Mitsugi Sugiyama

Psychiatric assessment of suicide attempters in Japan: a pilot study at a critical emergency unit in an urban area

BackgroundThe incidence of suicide has increased markedly in Japan since 1998. As psychological autopsy is not generally accepted in Japan, surveys of suicide attempts, an established risk factor of suicide, are highly regarded. We have carried out this study to gain insight into the psychiatric aspects of those attempting suicide in Japan.MethodsThree hundred and twenty consecutive cases of attempted suicide who were admitted to an urban emergency department were interviewed, with the focus on psychosocial background and DSM-IV diagnosis. Moreover, they were divided into two groups according to the method of attempted suicide in terms of lethality, and the two groups were compared.ResultsNinety-five percent of patients received a psychiatric diagnosis: 81% of subjects met the criteria for an axis I disorder. The most frequent diagnosis was mood disorder. The mean age was higher and living alone more common in the high-lethality group. Middle-aged men tended to have a higher prevalence of mood disorders.ConclusionThis is the first large-scale study of cases of attempted suicide since the dramatic increase in suicides began in Japan. The identification and introduction of treatments for psychiatric disorders at emergency departments has been indicated to be important in suicide prevention.

Treatment of hepatic encephalopathy by on-line hemodiafiltration: a case series study

BackgroundIt is thought that a good survival rate of patients with acute liver failure can be achieved by establishing an artificial liver support system that reliably compensates liver function until the liver regenerates or a patient undergoes transplantation. We introduced a new artificial liver support system, on-line hemodiafiltration, in patients with acute liver failure.MethodsThis case series study was conducted from May 2001 to October 2008 at the medical intensive care unit of a tertiary care academic medical center. Seventeen consecutive patients who admitted to our hospital presenting with acute liver failure were treated with artificial liver support including daily on-line hemodiafiltration and plasma exchange.ResultsAfter 4.9 ± 0.7 (mean ± SD) on-line hemodiafiltration sessions, 16 of 17 (94.1%) patients completely recovered from hepatic encephalopathy and maintained consciousness for 16.4 ± 3.4 (7-55) days until discontinuation of artificial liver support (a total of 14.4 ± 2.6 [6-47] on-line hemodiafiltration sessions). Significant correlation was observed between the degree of encephalopathy and number of sessions of on-line HDF required for recovery of consciousness. Of the 16 patients who recovered consciousness, 7 fully recovered and returned to society with no cognitive sequelae, 3 died of complications of acute liver failure except brain edema, and the remaining 6 were candidates for liver transplantation; 2 of them received living-related liver transplantation but 4 died without transplantation after discontinuation of therapy.ConclusionsOn-line hemodiafiltration was effective in patients with acute liver failure, and consciousness was maintained for the duration of artificial liver support, even in those in whom it was considered that hepatic function was completely abolished.

Relation between C-reactive protein levels on admission and pattern of acute myocardial infarction onset

The pathogenic mechanisms underling the onset of acute myocardial infarction (AMI) have not been fully clarified. Recent observations of inflammatory cell infiltration in unstable coronary plaques suggest that inflammation may play an important role in the pathogenesis of AMI. Plasma levels of C-reactive protein (CRP), a sensitive marker of inflammation, start to rise at least 6 hours after the onset of AMI. Therefore, CRP levels within the first 6 hours after the onset of AMI more likely reflect preexisting inflammatory activity rather than myocardial cell necrosis. We examined the relation between CRP levels on admission and the onset pattern of AMI to estimate the contribution of inflammation to the pathogenesis of AMI.

Complications of bystander cardiopulmonary resuscitation for unconscious patients without cardiopulmonary arrest.

Background: Insufficient knowledge of the risks and complications of cardiopulmonary resuscitation (CPR) may be an obstructive factor for CPR, however, particularly for patients who are not clearly suffering out of hospital cardiopulmonary arrest (OH-CPA). The object of this study was to clarify the potential complication, the safety of bystander CPR in such cases. Materials and Methods: This study was a population-based observational case series. To be enrolled, patients had to have undergone CPR with chest compressions performed by lay persons, had to be confirmed not to have suffered OHCPA. Complications of bystander CPR were identified from the patients’ medical records and included rib fracture, lung injury, abdominal organ injury, and chest and/or abdominal pain requiring analgesics. In our emergency department, one doctor gathered information while others performed X-ray and blood examinations, electrocardiograms, and chest and abdominal ultrasonography. Results: A total of 26 cases were the subjects. The mean duration of bystander CPR was 6.5 minutes (ranging from 1 to 26). Nine patients died of a causative pathological condition and pneumonia, and the remaining 17 survived to discharge. Three patients suffered from complications (tracheal bleeding, minor gastric mucosal laceration, and chest pain), all of which were minimal and easily treated. No case required special examination or treatment for the complication itself. Conclusion: The risk and frequency of complications due to bystander CPR is thought to be very low. It is reasonable to perform immediate CPR for unconscious victims with inadequate respiration, and to help bystanders perform CPR using the T-CPR system.

