[Consideration of the Work Content of the Clinic Pharmacist and Its Usefulness].

"Medical teams"have been promoted in the home care setting. For the pharmacist, it is possible to maintain the safety and improve the quality of medical care by working with a multidisciplinary team. The arrangement of the pharmacist with the clinic is specified in Article 18 of the Medical Care Law, but there is no medical treatment fee for the clinic pharmacist. We examined the work content and usefulness of the clinic pharmacist. The work content was to participate in visiting consultation, introduce pharmacotherapy management based on the clinic pharmacist's working protocol, propose prescriptions, provide drug information service, and cooperate with insurance pharmacy pharmacists. Because the pharmacist was working in the clinic, he or she was able to actively intervene in drug treatment. Intervention in medication requires organizing and gathering information, which is difficult in the position of the insurance pharmacy pharmacist. The fact that the clinic pharmacist assumes this role and works with insurance pharmacy pharmacists makes it possible to maintain the safety and improve the quality of medical care.

[Differential Diagnosis of Interstitial Pneumonia by Home Ultrasound Examination].

BACKGROUND: Patients receiving home care present clinically diverse forms of chronic respiratory failure, for which it is difficult to establish a definite diagnosis. CT diagnosis requires the patient to be transported, and obtaining the blood test results for the serum maker KL-6 requires a few days. Nevertheless, with the widespread use of portable ultrasound devices, we can now make an immediate ultrasound diagnosis of the lung in the home care setting. In our experience, most patients with deteriorated interstitialpneumonia show characteristic large disseminated B-lines or pleural effusion. This makes it possible to differentiate it from pneumonia, pulmonary emphysema, or cardiac insufficiency, which have similar clinical findings. PURPOSE: To consider the possibility of using ultrasonography for the differential diagnosis of interstitial pneumonia. SUBJECTS: Eighteen patients with chronic respiratory failure receiving home care underwent ultrasonography and blood test(serum KL-6). METHODS: We examined the presence or absence of pleural effusion and B-line in patients who underwent lung echocardiogram examination and had a serum KL-6 level greater or less than 500 U/mL. RESULTS: All 8 patients with KL-6 levels greater than 500 U/mL showed B-lines or pleural effusion. However, only 2 of the 10 patients with KL-6 levels less than 500 U/mL showed B-lines. CONCLUSION: Ultrasonography of patients with interstitial pneumonia, which is a cause of chronic respiratory failure, revealed a characteristic large and disseminated hyperechoic area. Although the number of patients was limited, we may consider ultrasonography effective for the diagnosis of interstitial pneumonia in the home care setting.

[How to make sure a balloon-type gastrostomy replacement was made right by ultrasound].

With the spread of gastric fistula, there have been increased reports of catheter aberrant and fistula damage during the time of catheter exchange procedures. Therefore, it has been recommended that a diagnostic imaging or endoscopic gastrostomy should be employed to make sure a catheter exchange was properly done. However, it is difficult to enforce an inspection using an X-ray or endoscopy in the home care environment. Here we examined the usefulness and problems associated with ultrasound catheter-validation for home care environment. Of 33 patients who received gastrostomy, we focused on 6 patients who had gastrostomy exchanged at home. Four out of 6 patients with a balloon-type gastrostomy exchanged clearly confirmed a good result by ultra sound. However, a patient with bumper-type was unclear. The reason being unclear was due to the material and shape of the appearance by the echo. Left costal arch operations approach is to scan the probe along the left side of the abdomen below the costal arch, so that a replaced gastrostomy catheter could be confirmed by following the low echoic area of the spleen, stomach vault and into the stomach cavity. It is considered that ultrasound examination of the exchanged balloon-type gastrostomy was useful under a consideration of patient's health conditions.

[Introduction of Rapidtip BNP and Rapidpia--a clinical significance of rapid measurement BNP for home medicine care].

Dyspnea is a common symptom, and a heart failure is one of the most important preferred diagnoses of dyspnea. But it is difficult to undergo ECG, US, or other examination to diagnose a heart failure at the patient home, especially in the case of such examination was needed quickly or frequently. Rapidtip BNP and Rapidpia were invented in order to measure BNP rapidly at the patient home, or in the physician's car.

Rapid assay for plasma soluble E-selectin predicts the development of acute respiratory distress syndrome in patients with systemic inflammatory response syndrome.

