Patients With Refractory Out-of-Cardiac Arrest and Sustained Ventricular Fibrillation as Candidates for Extracorporeal Cardiopulmonary Resuscitation　- Prospective Multi-Center Observational Study.

BACKGROUND: We investigated whether patients with out-of-hospital cardiac arrest (OHCA) and sustained ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT) or conversion to pulseless electrical activity/asystole (PEA/asystole) benefit more from extracorporeal cardiopulmonary resuscitation (ECPR). Methods and Results: We analyzed data from the Study of Advanced Life Support for Ventricular Fibrillation with Extracorporeal Circulation in Japan, which was a prospective, multicenter, observational study with 22 institutions in the ECPR group and 17 institutions in the conventional CPR (CCPR) group. Patients were divided into 4 groups by cardiac rhythm and CPR group. The primary endpoint was favorable neurological outcome, defined as Cerebral Performance Category 1 or 2 at 6 months. A total of 407 patients had refractory OHCA with VF/pVT on initial electrocardiogram. The proportion of ECPR patients with favorable neurological outcome was significantly higher in the sustained VF/pVT group than in the conversion to PEA/asystole group (20%, 25/126 vs. 3%, 4/122, P<0.001). Stratifying by cardiac rhythm, on multivariable mixed logistic regression analysis an ECPR strategy significantly increased the proportion of patients with favorable neurological outcome at 6 months in the patients with sustained VF/pVT (OR, 7.35; 95% CI: 1.58-34.09), but these associations were not observed in patients with conversion to PEA/asystole. CONCLUSIONS: OHCA patients with sustained VF/pVT may be the most promising ECPR candidates (UMIN000001403).

Subarachnoid hemorrhage after resuscitation from out-of-hospital cardiac arrest.

BACKGROUND: This study was undertaken to retrospectively investigate clinical features of subarachnoid hemorrhage (SAH) with cardiopulmonary arrest in patients achieving return of spontaneous circulation (ROSC) in order to explore the possibility of long-term survival. METHODS: Of 143 SAH patients with cardiopulmonary arrest in our hospital between April 2004 and June 2012, data on 59 (41%) patients who attained ROSC were analyzed to determine the predictive factors for neurologic recovery and outcome. Recovery of brainstem reflexes and improvement of Glasgow Coma Scale (GCS) motor score were noted (postresuscitation neurologic restorative assessment, grade I) in 5, and 2 of these patients survived. RESULTS: By-grade analysis of patient background characteristics revealed a significantly shorter duration of cardiac arrest (P = .001) and a significantly smaller adrenaline dose (P = .011) for grade I patients. A logistic analysis of 1-week survival data revealed significant differences in duration of cardiac arrest (P = .022) and adrenaline dose (P = .019), with odds ratios of 0.89 and 0.25, respectively. Cox regression analysis of mortality data revealed significant differences in the duration of cardiac arrest (P = .012), adrenaline dose (P < .0001), and location of ROSC (P = .016), with hazard ratios of 1.03, 1.43, and 1.98, respectively. CONCLUSIONS: Cardiac arrest caused by SAH is a disease state with a grave prognosis, but there is the possibility of a good survival outcome when the administration of a small dose of adrenaline results in the rapid recovery of brainstem reflexes.

Extracorporeal cardiopulmonary resuscitation for patients with out-of-hospital cardiac arrest of cardiac origin: a propensity-matched study and predictor analysis.

