Hisashi Ikeuchi

Continuous Improvements in “Chain of Survival” Increased Survival After Out-of-Hospital Cardiac Arrests A Large-Scale Population-Based Study

Background— The impact of ongoing efforts to improve the “chain of survival” for out-of-hospital cardiac arrest (OHCA) is unclear. The objective of this study was to evaluate the incremental effect of changes in prehospital emergency care on survival after OHCA. Methods and Results— This prospective, population-based observational study involved consecutive patients with OHCA from May 1998 through December 2006. The primary outcome measure was 1-month survival with favorable neurological outcome. Multiple logistic regression analysis was used to assess factors that were potentially associated with better neurological outcome. Among 42 873 resuscitation-attempted adult OHCAs, 8782 bystander-witnessed arrests of presumed cardiac origin were analyzed. The median time interval from collapse to call for medical help, first cardiopulmonary resuscitation, and first shock shortened from 4 (interquartile range [IQR] 2 to 11) to 2 (IQR 1 to 5) minutes, from 9 (IQR 5 to 13) to 7 (IQR 3 to 11) minutes, and from 19 (IQR 13 to 22) to 9 (IQR 7 to 12) minutes, respectively. Neurologically intact 1-month survival after witnessed ventricular fibrillation increased from 6% (6/96) to 16% (49/297; P<0.001). Among all witnessed OHCAs, earlier cardiopulmonary resuscitation (odds ratio per minute 0.89, 95% confidence interval 0.85 to 0.93) and earlier intubation (odds ratio per minute 0.96, 95% confidence interval 0.94 to 0.99) were associated with better neurological outcome. For ventricular fibrillation, only earlier shock was associated with better outcome (odds ratio 0.84, 95% confidence interval 0.80 to 0.88). Conclusions— Data from a large, population-based cohort demonstrate a continuous increase in OHCA survival with improvement in the chain of survival. The incremental benefit of early advanced care on OHCA survival is also suggested.

Incidence and survival rate of bystander-witnessed out-of-hospital cardiac arrest with cardiac etiology in Osaka, Japan: a population-based study according to the Utstein style

PURPOSE To clarify the incidence and survival rate of bystander-witnessed out-of-hospital cardiac arrests (OHCA) with cardiac etiology in Osaka Prefecture, Japan, with a population of nearly 9 million according to the Utstein style. SUBJECTS AND METHODS 5047 consecutive OHCA cases were treated by ambulance personnel during the 12-month period starting since 1 May 1998. 974 cases were considered to be bystander-witnessed OHCA with cardiac etiology and analyzed using the Utstein style. RESULTS Of the 974 cases (100%), 50 cases (5.1%) survived after 1 month and 28 (2.9%) of them after 1 year. The Ventricular fibrillation (VF)/ventricular tachycardia (VT) group comprised 164 (16.8%) cases and there were statistically differences between the two groups as below (the VF/VT group vs. the non-VF/VT group): gender (male: 76.8 vs. 60.7%), age (61.7+/-14.7 vs. 68.7+/-17.1), history of ischemic heart disease (IHD) (30.5 vs. 15.3%), performance rate of bystander cardiopulmonary resuscitation (CPR) (34.1 vs. 21.4%) and time interval between receipt of an emergency call and arrival at the scene (5.5+/-2.9 vs. 6.0+/-2.9 min). CONCLUSION The incidence of bystander-witnessed (OHCA) with cardiac etiology and VF or VT were remarkably low compared with those reported by other studies conducted in some areas of Europe or the USA.

Reduction in incidence and fatality of out-of-hospital cardiac arrest in females of the reproductive age

AIMS The aim of this study was to determine relative risk (RR) of incidence and fatality of out-of-hospital cardiac arrest (OHCA) by gender and oestrogen status. METHODS AND RESULTS In a prospective, population-based observational study from 1998 through 2007, incidence and neurologically intact 1-month survival after OHCA were compared by gender after grouping: 0-12 years, 13-49 years, and > or =50 years according to menarche and menopause age. Among 26 940 cardiac arrests, there were 11 179 females and 15 701 males. Age-adjusted RR of females for OHCA incidence compared with males was 0.72 [95% confidence interval (CI), 0.58-0.91] in age 0-12 years, 0.39 (95% CI, 0.37-0.43) in age 13-49 years, and 0.54 (95% CI, 0.52-0.55) in age > or =50 years. Females aged 13-49 years had a significantly higher good neurological outcome than males [adjusted odds ratio (OR), 2.00 (95% CI 1.21-3.32)]. This sex difference was larger than that in the other age groups [adjusted OR, 0.82 (95% CI, 0.06-12.02) in age 0-12 years and 1.23 (95% CI, 0.98-1.54) in age > or =50 years]. CONCLUSION Reproductive females had a lower incidence and a better outcome of OHCA than females of other ages and males, which might be explained by cardioprotective effects of endogenous oestrogen on OHCA.

