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Increase in body temperature has been thought to play an important role in the regulation of immune responses, although its precise mechanisms are still under investigation. Here, we examined the effects of physiologically relevant thermal stress on the cytokine production from human peripheral T cells. Volunteers were heated using a whole-body hyperthermia device, the rectal temperature was maintained above 38.5 °C for more than 60 min, and peripheral blood mononuclear cells (PBMCs) were obtained before and after the treatment. When T cells were stimulated with anti-CD3/CD28 antibodies, marked increases in the production of interferon-γ (IFN-γ) and interleukin-2 were observed in PBMCs prepared immediately after and 24h after the treatment. Similarly, enhanced production of IFN-γ in response to the tuberculin purified protein derivative or antigenic viral peptides was also observed immediately after and 24h after the treatment. Fluorescence photo-bleaching analyses showed heat-induced increase of membrane fluidity in T cells, which probably enables them to induce rapid and efficient cluster formation of molecules involved in antigen recognition and signal transduction for T-cell stimulation. We concluded that physiologically relevant thermal stress could efficiently modify T-cell responsiveness to various stimuli, including enhanced responses to specific antigens., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Backgrounds: In Japan, ambulance staffing for cardiac arrest responses consists of a 3-person unit with at least one emergency life-saving technician (ELST). Recently, the number of ELSTs on ambulances has increased since it is believed that this improves the quality of on-scene care leading to better outcomes from out-of-hospital cardiac arrest (OHCA). The objective of this study was to evaluate the association between the number of on-scene ELSTs and OHCA outcome., Methods: This was a prospective cohort study of all bystander-witnessed OHCA patients aged ≥ 18 years in Osaka City from January 2005 to December 2007 using on an Utstein-style database. The primary outcome measure was one-month survival with favorable neurological outcome defined as a cerebral performance category ≤ 2. Multivariable logistic regression model were used to assess the contribution of the number of on-scene ELSTs to the outcome after adjusting for confounders., Results: Of the 2408 bystander-witnessed OHCA patients, one ELST group was present in 639 (26.5%), two ELST were present in 1357 (56.4%), and three ELST group in 412 (17.1%). The three ELST group had a significantly higher rate of one-month survival with favorable neurological outcome compared with the one ELST group (8.0% versus 4.5%, adjusted OR 2.26, 95% CI 1.27-4.04), while the two ELST group did not (5.4% versus 4.5%, adjusted OR 1.34, 95% CI 0.82-2.19)., Conclusions: Compared with the one on-scene ELST group, the three on-scene ELST group was associated with the improved one-month survival with favorable neurological outcome from OHCA in Osaka City., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Objective: Little is known about which symptoms are manifested before out-of-hospital cardiac arrest (OHCA). The objective of this study is to describe the prodromal symptoms of OHCA focusing on the onset of the symptom in relation of etiology of cardiac arrests, and to analyze the association between those symptoms and their outcomes after OHCA., Methods: This prospective, population-based cohort study enrolled all persons aged 18 years or older who had experienced OHCA of presumed cardiac and non-cardiac origin that were witnessed by bystanders or emergency medical system (EMS) personnel in Osaka from 2003 through 2004., Results: There were 1042 were presumed to be of cardiac origin and 424 of non-cardiac. Patients with non-cardiac origin were more likely to have prodromal symptoms than those with cardiac etiology (70.0% vs. 61.8%, p=0.003). Over 40% of OHCA regardless of etiology had displayed symptoms at least several minutes before their arrest (40.2% [259/644] in those of cardiac origin and 45.5% [135/297] in those of non-cardiac origin). As to cardiac origin, the most frequent prodromal symptom was dyspnea (27.6%), followed by chest pain (20.7%) and syncope (12.7%). For non-cardiac origin, the most frequent symptom was also dyspnea (40.7%), but chest pain was rarely presented (3.4%). Although, prodromal symptoms themselves were not associated with better neurological outcomes (adjusted odds ratio [AOR], 2.03; 95% confidence interval [CI], 1.00-4.13), earlier contact to a patient yielded better neurological outcomes (AOR per