OBJECTIVE: Encouraging results of extracorporeal cardiopulmonary resuscitation for patients with refractory cardiac arrest have been shown. However, the independent impact on the neurologic outcome remains unknown in the out-of-hospital population. Our objective was to compare the neurologic outcome following extracorporeal cardiopulmonary resuscitation and conventional cardiopulmonary resuscitation and determine potential predictors that can identify candidates for extracorporeal cardiopulmonary resuscitation among patients with out-of-hospital cardiac arrest of cardiac origin. DESIGN: Post hoc analysis of data from a prospective observational cohort. SETTING: A tertiary care university hospital in Sapporo, Japan (January 2000 to September 2004). PATIENTS: A total of 162 adult patients with witnessed cardiac arrest of cardiac origin who had undergone cardiopulmonary resuscitation for longer than 20 minutes (53 in the extracorporeal cardiopulmonary resuscitation group and 109 in the conventional cardiopulmonary resuscitation group). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary endpoint was neurologically intact survival at three months after cardiac arrest. We used propensity score matching to reduce selection bias and balance the baseline characteristics and clinical variables that could potentially affect outcome. This matching process selected 24 patients from each group. The impact of extracorporeal cardiopulmonary resuscitation was estimated in matched patients. Intact survival rate was higher in the matched extracorporeal cardiopulmonary resuscitation group than in the matched conventional cardiopulmonary resuscitation group (29.2% [7/24] vs. 8.3% [2/24], log-rank p = 0.018). According to the predictor analysis, only pupil diameter on hospital arrival was associated with neurologic outcome (adjusted hazard ratio, 1.39 per 1-mm increase; 95% confidence interval, 1.09-1.78; p = 0.008). CONCLUSIONS: Extracorporeal cardiopulmonary resuscitation can improve neurologic outcome after out-of-hospital cardiac arrest of cardiac origin; furthermore, pupil diameter on hospital arrival may be a key predictor to identify extracorporeal cardiopulmonary resuscitation candidates.

Long-term prognostic significance of gasping in out-of-hospital cardiac arrest patients undergoing extracorporeal cardiopulmonary resuscitation: a post hoc analysis of a multi-center prospective cohort study.

BACKGROUND: Gasping during resuscitation has been reported as a favorable factor for out-of-hospital cardiac arrest. We examined whether gasping during resuscitation is independently associated with favorable neurological outcomes in patients with refractory ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT) undergoing extracorporeal cardiopulmonary resuscitation ECPR. METHODS: Data from a 2014 study on advanced cardiac life support for ventricular fibrillation with extracorporeal circulation in Japan (SAVE-J), which examined the efficacy of ECPR for refractory VF/pVT, were analyzed. The primary endpoint was survival with a 6-month favorable neurological outcome in patients who underwent ECPR with or without gasping during resuscitation. Multivariate logistic regression analysis was performed to evaluate the association between gasping and outcomes. RESULTS: Of the 454 patients included in the SAVE-J study, data from 212 patients were analyzed in this study after excluding those with missing information and those who did not undergo ECPR. Gasping has been observed in 47 patients during resuscitation; 11 (23.4%) had a favorable neurological outcome at 6 months. Multivariate logistic regression analysis showed that gasping during resuscitation was independently associated with a favorable neurological outcome (odds ratio [OR], 10.58 [95% confidence interval (CI) 3.22-34.74]). The adjusted OR for gasping during emergency medical service transport and on arrival at the hospital was 27.44 (95% CI 5.65-133.41). CONCLUSIONS: Gasping during resuscitation is a favorable factor in patients with refractory VF/pVT. Patients with refractory VF/pVT with continuously preserved gasping during EMS transportation to the hospital are expected to have more favorable outcomes.

Correlation between antibiotic use and antibiotic resistance: A multicenter study using the Japan Surveillance for Infection Prevention and Healthcare Epidemiology (J-SIPHE) system in Hokkaido, Japan.