A newly developed rapid immunoassay method for plasma soluble E-selectin (sES) was examined to determine whether it can predict the development of acute respiratory distress syndrome (ARDS) in critically ill patients with systemic inflammatory response syndrome (SIRS). Plasma levels of sES were measured on admission (day 1) to the emergency unit. Development of various types of organ failures including ARDS was compared in the first 5 days of admission (from day 1 to day 5) between patients with normal plasma levels of sES and those with elevated plasma levels of sES. Plasma levels of sES were determined using a newly developed latex agglutination method that takes 20 min to obtain the test results. The normal range of the plasma sES level was 4.8-29.7 ng/mL with this method. Among the patients examined, 22 patients showed elevated sES levels (D(A)E group) and 28 showed normal sES levels (D(A)N group). Development of ARDS was significantly higher in the D(A)E group (15/22, 68.2%) than in the D(A)N group (4/28, 14.3%) (P < 0.001) and that of cardiovascular system failure, renal failure, and coagulation system failure was also significantly higher in the D(A)E group than in the D(A)N group. The mortality rate at 28 days after admission was higher in the D(A)E group (27.3%) than in the D(A)N group (0%) (P < 0.05). Determination of sES levels by this new rapid assay method might be useful for prediction of the development of ARDS in critically ill patients with SIRS, a pathologic condition that has the potential risk for development of multiple organ failure.

Reinforcement therapy using nitric oxide synthase inhibitors against endotoxin shock in dogs.

PURPOSE: Nitric oxide synthase (NOS) inhibitors were confirmed to correct the hypotension associated with septic shock, but the overall prognosis is often pessimistic. The histological findings failed to show any improvement. In fact, some patients even exhibited signs of exacerbation. The purpose of this study was to investigate the therapeutic effects of NOS inhibitors and catecholamines in dogs suffering from endotoxin shock. The histological changes produced by these agents were also evaluated. METHODS: Mongrel dogs were used under midazolam anesthesia. A PiCCO continuous cardiac output monitoring catheter was placed in the femoral artery, and a central venous monitoring catheter was placed in the external carotid artery. RESULTS: Endotoxin (0.5 mg/kg, i.v.) was administered to cause shock. After this shock state was observed, the NOS inhibitors and catecholamines raised the blood pressure, and norepinephrine (NA, 2 microg/kg/h) was found to be more potent than S-methylisothiourea (SMT, 20 microg/kg/h). The combined effects of SMT-NA or SMT-DOB were greater than those of NA or dobutamine (DOB) alone. The histological changes induced by endotoxin shock were not ameliorated by the administration of NOS inhibitors but instead appeared to be exacerbated to some degree. CONCLUSION: NOS inhibitors combined with cathecholamines were thus suggested to be able to reduce the cathecolamine dosage in patients suffering from septic shock; They are thus considered to be hemodynamically effective agents.

Case with bromine exposure leading to respiratory insufficiency.

A 21-year-old male had a chemical burn on the right forearm when he inadvertently spilled bromine during an experiment. Since he inhaled vaporized bromine and had dyspnea and pharyngalgia, he arrived at our hospital in an ambulance as an emergency patient. On arrival, he kept a clear consciousness with a pulse rate of 98, body temperature of 36.8 degrees C, blood pressure of 132/80 mmHg, respiratory rate of 25, and oxygen saturation of 100%. (10 L/min of oxygen were administered.) He had marked dry coughs. His clothes had a foreign odor with mucosal irritation. Arterial blood gas analysis and blood biochemistry were normal. Based on these findings, he was diagnosed with chemical airway damage and bulbar conjunctiva from the exposure to bromine and a chemical burn on the right forearm. His respiratory condition became worse after admission, resulting in pulmonary edema. He was endotracheally intubated and controlled with an artificial ventilator on Day 3 after his injury. He was continuously treated with steroids and sivelestat sodium hydrate, which gradually improved his respiration. He was released from the artificial ventilator and extubated on Day 7. Although dyspnea associated with body movement and hoarseness persisted after extubation, the symptoms decreased and he was discharged on Day 41. This rare case is worth attention because serious respiratory insufficiency requiring artificial ventilation due to pulmonary edema from bromine exposure has not been reported in Japan.

Endoscopic hemostasis using fibrin adhesive to treat hemorrhage in the upper digestive system.

PURPOSE: There are several methods of achieving endoscopic hemostasis of hemorrhage in the upper digestive system. We compared the therapeutic results and advantages of using a local injection of fibrin adhesive for endoscopic hemostasis, which we have found more effective than other hemostatic methods. METHODS: Between October 2000 and April 2002, 16 patients with hemorrhage in the upper digestive system underwent endoscopic hemostasis using fibrin adhesive. The hemorrhage was caused by a hemorrhagic tendency from liver disease, anticoagulant therapy, or failed hemostasis with clipping or local ethanol injection. The fibrin adhesive was injected through a standard 21-gauge endoscopic needle using the so-called sandwich method. RESULTS: Hemostasis was successfully achieved by a single local injection of fibrin adhesive, in all except one patient who had been on anticoagulant therapy for a long time and needed an additional local injection of fibrin adhesive. CONCLUSION: Fibrin adhesive does not cause any tissue injury, and a sufficient amount can be injected endoscopically even in patients with liver dysfunction and those on anticoagulant therapy. Thus, we think that endoscopic hemostasis with fibrin adhesive is safe and effective.