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The railway embankment applied to high-speed railways is required to have high performance in terms of strength and deformation characteristics. Especially in the case of railway embankments that support slab tracks, the allowable settlement is very small. There are two technical challenges in constructing high-speed rail embankments to support slab tracks in India. The first challenge is dealing with problematic black cotton soil (BCS), which is widely distributed in India but very unusual soil in Japan. The second challenge is posed by the strict deformation requirement in the construction of the embankments. In this study, a 6 m-high test embankment was constructed on BCS in India. The deformation of the embankment and changes in water content were measured over a period of 18 months. In the construction of the test embankment, two different BCS countermeasures were applied. The results of the tests on this embankment were compared with those from an embankment without countermeasures. Complicated deformation behaviors, including settlement and the uplift of embankment, were observed in the section without countermeasure. However, in the embankment with cement-mixed gravelly soil (CGS) slab improvement with geosynthetics, the much lower amplitude of embankment deformation is evidence of the effectiveness of this countermeasure. The cohesive non-swelling soil (CNS) layer applied immediately below the embankment to reduce the water content fluctuation of BCS was not effective enough for use for high-speed railway embankment. Besides determining the technical challenges for the BCS countermeasures, the results of this study confirmed that a high-performance embankment can be constructed with Indian embankment material by performing sufficient compaction management. [ABSTRACT FROM AUTHOR]

Background and Purpose: Ozagrel sodium (ozagrel), a thromboxane A2 synthesis inhibitor, is used for ischemic stroke patients in several countries, despite a lack of strict evidence of its benefits. We investigated whether ozagrel was beneficial for patients with atherothrombotic stroke or lacunar infarction.Methods: This was a retrospective observational study using the Diagnosis Procedure Combination database in Japan. We identified patients with atherothrombotic stroke or lacunar infarction who were admitted to 781 hospitals from July 1, 2010 to March 31, 2012. Propensity score-matched analyses were performed separately for patients with atherothrombotic stroke and those with lacunar infarction, which balanced differences in baseline characteristics between patients who received ozagrel (ozagrel group) and those who did not (control group) in each stroke subtype. The modified Rankin Scale scores at discharge and occurrence of hemorrhagic complications after admission were compared between the ozagrel and control groups.Results: After the propensity score matching, 2726 pairs of patients with atherothrombotic stroke and 1612 pairs of patients with lacunar infarction were analyzed. Ordinal logistic regression analyses showed that ozagrel use was not significantly associated with modified Rankin Scale score at discharge in patients with atherothrombotic stroke (odds ratio: .99; 95% confidence interval: .88-1.11) or in those with lacunar infarction (odds ratio: 1.00; 95% confidence interval: .87-1.16). The occurrence of hemorrhagic complications did not differ significantly between the ozagrel and control groups.Conclusion: The present study suggested that ozagrel was safe to use but did not improve functional outcomes in patients with atherothrombotic or lacunar infarction. [ABSTRACT FROM AUTHOR]

Introduction: Plasma lactate concentration is known to increase after alcohol intake. However, this increase has rarely been analyzed quantitatively in emergency department (ED) settings. Evaluating plasma lactate elevation in ED patients after alcohol intake is important because it can affect patients' evaluation based on the plasma lactate level.Methods: This study analyzed venous lactate concentrations of 196 continuous patients presented to our ED after alcohol intake. The control group comprised 219 successive ED patients without alcohol intake. Patients who had conditions that might induce lactate elevation were excluded from both groups.Results: Venous lactate concentration was significantly higher in the alcohol intake group (2.83 mmol/L; 95% confidence interval, 2.69-2.96 mmol/L) than in the control group (1.65 mmol/L; 95% confidence interval, 1.53-1.77 mmol/L; P<.05). Lactate concentrations exceeding 3 mmol/L and exceeding 4 mmol/L were found, respectively, in 41.8% and 12.2% of the alcohol intake group compared with in 8.7% and 2.3% of the control group (P<.05). Lactate concentrations do not correlate with patients' level of consciousness. Therefore, a higher plasma ethanol level is apparently unrelated to elevated lactate.Discussion and Conclusion: Analyses show that plasma lactate concentration is significantly higher in ED patients after alcohol intake and to a greater degree than previously reported, even in patients without previously known alcohol-related diseases. Emergency department physicians must be careful when interpreting the lactate level of the patients with alcohol intake. [ABSTRACT FROM AUTHOR]