Factors associated with preventable out-of-hospital nontraumatic cardiac arrest

To identify ways to decrease the risk of out-of-hospital cardiac arrest (CA) caused by an acute coronary syndrome, we examined factors associated with the development of CA > or = 1 hour after symptom onset. Multivariate analysis revealed that a low level of physical activity, a history of diabetes mellitus, and a history of unstable angina are associated with out-of-hospital CA occurring > or = hour after symptom onset.

Blood transfusion therapy for traumatic cardiopulmonary arrest

Background: Blood transfusion therapy (BTT), which represents transplantation of living cells, poses several risks. Although BTT is necessary for trauma victims with hemorrhagic shock, it may be futile for patients with blunt traumatic cardiopulmonary arrest (BT-CPA). Materials and Methods: We retrospectively examined the medical records of consecutive patients with T-CPA. The study period was divided into two periods: The first from 1995-1998, when we used packed red cells (PRC) regardless of the return of spontaneous circulation (ROSC), and the second from 1999-2004, when we did not use PRC before ROSC. The rates of ROSC, admission to the ICU, and survival-to-discharge were compared between these two periods. Results: We studied the records of 464 patients with BT-CPA (175 in the first period and 289 in the second period). Although the rates of ROSC and admission to the ICU were statistically higher in the first period, there was no statistical difference in the rate of survival-to-discharge between these two periods. In the first period, the rate of ROSC was statistically higher in the non-BTT group than the BTT group. However, for cases in which ROSC was performed and was successful, there were no statistical differences in the rate of admission and survival-to-discharge between the first and second group, and between the BTT and non-BTT group. Conclusion: Our retrospective consecutive study shows the possibility that BTT before ROSC for BT-CPA and a treatment strategy that includes this treatment improves the success rate of ROSC, but not the survival rate. BTT is thought to be futile as a treatment for BT-CPA before ROSC.

Securing of tracheostomy tube using detachable clip in patients requiring neck wound management after esophageal, pharyngeal, and supinal surgery

To the Editors: We read with great interest the article by DeBosch et al examining the ethical dilemma posed when a pregnant patient refuses Caesarian section in the face of impending fetal demise. Although an exceedingly complex scenario, the authors provide a comprehensive and helpful discussion of its various components. We wish to draw further attention to one aspect of the authors analysis, specifically the role that surrogate decision making might have in achieving an ethically justifiable resolution. We believe that the authors application of the ‘‘substituted judgment’’ standard for surrogate decision making to this scenario is inadequate. Although we agree that seeking a psychiatric evaluation of the patient’s decision-making capacity is likely to be time-consuming and impractical, particularly given the urgency of the clinical situation, it should be noted that all physicians should have the basic skills needed to evaluate a patient’s decision-making capacity. The scenario as presented does not contain enough information to establish that the patient lacks decision-making capacity; however, if the patient were judged to lack decisionmaking capacity, it does not necessarily follow that the patient’s designated surrogate decision maker would be ‘‘ethically obliged’’ to also refuse the Caesarian section. The authors acknowledge that, when appropriately executing substituted judgment, surrogate decision makers are instructed to arrive at the decision that most approximates what the patient would have wanted under the circumstances if she had decision-making capacity. The clinical scenario suggests that the patient currently does not want a Caesarian section; however, if the physicians determined that the patient did not have decision-making capacity, it would be inappropriate for a surrogate decision maker to choose a course of action based solely on these expressed wishes, because they are being voiced by a patient who has been found to lack decision-making capacity. More information would be needed to better predict how the patient’s surrogate might best approximate her autonomy. To do this, the patient s surrogate would have to either supply background information regarding the patient’s previously held wishes or values or provide previous statements the patient might have made when she did have decision-making capacity. With that evidence in hand, the patient’s surrogate could come to a decision contrary to the patient’s currently expressed desires that is a more faithful representation of what she would have wanted. This outcome would be ethically justified. In conclusion, if the patient in this scenario lacks decision-making capacity, we cannot say what the ethically appropriate course of action is until the surrogate decision maker gives voice to the patient’s preferences based on the values that she held prior to losing decisional capacity. This additional insight is precisely the benefit---and responsibility---of a surrogate decision maker.

Confirmation of the mechanism of post-operative wheezing by chest CT scan in both inspiratory and expiratory phases

A 63-yr-old female with acute aortic dissection underwent emergency surgery. After admission to ICU, wheezing was heard over the chest with concomitant increase in peak airway pressure. Chest CT scan in both inspiratory and expiratory phases with positive airway pressure ventilation was performed. Tracheal lumen was significantly compressed by mediastinal haematoma in the expiratory phase. The chest CT scan in both inspiratory and expiratory phases was helpful to clarify the mechanism of this condition.