Does Splenic Preservation Treatment (Embolization, Splenorrhaphy, and Partial Splenectomy) Improve Immunologic Function and Long-Term Prognosis After Splenic Injury?

BACKGROUND : To assess the immunologic alteration and long-term prognosis after splenic injury from preservation treatment (PT) (embolization, splenorrhaphy, partial splencetomy) and to compare with splenectomy (SN). METHODS : The long-term prognosis of patients with blunt splenic injury treated at seven tertiary emergency centers in Japan was retrospectively studied. Patients were followed up by telephone interview and written questionnaire. Blood samples and abdominal computer tomography scans were taken from patients who consented, and immunologic indices and the remaining volume of the spleen were measured. RESULTS : There was no episode of severe infection requiring hospitalization among the 66 SN patients (760 patient-year) and the 34 PT (213 patient-year) patients. Blood tests from 58 patients (24 SN vs. 34 PT) revealed significant differences in platelet count, Howell-Jolly body positive rate (SN 87% vs. PT 3%), white blood cells, total lymphocyte count, T-cell count, B-cell count, and serum IgG level. There was no significant difference in serum levels of IgM or specific IgG antibodies against 14 types of Streptococcus pneumoniae capsular polysaccharide, C3, C4, high-sensitivity C-reactive protein, and B -cell subset (surface marker immunoglobulins: IgA, IgG, and IgM). Most patients had anti-S. pneumoniae antibody levels less than that of the reference level for multiple serotypes (average 3 in SN and 4 in PT). A computer tomography scan was taken from 33 PT patients; the volume of spleen remaining averaged 130 mL (range, 48-287 mL). CONCLUSION : PT did not show discernible advantage over SN in immunologic indices including IgM and 14 serotypes of anti-S. pneumoniae antibodies, suggesting prophylactic measures and close follow-up are necessary after PT and SN.

Subsequent ventricular fibrillation and survival in out-of-hospital cardiac arrests presenting with PEA or asystole

BACKGROUND The prognostic implications of conversion to ventricular fibrillation (VF) in out-of-hospital cardiac arrest (OHCA) patients with an initial non-shockable rhythm are unclear. HYPOTHESIS Among OHCA patients with an initial non-shockable rhythm, survival is better in individuals who subsequently develop VF and are defibrillated. METHODS DESIGN Utstein style population-based cohort study. SUBJECTS adults (age>or=18 years) with OHCA of presumed cardiac etiology and initial rhythm of pulseless electrical activity (PEA) or asystole treated by emergency medical services systems in Osaka, Japan from January 1, 2001 to December 31, 2005. Primary outcome measure was one-month neurologically favorable survival (CPC<or=2). Outcome of patients with subsequent VF (SHOCK group) was compared to that of patients with sustained non-shockable rhythm (NON-SHOCK group) using logistic regression to adjust for potential confounding variables. RESULTS Of 14,316 OHCA, 12,353 cases had PEA or asystole as the initial rhythm. Of these, 11,766 (95%) remained in a non-shockable rhythm throughout the resuscitation effort while 587 (5%) subsequently developed VF and were defibrillated. Neurologically favorable survival at one month was significantly better in the SHOCK group (6% versus 1%, p<0.001). Subsequent VF remained a significant predictor (OR, 4.3; 95% CI, 2.8-6.7) of neurologically favorable survival after adjustment for potential confounders. CONCLUSIONS Based on a large-scaled population-based cohort of OHCA, subsequent VF with defibrillation was associated with better outcomes among patients with an initial non-shockable rhythm.