BACKGROUND: Cerebral regional oxygen saturation (rSO2) can be measured immediately and noninvasively just after arrival at the hospital and may be useful for evaluating the futility of resuscitation for a patient with out-of-hospital cardiopulmonary arrest (OHCA). We examined the best practices involving cerebral rSO2 as an indicator of the futility of resuscitation. METHODS: This study was a single-center, prospective, observational analysis of a cohort of consecutive adult OHCA patients who were transported to the University of Tokyo Hospital from October 1, 2012, to September 30, 2013, and whose cerebral rSO2 values were measured. RESULTS: During the study period, 69 adult OHCA patients were enrolled. Of the 54 patients with initial lower cerebral rSO2 values of 26% or less, 47 patients failed to achieve return of spontaneous circulation (ROSC) in the receiver operating characteristic curve analysis (optimal cutoff, 26%; sensitivity, 88.7%; specificity, 56.3%; positive predictive value, 87.0%; negative predictive value, 60.0%; area under the curve [AUC], 0.714; P = .0033). The AUC for the initial lower cerebral rSO2 value was greater than that for blood pH (AUC, 0.620; P = .1687) or lactate values (AUC, 0.627; P = .1081) measured upon arrival at the hospital as well as that for initial higher (AUC, 0.650; P = .1788) or average (AUC, 0.677; P = .0235) cerebral rSO2 values. The adjusted odds ratio of the initial lower cerebral rSO2 values of 26% or less for ROSC was 0.11 (95% confidence interval, 0.01-0.63; P = .0129). CONCLUSIONS: Initial lower cerebral rSO2 just after arrival at the hospital, as a static indicator, is associated with non-ROSC. However, an initially lower cerebral rSO2 alone does not yield a diagnosis performance sufficient for evaluating the futility of resuscitation. [ABSTRACT FROM AUTHOR]

BACKGROUND: Although electronic health record systems (EHRs) and emergency department information systems (EDISs) enable safe, efficient, and high-quality care, these systems have not yet been studied well. Here, we assessed (1) the prevalence of EHRs and EDISs, (2) changes in efficiency in emergency medical practices after introducing EHR and EDIS, and (3) barriers to and expectations from the EHR-EDIS transition in EDs of medical facilities with EHRs in Japan. MATERIALS AND METHODS: A survey regarding EHR (basic or comprehensive) and EDIS implementation was mailed to 466 hospitals. We examined the efficiency after EHR implementation and perceived barriers and expectations regarding the use of EDIS with existing EHRs. The survey was completed anonymously. RESULTS: Totally, 215 hospitals completed the survey (response rate, 46.1%), of which, 76.3% had basic EHRs, 4.2% had comprehensive EHRs, and 1.9% had EDISs. After introducing EHRs and EDISs, a reduction in the time required to access previous patient information and share patient information was noted, but no change was observed in the time required to produce medical records and the overall time for each medical care. For hospitals with EHRs, the most commonly cited barriers to EDIS implementation were inadequate funding for adoption and maintenance and potential adverse effects on workflow. The most desired function in the EHR-EDIS transition was establishing appropriate clinical guidelines for residents within their system. CONCLUSION: To attract EDs to EDIS from EHR, systems focusing on decreasing the time required to produce medical records and establishing appropriate clinical guidelines for residents are required. [ABSTRACT FROM AUTHOR]