BACKGROUND: The Japan Surveillance for Infection Prevention and Healthcare Epidemiology (J-SIPHE) system aggregates information related to antimicrobial resistance (AMR) measures in participating medical institutions nationwide and is intended to be used for promotion of AMR measures in participating facilities and their communities. This multicenter study aimed to determine the usefulness of the J-SIPHE system for evaluating the correlation between antibiotic use and antibiotic resistance in Hokkaido, Japan. METHODS: Data on antibiotic use and detection rate of major resistant Gram-negative bacteria at 19 hospitals in 2020 were collected from the J-SIPHE system, and data correlations were analyzed using JMP Pro. RESULTS: The detection rate of carbapenem-resistant Pseudomonas aeruginosa was significantly positively correlated with carbapenem use (Spearman's ρ = 0.551; P = .015). There were significant positive correlations between the detection rate of fluoroquinolone-resistant Escherichia coli and the use of piperacillin/tazobactam, carbapenems, and quinolones [ρ = 0.518 (P = .023), ρ = 0.76 (P < .001), and ρ = 0.502 (P = .029), respectively]. CONCLUSIONS: This is the first multicenter study to investigate the correlation between antibiotic use and antibiotic resistance using the J-SIPHE system. The results suggest that using this system may be beneficial for promoting AMR measures.

Delayed visceral bleeding from liver injury after cardiopulmonary resuscitation.

BACKGROUND: Visceral injury is a life-threatening complication of cardiopulmonary resuscitation (CPR); however, the clinical significance has been masked by the lethal outcome of out-of-hospital cardiac arrest (OHCA). OBJECTIVE: The objective is to share our experience of successful treatment of OHCA patients with serious, CPR-related visceral complications. CASE REPORTS: We report two cases of cardiac-origin OHCA with liver injury exacerbated by heparinization during mechanical circulatory support. Although both patients presented with delayed massive liver bleeding (intrahepatic or peritoneal) that compromised hemodynamic status, one patient was successfully treated by selective transcatheter arterial embolization and the other by a surgical procedure. CONCLUSION: Preventive measures such as careful CPR, as well as interventional or surgical repair after the early diagnosis of visceral injury, are required to improve the outcome in some cases of OHCA.

A case of cardiopulmonary arrest caused by laxatives-induced hypermagnesemia in a patient with anorexia nervosa and chronic renal failure.

We report a case of laxatives induced severe hypermagnesemia complicated with cardiopulmonary arrest. A 55-year-old woman, with nephritic syndrome and anorexia nervosa, was later transported to our emergency room (ER) because of oliguria and consciousness disturbance. During transfer to the intensive care unit from the ER, cardiopulmonary arrest suddenly occurred. Cardiopulmonary resuscitation was immediately performed, and spontaneous circulation was restored after 3 min. Thereafter, administration of dopamine, norepinephrine, and epinephrine was required to maintain systolic blood pressure at 80 mmHg. Arterial blood gas analysis showed severe metabolic alkalosis, and blood biochemical tests revealed hypermagnesemia (serum magnesium concentration, 18.5 mg/dl) and renal dysfunction. Continuous infusion of diuretics followed by massive hydration and continuous hemodiafiltration (CHDF) was started. Five days after starting CHDF, magnesium concentration was almost normalized and administration of catecholamine was stopped. It was thought that progression of renal dysfunction that occurred in the patient taking a magnesium product for chronic constipation caused reduction in magnesium excretion ability, resulting in hypermagnesemia-induced cardiopulmonary arrest. To avoid a rebound phenomenon following magnesium flux from cells, continuous blood purification seems to be an effective treatment for symptomatic hypermagnesemia.

[Threshold levels of intracranial pressure as determinants of survival from diffuse brain injury. An observational study].

OBJECTIVE: Intracranial pressure (ICP) is frequently monitored in patients with severe head injuries. In this study of a series of diffuse brain injury patients, we investigated whether there are significant threshold levels that determine the outcome. METHOD: Data were obtained from 17 patients with severe head injuries (adults aged ≥ 15-years-old). The outcome was categorized using the Glasgow Outcome Scale and survival or death. Patients were also grouped according to the Traumatic Coma Data Bank (TCDB) CT classification for diffuse injury: type I (n=0); II (n=5); III (n=10); IV (n=2). CONCLUSION AND RESULT: The mortality rate was 29% (5 of 17 patients). The average initial ICP within 24 hours (14.08 mmHg) and the peak ICP (26.75 mmHg) were lower in the survivors than that in the patients who died (57.60 mmHg and 91.00 mmHg, respectively; p=0.0006 and 0.0002, respectively). Patients with an initial ICP score>35 mmHg did not survive, and patients with a peak ICP<35 mmHg, except one who died of a traumatic brainstem hemorrhage, did survive. Using an X-bar chart, a threshold value for the initial ICP within 24 hours of 27 mmHg and for the peak ICP 46 mmHg appear to be the survival predictors in patients with diffuse brain injury.