Survival rate and factors associated with 1-month survival of witnessed out-of-hospital cardiac arrest of cardiac origin with ventricular fibrillation and pulseless ventricular tachycardia: The Utstein Osaka project

OBJECTIVE We reassessed 1-month survival of patients with witnessed out-of-hospital cardiac arrest (OHCA) of cardiac origin with ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) in Osaka, Japan, and identified factors associated with 1-month survival using updated data from 1998 to 2004 collected based on the Utstein Style. METHODS Using the Utstein Osaka Project database, we analyzed 1028 cases which met the following criteria: (1) patient age 18 years or older; (2) presumed cardiac origin based on the definition of the Utstein Style; (3) witnessed by citizens; (4) VF or pulseless VT at the time of arrival of the ambulance. The main outcome measure was survival at 1 month after collapse. Variables to develop a predictive model for 1-month survival were selected by stepwise logistic regression. RESULTS Survival at 1 month was 19.6%. Factors retained in the final logistic regression were age, sex, type of witness, and time interval from (a) ambulance call receipt to cardiopulmonary resuscitation (CPR) by the ambulance crew; (b) ambulance call to defibrillation; (c) CPR by the ambulance crew to hospital arrival. Area under the receiver-operating characteristic curve for the model developed with the six variables was 0.738 and Hosmer-Lemshow goodness-of-fit p-value was 0.94. CONCLUSION We successfully developed a model to estimate the probability of 1-month survival using variables easy to collect in the early phase of resuscitation, and this model would help physicians and family members predict the likelihood of 1-month survival of OHCA patients on admission.

The Relationship between Functional Outcome and Prehospital Time Interval in Patients with Cerebral Infarction

BACKGROUND When symptoms of cerebral infarction are recognized in a patient, he or she should be transported to a hospital and should be started on the appropriate treatments. The effectiveness of delayed treatment of cerebral infarction with respect to the initial diagnosis or perception of the disease is still unclear. METHODS We retrospectively investigated whether the functional outcomes would improve if patients with cerebral infarction were transported to the hospital with minimum delay. One-hundred twenty-two patients who were transported to Mishuku Hospital from January 2012 to August 2015 were included. We conducted multiple regression analyses. The criterion variable included the BI at discharge, and the explanatory variables were age, sex, days of hospital stay, the Barthel Index (BI) on admission, time from symptom onset to hospital arrival, time from emergency medical service perception to hospital arrival, recombinant tissue plasminogen activator (rt-PA) treatment, and the occluded artery type. RESULTS In all 122 cases, the BI at the time of discharge was not related to onset time (P = .453) but was significantly related to perception time (P = .026). BI scores at discharge were high for young patients (P = .002) and for patients with short hospital stays (P <.001). In the rt-PA group (52 cases), BI scores at discharge were also high when the perception time was short (P = .036). CONCLUSIONS A short interval between perception and hospital arrival improves the functional outcomes for patients with cerebral infarction. Thus, patients with cerebral infarctions must be treated with minimal delay after diagnosis of the condition.

Fulminant pseudomembranous enterocolitis caused by Klebsiella oxytoca: an autopsy case report

We describe a rare case of antibiotic‐associated fulminant pseudomembranous enterocolitis caused by Klebsiella oxytoca. A 79‐year‐old man with a history of antibiotic therapy was admitted to our emergency department, complaining of consciousness disturbance. Initially, we suspected septic shock and diabetic ketoacidosis caused by intestinal infection. Although we administered sufficient extracellular fluid, his blood pressure was not elevated and his abdomen gradually swelled.

Self-penile glans amputation: a report of two cases

Self‐penile amputation, especially at the glans, has rarely been reported. Most reported cases of self‐amputation were performed at the proximal or peripubic area, and there only one case of self‐amputation at the glans has been reported in Japan. We report two cases of self‐penile amputation at the glans. Case 1: A 31‐year‐old man with no psychiatric disease completely amputated his penis at the glans. He underwent a stump plasty under spinal anesthesia. Case 2: A 46‐year‐old man with schizophrenia amputated his penis at the glans. Surgery and the post‐surgical course were almost the same as described in Case 1.

Direct intrahepatic portocaval shunt for refractory hepatic hydrothorax: a case report

A 64‐year‐old man with complaints of dyspnea and orthopnea secondary to a hepatic hydrothorax refractory to diuretic medication underwent the transjugular intrahepatic portosystemic shunt (TIPS) procedure to decrease the portal vein pressure. The TIPS procedure failed due to severe liver stiffness. Direct intrahepatic portocaval shunt (DIPS), a modified TIPS procedure that directly inserts a stent from the inferior vena cava to the portal vein, was successfully carried out.