytoplasmic inclusion bodies. It is worthwhile detecting and recognizing the significance of these intracytoplasmic inclusions because of the poor prognosis of this tumor.

Proliferative activity and apoptosis in thymic epithelial neoplasms.

The classification of thymic epithelial tumors is controversial because prediction of the biological behavior of these tumors from their morphologic appearance is difficult. The aim of this study was to evaluate the proliferative activity and rate of apoptosis of thymic epithelial tumors classified according to World Health Organization histological classification. We also attempted to determine the importance of a number of proapoptotic factors in these processes. We investigated 46 surgically resected thymic epithelial tumors (8 Type A, 8 Type AB, 7 Type B1, 7 Type B2, 6 Type B3, and 10 Type C). Immunohistochemical staining was performed to determine the tumor expression of p53 protein, Bax, Bcl-2, and survivin. In addition, the Ki-67 labeling index (LI) and apoptotic index (AI) of these tumors were evaluated. Type C thymoma had a higher LI (16.55 +/- 12.12%) than did the other histological subtypes. Stage IV thymoma (12.36 +/- 9.99%) had a higher LI than did Stage I tumor. The AI was significantly elevated in Type B1 thymoma (1.47 +/- 0.55%). Overexpression of p53 protein was observed in Type B3 and C thymomas. p53 protein-positive tumors had a higher LI than did p53 protein-negative tumors (P <.0001). Bcl-2 expression was observed in Type A, AB, and C thymomas. Bcl-2-positive thymoma had a lower AI than did Bcl-2-negative thymoma (P =.0157). These results suggest that overexpression of p53 protein is associated with a higher tumor proliferative activity and that Bcl-2 acts as an inhibitor of apoptosis in thymoma. Bcl-2 and p53 protein expression may be useful markers in differentiating thymoma subtypes.

Long-term results of initial and repeated partial splenic embolization for the treatment of chronic idiopathic thrombocytopenic purpura.

OBJECTIVE: Although splenectomy is a standard surgical treatment for chronic idiopathic thrombocytopenic purpura, partial splenic embolization is another treatment option. We retrospectively studied the long-term results of initial and repeated partial splenic embolization. MATERIALS AND METHODS: Thirty-nine patients, 15 men and 24 women, underwent initial embolization; 12 of the 39 underwent a repeated embolization. The therapeutic effects of the initial and repeated embolization were classified as a complete response if the patient's platelet count rose to more than 10 x 10(4)/ micro L without medication 1 year after the initial or repeated embolization, as a partial response if the platlet count reached 5-10 x 10(4)/ micro L under the same circumstances, or as no response. RESULTS: Twenty patients (51%) responded to the initial embolization (complete response in 11 and partial response in nine). No significant differences were found between those patients who responded to the treatment (responders) and those who did not respond to the treatment (nonresponders) in age, sex, lowest platelet counts, and steroid response before embolization. Peak platelet response was significantly higher in the responders (p = 0.029). One of the 11 complete responders and five of the nine partial responders relapsed after a median follow-up period of 34 months (range, 15-23 months) and underwent repeated embolization, resulting in complete response in one patient, partial response in the remaining four patients, and no response in one patient. However, in the six nonresponders (to the initial embolism), repeated embolization elicited a partial response in only one patient. The remission rate of 51% was maintained by means of repeated embolization for a median follow-up period of 76 months after the initial embolization. CONCLUSION: Partial splenic embolization combined with repeated embolization may be an effective alternative to splenectomy in the treatment of chronic idiopathic thrombocytopenic purpura.