Acquisition of a transposon encoding extended-spectrum beta-lactamase SHV-12 by Pseudomonas aeruginosa isolates during the clinical course of a burn patient.

Three of seven clonally related Pseudomonas aeruginosa strains isolated from a burn patient produced the extended-spectrum beta-lactamase (ESBL) SHV-12. Its gene was flanked by two IS26 elements with a large transposon (>24 kb). The transposon also contained at least five IS26 elements and a gene encoding the amikacin resistance determinant aminoglycoside 6'-N-acetyltransferase type Ib [aac(6')-Ib]. It was inserted into the gene PA5317 in the P. aeruginosa chromosome.

Cost-effectiveness of extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: A multi-centre prospective cohort study.

AIM: Extracorporeal cardiopulmonary resuscitation (ECPR) is an evolving resuscitative method for refractory cardiopulmonary arrests. However, considering the substantial healthcare costs and resources involved, there is an urgent need for a full economic evaluation. We therefore assessed the cost-effectiveness of ECPR for refractory ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT). METHODS: We developed a decision model to estimate lifetime costs and outcomes for out-of-hospital cardiac arrest patients with VF/pVT who received either ECPR or conventional cardiopulmonary resuscitation. Quality-adjusted life-years (QALY) was used as the main outcome measure. This model was a combination of a decision tree model for the acute phase based on a prospective observational study (SAVE-J study), together with a Markov model for long-term follow-up periods extrapolated from published data. To evaluate the robustness of this model, we conducted a comprehensive deterministic sensitivity analysis (DSA) and a probabilistic sensitivity analysis (PSA). RESULTS: ECPR was cost-effective, with an incremental cost of ¥3,521,189 (Є30,227), an incremental effectiveness of 1.34 QALY, and an incremental cost-effectiveness ratio of ¥2,619,692 (Є22,489) per QALY gained. DSA revealed that the present model was most sensitive to probability of Cerebral Performance Category 1 after ECPR (¥2,153,977/QALY to ¥3,186,475/QALY), patient age (¥2,170,112/QALY to ¥3,334,252/QALY), and long-term medical cost for modified Rankin Scale 0 (¥2,280,352/QALY to ¥2,855,330/QALY). PSA indicated ECPR to be cost-effective and below the willingness-to-pay threshold of ¥5,000,000 with an 86.7 % possibility. CONCLUSIONS: ECPR was an economically acceptable resuscitative strategy, and the results of the present study were robust even when considering the uncertainty of all parameters.

Shortening of cardiopulmonary resuscitation time before the defibrillation worsens the outcome in out-of-hospital VF patients.

OBJECTIVE: The purpose of the study is to investigate the influence of cardiopulmonary resuscitation (CPR) time before the first defibrillation. METHODS: The present study retrospectively analyzed the Utstein template records from April 1, 2002, to June 30, 2005. Patients who had out-of-hospital-witnessed cardiac arrest caused by cardiac disease and who presented with ventricular fibrillation (VF) as the initial cardiac rhythm were included in the study. Before April 1, 2003, the emergency medical technician (EMT) needed to obtain telephone permission before attempting defibrillation, and CPR was continued until permission was received (CPR first). On and after April 1, 2003, the EMT was immediately able to attempt a defibrillation without obtaining permission (shock first). RESULTS: In 143 patients who had out-of-hospital-witnessed VF, 43 patients and 100 patients were treated with the CPR-first strategy and the shock-first strategy, respectively. The duration of CPR before the first defibrillation was longer in the CPR-first group than that in the shock-first group. The CPR-first group showed a higher rate of favorable neurologic outcome 30 days after (28% vs 14%; P = .048) and 1 year after cardiac arrest (26% vs 11%; P = .033) than those of the shock-first group. In the patients with witnessed VF, a stepwise multiple logistic regression analysis showed the CPR-first strategy to improve the neurologic outcome. CONCLUSIONS: In patients with out-of-hospital-witnessed VF, sufficient CPR before the first defibrillation is considered to improve the neurologic outcome in comparison to the performance of immediate defibrillation.