every one-minute increase, 0.90; 95% CI, 0.82-0.99)., Conclusions: Many of OHCA regardless of etiology have prodromal symptoms before arrest. Prodromal symptoms induced early activation of the EMS system, and may thus improve outcomes after OHCA., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Background: This study aimed to evaluate the association of cardiopulmonary resuscitation (CPR) training with bystander resuscitation performance and patient outcomes after out-of-hospital cardiac arrest (OHCA)., Methods: This was a prospective, population-based cohort study of all persons aged 18 years or older with OHCA of presumed intrinsic origin and their rescuers from January through December 2008 in Takatsuki, Osaka prefecture, Japan. Data on resuscitation of OHCA patients were obtained by emergency medical service (EMS) personnel in charge based on the Utstein style. Rescuers' characteristics including experience of CPR training were obtained by EMS personnel interview on the scene. The primary outcome was the attempt of bystander CPR., Results: Data were collected for 120 cases out of 170 OHCAs of intrinsic origin. Among the available cases, 60 (50.0%) had previous CPR training (trained rescuer group). The proportion of bystander CPR was significantly higher in the trained rescuer group than in the untrained rescuer group (75.0% and 43.3%; p = 0.001). Bystanders who had previous experience of CPR training were 3.40 times (95% confidence interval 1.31-8.85) more likely to perform CPR compared with those without previous CPR training. The number of patients with neurologically favorable one-month survival was too small to evaluate statistical difference between the groups (2 [3.3%] in the trained rescuer group versus 1 [1.7%] in the untrained rescuer group; p = 0.500)., Conclusions: People who had experienced CPR training had a greater tendency to perform bystander CPR than people without experience of CPR training. Further studies are needed to prove the effectiveness of CPR training on survival., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Background: No previous study has investigated the safety of hand position during chest compression determined by the inter-nipple line, in which the heel of one hand is positioned on the centre of the chest between the nipples, from the standpoint of prevention of organ injury., Methods: We measured the distance from the xiphisternal junction to the inter-nipple line (dN) in 1000 surgical patients and the heel length (H) of hands in 100 healthy volunteers, then used the formula H/2-dN to determine the amount of deviation when the heel of the rescuer's hand extended to the xiphoid process (D). Next, 100 surgical patients were randomly assigned to 18 anaesthesiologists, who placed the heels of their hands on the sternum for validation., Results: The D value was positive in 551 patients, indicating that the heel may extend to the xiphoid process during chest compression in those individuals. Multivariate logistic-regression analyses showed that deviations beyond the xiphoid process to the epigastric region were more likely to occur in female (OR 3.52), elderly (OR 2.00), and short-statured (OR 2.09) patients, and with male rescuers (OR 2.81). During actual positioning, deviation occurred in 51 patients and extended to the epigastric region in 5 females., Conclusions: Simulation of hand position determined by the inter-nipple line resulted in placement of the rescuer's hands over the xiphoid process in nearly half of the patients. Hand deviation to the epigastric region may occur when the patient is a short-statured or elderly female, and when the rescuer is male.

Emergency medical services are provided by the fire defence headquarters of the local government in Japan. There is a one-tiered EMS system. Ambulances are staffed by three crew members trained in rescue, stabilisation, transport, and advanced care of traumatic and medical emergencies. There are three levels of care provided by ambulance personnel including a basic-level ambulance crew (First Aid Class One, FAC-1), a second level (Standard First Aid Class, SFAC), and the highest level (Emergency Life Saving Technician, ELST). ELSTs are trained in all aspects of BLS and some ALS procedures relevant to pre-hospital emergency care. Further development of an effective medical control system is imperative as the activities of ambulance crews become more sophisticated. A marked recent increase in the volume of emergency calls is another issue of concern. Currently, private services for transportation of non-acute or minor injury/illness have been introduced in some areas, and dispatch protocols to triage 119 calls are being developed.