Fenestrated stent-graft facilitates emergency endovascular therapy for blunt aortic injury.

BACKGROUND: Endovascular stent-grafting with intentional coverage of the left subclavian artery may be used to treat aortic isthmus injury, but this procedure may have serious neurologic sequelae and may not provide an adequate proximal landing zone. In 2005, in an effort to mitigate these problems, we began to use fenestrated stent-grafts for emergency repair of blunt aortic injury (BAI). METHODS: Between 2005 and 2007, all patients in our practice with a BAI with mediastinal hematoma (except young patients without an associated critical injury) were treated with immediate endovascular stent-grafting, if anatomically possible. A fenestrated stent-graft was placed from the aortic arch, if the BAI was less than 20-mm distal of the left subclavian artery. The records of the 13 patients in the series were reviewed retrospectively. RESULTS: The BAI treatment was successful in all 13 patients. Eight patients (61.5%) were given a fenestrated stent-graft, placed distal to either the ascending aorta (n = 2), brachio-cephalic artery (n = 4), or left common carotid artery (n = 2), without concomitant bypass grafting or transposition of the head vessels. Two patients died of an associated critical brain injury (hospital mortality rate, 15.4%). There were no perioperative complications related to stent-graft usage and no unintentional occlusions of the head vessels by a fenestrated device. One patient underwent open repair of a newly developed type Ia endoleak 7 months after placement of a nonfenestrated stent-graft. CONCLUSION: Fenestrated stent-grafts can be used to treat BAI, without any concomitant procedures to provide an adequate proximal landing zone.

Successful extracorporeal membranous oxygenation for a patient with life-threatening transfusion-related acute lung injury.

A case of transfusion-related acute lung injury (TRALI) that was successfully treated with extracorporeal membranous oxygenation (ECMO) is reported. A 58-year-old male patient underwent hepatectomy, and pulmonary edema occurred after the administration of fresh-frozen plasma and packed red cells. In the postoperative period, the impaired oxygenation progressively worsened, resulting in life-threatening hypoxemia, despite vigorous treatments. ECMO was therefore applied to the patient as a method of safe emergency support. Aggressive treatments under ECMO led to the successful improvement of the impaired oxygenation. TRALI is recognized as part of acute respiratory distress syndrome (ARDS). As a treatment for ARDS, ECMO does not cure the underlying disease of the lungs, however, with ECMO, TRALI, usually improves within 96 h with respiratory support. ECMO for TRALI-induced lethal hypoxemia is useful for providing time to allow the injured lung to recover. It is suggested that ECMO might be a useful option for the treatment of TRALI-induced, potentially lethal hypoxemia.

Utstein style study of cardiopulmonary bypass after cardiac arrest.

OBJECTIVE: The aim of this study is to describe the effect emergency cardiopulmonary bypass (CPB) for resuscitation on the survival rate of patients. METHODS: The study population was composed of persons 16 years or older who had out-of-hospital cardiac arrest and were transferred to the Sapporo Medical University Hospital from the scene between January 1, 2000, and September 30, 2004. Children younger than 16 years and persons who were dead were excluded. Data were collected according to the Utstein style. Survival rates and cerebral performance category were analyzed using chi(2) analysis for the patients with presumed cardiac etiology. Cardiopulmonary bypass was applied to patients who showed no response with standard advanced cardiac life support. The interval from collapse and other noncardiac etiologies were considered criteria for exclusion. RESULTS: Of the 919 patient medical records reviewed, CPB was performed in 92 patients. Of the 919 patients, 398 were of presumed cardiac etiology (n = 66 for CPB), 48 patients survived, and 24 patients (n = 7 for CPB) had a good cerebral outcome (cerebral performance category score 1). With CPB, the rate of survival at 3 months increased significantly (22.7% vs 9.9%, P < .05), but the rate of good cerebral outcome (10.6% vs 5.1%, P = .087) showed a positive trend. CONCLUSION: The use of CPB for arrest patients was associated with reduced mortality. It did not increase good neurologic outcome significantly. Still, 7 cases with intact central nervous system would have been lost without CPB.

Lhermitte-Duclos disease with cervical paraspinal arteriovenous fistula.

A 38-year-old man presented with a dysplastic cerebellar gangliocytoma associated with a paraspinal arteriovenous fistula (AVF) at the upper cervical portion. Neuroimaging examination indicated the diagnosis of Lhermitte-Duclos disease. The patient was treated by embolization of the AVF followed by partial resection of the cerebellar tumor. Genetic examination showed a mutation of the phosphatase and tensin homolog deleted on chromosome ten (PTEN) gene. Histological examination confirmed the diagnosis. Lhermitte-Duclos disease is a rare dysplastic gangliocytoma manifesting as a slowly growing mass in the cerebellum and is usually asymptomatic. This case of Lhermitte-Duclos disease associated with paraspinal AVF and mutation of the PTEN gene suggests a relationship between Lhermitte-Duclos disease and Cowden disease.

Endovascular stent-graft placement for vascular failure of the thoracic aorta.

It still remains undetermined whether endovascular stent-graft placement (ESGP) is the optimal initial treatment for elective cases of thoracic aortic disease because of unknown long-term results. However, it is also recognized that ESGP contributes to better outcome as an initial treatment for aortic emergency, such as rupture, aortic injury, and complicated acute type B aortic dissection. Despite the fact that most patients are elderly, early mortality rates of ESGP are reportedly around 10% in cases of ruptured degenerative thoracic aortic aneurysm. Postoperative morbidity is also superior in ESGP compared with conventional open repair. Postoperative paraplegia has rarely occurred with ESGP. In cases of blunt aortic injury (BAI), other complications may also be present because of other serious injuries. ESGP has changed the surgical strategy for BAI and partially resolved some of the clinical dilemmas. Early mortality rate is almost zero when a stent graft can be placed before re-rupture. While BAI is a very good indication for ESGP, young patients need careful management and attention because of the unknown long-term outcome. In cases of complicated acute type B aortic dissection, the two main determinants of death, shock from rupture and visceral ischemia, could be managed by ESGP with or without conventional endovascular interventions. Recent reports disclosed less than 10% early mortality with ESGP for complicated acute aortic dissection. Even if the possibility of endotension remains, ESPG seems to be beneficial for these critical patients as the preferable initial treatment. The importance of close follow-up should be stressed to avoid some devastating late complications following ESGP.

Therapeutic temperature modulation in severe or moderate traumatic brain injury: a propensity score analysis of data from the Nationwide Japan Neurotrauma Data Bank.