We studied prospectively the reliability of clinical methods, end-tidal carbon dioxide (ETCO(2)) detection, and the esophageal detector device (EDD) for verifying tracheal intubation in 137 adult patients in the emergency department. Immediately after intubation, the tracheal tube position was tested by the EDD and ETCO(2) monitor, followed by auscultation of the chest. The views obtained at laryngoscopy were classified according to the Cormack grade. Of the 13 esophageal intubations that occurred, one false-positive result occurred in the EDD test and auscultation. In the non-cardiac arrest patients (n=56), auscultation, the ETCO(2), and EDD test correctly identified 89.3, 98.2*, and 94.6%* of tracheal intubations, respectively (*, P<0.05 vs. the cardiac arrest patients). In the cardiac arrest patients (n=81), auscultation, the ETCO(2), and the EDD tests correctly identified 92.6**, 67.9, and 75.3% of tracheal intubations, respectively (**, P<0.05 vs. EDD and ETCO(2)). The frequencies of Cormack grade 1 or 2 were 83.9% in the non-cardiac arrest, and 95.1% in the cardiac arrest patients. In conclusion, the ETCO(2) monitor is the most reliable method for verifying tracheal intubation in non-cardiac arrest patients. During cardiac arrest and cardiopulmonary resuscitation, however, negative results by the ETCO(2) or the EDD are not uncommon, and clinical methods are superior to the use of these devices.

We postulate that mitigating the multifactorial pathogenesis of postischemic encephalopathy requires multifaceted treatments. In preparation for expensive definitive studies, we are reporting here the results of small exploratory series, compared with historic controls with the same model. We hypothesized that the brain damage mitigating effect of mild hypothermia after cardiac arrest can be enhanced with thiopental loading, and even more so with the further addition of phenytoin and methylprednisolone. Twenty-four dogs (four groups of six dogs each) received VF 12.5 min no-flow, reversed with brief cardiopulmonary bypass (CPB), controlled ventilation to 20 h, and intensive care to 96 h. Group 1 with normothermia throughout and randomized group 2 with mild hypothermia (from reperfusion to 2 h) were controls. Then, group 3 received in addition, thiopental 90 mg/kg i.v. over the first 6 h. Then, group 4 received, in addition to group 2 treatment, thiopental 30 mg/kg i.v. over the first 90 min (because the larger dose had produced cardiopulmonary complications), plus phenytoin 15 mg/kg i.v. at 15 min after reperfusion, and methylprednisolone 130 mg/kg i.v. over 20 h. All dogs survived. Best overall performance categories (OPC) achieved (OPC 1 = normal, OPC 5 = brain death) were better in group 2 than group 1 (< 0.05) and numerically better in groups 3 or 4 than in groups 1 or 2. Good cerebral outcome (OPC 1 or 2) was achieved by all six dogs only in group 4 (P < 0.05 group 4 vs. 2). Best NDS were 44 +/- 3% in group 1; 20 +/- 14% in group 2 (P = 0.002); 21 +/- 15% in group 3 (NS vs. group 2); and 7 +/- 8% in group 4 (P = 0.08 vs. group 2). Total brain histologic damage scores (HDS) at 96 h were 156 +/- 38 in group 1; 81 +/- 12 in group 2 (P < 0.001 vs. group 1); 53 +/- 25 in group 3 (P = 0.02 vs. group 2); and 48 +/- 5 in group 4 (P = 0.02 vs. group 2). We conclude that after prolonged cardiac arrest, the already established brain damage mitigating effect of mild immediate postarrest hypothermia might be enhanced by thiopental, and perhaps then further enhanced by adding phenytoin and methylprednisolone.

The aim of this study was to provide data on the outcomes of out-of-hospital cardiac arrest caused by ventricular fibrillation (VFOHCA) and analyze factors influencing patient outcomes in order to further improve EMS system performance in the resuscitation of VFOHCA patients in Japan. A datasheet was mailed to the fire defense headquarters throughout Japan, and returned data were analyzed for 614 cases of VFOHCA that occurred from January 1 through December 31, 1996. In relation to the time interval from receipt of emergency call to defibrillation, the subjects were stratified into five groups: 0-8 (n = 39), 9-12 (n = 87), 13-16 (n = 154), 17-20 (n = 118) and more than 21 min (n = 216). The discharge survival rates were 18*, 13.8*, 5.2, 4.2 and 4.2%, respectively (*P < 0.05). When defibrillation was delivered within 12 min after a call, 30.2% (38/126) converted to pulse-generating rhythm (PGR) after defibrillation and 43.6% (17/39) of patients with PGR on arrival at the hospital survived to discharge. In spite of these findings, a marked delay to defibrillation (more than 13 min) was observed in the majority (79.5%). The data shown in this study demonstrated that important issues that limit the benefits of an early defibrillation program reside in the EMS system.