OBJECTIVE: In patients with severe traumatic brain injury (TBI), a randomized controlled trial revealed that outcomes did not significantly improve after therapeutic hypothermia (TH) or normothermia (TN). However, avoiding pyrexia, which is often associated with intracranial disorders, might improve clinical outcomes. The objective of this study was to compare neurological outcomes among patients with moderate and severe TBI after therapeutic temperature modulation (TTM) in the absence of other interventions. METHODS: Data from 1091 patients were obtained from the Japan Neurotrauma Data Bank Project 2009, a cohort observational study. Patients with cardiac arrest, those with a Glasgow Coma Scale score of 3 and dilated fixed pupils, and those whose cause of death was injury to another area of the body were excluded, leaving 687 patients aged 16 years or older in this study. The patients were divided into 2 groups: the TTM group underwent TN (213 patients) or TH (82 patients), and the control group (392 patients) did not receive TTM. The primary end point for this study was the rate of poor outcome at hospital discharge, and the secondary end point was in-hospital death. Out of the 208 total items in the database, 29 variables that could potentially affect outcome were matched using the propensity score (PS) method in order to reduce selection bias and balance the baseline characteristics. RESULTS: From each group, 141 patients were extracted using the PS-matching process. Among the patients in the TTM group, 29 had undergone TH and 112 had undergone TN. In a log-rank test using Kaplan-Meier survival curves, no significant differences in patient outcome or death were observed between the 2 groups (poor outcome, p = 0.83; death, p = 0.18). A Cox proportional-hazards regression analysis established the HR for poor outcome and mortality at 1.03 (95% CI 0.78-1.36, p = 0.83) and 1.34 (95% CI 0.87-2.07, p = 0.18), respectively. CONCLUSIONS: There was no clear improvement in neurological outcomes after TTM in patients with moderate or severe TBI. To elucidate the role of TTM in patients with these injuries, a prospective study is needed with long-term follow-up using specific target temperatures.

A simple but useful method of screening for mesenteric ischemia secondary to acute aortic dissection.

BACKGROUND: In spite of recent improvements in treatment for acute aortic dissection, mesenteric ischemia secondary to aortic dissection is still challenging. We propose a simple screening method to detect mesenteric ischemia secondary to acute aortic dissection. METHODS: From 1991 to 2002, 245 patients with acute aortic dissection were admitted to our hospital. Nine (3.7%) of those were complicated with mesenteric ischemia. The clinical records of those 9 patients were retrospectively analyzed. The ratios of the diameter of the superior mesenteric vein (SMV) to that of the superior mesenteric artery (SMA) were calculated in patients with mesenteric ischemia (group M) and in patients without mesenteric ischemia (group C). Blood test data, including results of arterial blood gas analysis, in the 2 groups were also compared. RESULTS: The SMV/SMA ratios in groups M and C were 1.16 +/- 0.33 and 1.78 +/- 0.29, respectively (P=.003). A cutoff value of the SMV/SMA ratio was 1.5 (sensitivity, 88.9%; specificity, 88.9%) with an odds ratio of 64.0. Although there were differences between the 2 groups in glutamate oxaloacetate transaminase, lactate dehydrogenase, creatine phosphate kinase, pH, and lactate values, the measurement of lactate was especially useful (P=.002). CONCLUSIONS: The combination of the SMV/SMA ratio and lactate concentration is a useful screening method to detect mesenteric ischemia secondary to acute aortic dissection.

Terrorism in Japan.

Although the 1995 Tokyo subway sarin attack probably was the most widely reported terrorist event in Japan to date (5,500 injured, 12 dead), the country has suffered numerous other large terrorism-related events in recent decades, including bombings of the headquarters of Mitsubishi Heavy Industries in Tokyo in 1974 (207 injured, 8 dead), the Hokkaido Prefectural Government office building in Sapporo in 1976 (80 injured, 2 dead), and the Yosakoi-Soran Festival in Sapporo in 2000 (10 injured, none dead). Japan also has experienced two other mass-casualty terrorist events involving chemical releases, including the 1994 Matsumoto sarin attack (600 injured, 7 dead) and the 1998 Wakayama arsenic incident (67 injured, 4 dead). Until 1995, emergency management in Japan focused on planning and preparedness at the local level for the frequent disasters caused by natural events. Since that time, substantial progress has been made in advancing emergency planning and preparedness for terrorism-related events, including the designation of disaster centers in each prefecture, the implementation of several education and training programs for nuclear, biological, and chemical terrorism, and the establishment of a national Anti terrorism Office within the Ministry of Health, Labor, and Welfare.