BACKGROUND: It is unclear whether the prehospital termination of resuscitation (TOR) rule is applicable in specific situations such as in areas extremely dense with hospitals. OBJECTIVES: The objective of the study is to assess whether the prehospital TOR rule is applicable in the emergency medical services system in Japan, specifically, in an area dense with hospitals in Tokyo. METHODS: This study was a retrospective, observational analysis of a cohort of adult out-of-hospital cardiopulmonary arrest (OHCA) patients who were transported to the University of Tokyo Hospital from April 1, 2009, to March 31, 2011. RESULTS: During the study period, 189 adult OHCA patients were enrolled. Of the 189 patients, 108 patients met the prehospital TOR rule. The outcomes were significantly worse in the prehospital TOR rule-positive group than in the prehospital TOR-negative group, with 0.9% vs 11.1% of patients, respectively, surviving until discharge (relative risk [RR], 1.11; 95% confidence interval [CI], 1.03-1.21; P = .0020) and 0.0% vs 7.4% of patients, respectively, discharged with a favorable neurologic outcome (RR, 1.08; 95% CI, 1.02-1.15; P = .0040). The prehospital TOR rule had a positive predictive value (PPV) of 99.1% (95% CI, 96.3-99.8) and a specificity of 90.0% (95% CI, 60.5-98.2) for death and a PPV of 100.0% (95% CI, 97.9-100.0) and a specificity of 100.0% (95% CI, 61.7-100.0) for an unfavorable neurologic outcome. CONCLUSIONS: This study suggested that the prehospital TOR rule predicted unfavorable outcomes even in an area dense with hospitals in Tokyo and might be helpful for identifying the OHCA patients for whom resuscitation efforts would be fruitless. [ABSTRACT FROM AUTHOR]

OBJECTIVE: It is known that patients with convulsion often present hyperammonemia. The elevation of ammonia levels in convulsion is considered to occur along with extensive muscle contractions, but the details remain unclear. In emergency pathologies, such as cardiopulmonary arrest or hemorrhagic shock without muscle contraction, red blood cells are known to produce ammonia through acidosis, leading to hyperammonemia. A similar effect would be considered to be involved in idiopathic epileptic seizure patients as well. METHODS: We retrospectively analyzed the cases of epileptic seizure that were transported to the emergency medical care center of Ohta Nishinouchi Hospital and diagnosed by neurologist as idiopathic epileptic seizure or epilepsy due to cerebrovascular disorder. Forty-four patients were idiopathic epilepsy, and 8 had epilepsy due to cerebrovascular disorder. Those with hepatic encephalopathy, metabolic disorder, alcohol consumption, tumor, and patients taking oral valproic acid were excluded. RESULTS: High ammonia levels (>35 [mu]mol/L) were observed in 22 cases. Maximum ammonia level was 506 [mu]mol/L. Significant differences were observed in the pH (r = 0.838, P < .0001) and base excess (BE) (r = 0.863, P < .0001), the values suggesting a strong negative correlation between the ammonia level and pH/BE. CONCLUSION: Idiopathic epileptic seizures can present with prominent hyperammonemia with acidosis. Because high ammonia level in epileptic seizure was strongly correlated with pH and BE, we speculate that hyperammonemia is not only because of extensive muscle contractions but is also related to ammonia production in the red blood cells through acidosis like other emergency conditions. [ABSTRACT FROM AUTHOR]

Abstract: Background: Although topical photodynamic therapy (PDT) using 5-aminolevulinic acid (ALA) is applied for skin tumors including actinic keratosis, Bowen disease, and squamous cell carcinoma, there are no approved photosensitizers in dermatological field in Japan. TONS501 and TONS504 are novel hydrophobic photosensitizers with anionic and cationic chemical characteristics, respectively. Objective: Using 7, 12-dimethylbenz[a]anthracene (DMBA) and 12-ο-tetradecanoylphorbol-13-acetate (TPA)-induced mouse skin papilloma model, we compared the efficacy of ALA-, TONS501-, and TONS504-PDT on the skin tumor regression. Methods: Following application of ALA, TONS501, TONS504 ointment or TONS501 lotion on DMBA- and TPA-induced mouse papillomas, 670nm laser irradiation by LD670-05 diode laser was performed. Then tumor regression rate was calculated at the indicated time. Results: The anti-tumor effect of ALA, TONS501, and TONS504 ointment was detected at 24h and the maximal response was observed at 3day following the PDT treatment. The maximal response was observed at 150J/cm2 irradiation in all 3 photosensitizers. Although both ALA, TONS501 (ointment)-PDT showed more potent anti-tumor effect compared with that of TONS504 ointment or TONS501 lotion, no significant difference was detected between ALA ointment and TONS501 ointment. Conclusion: A novel TONS501ointment-PDT shows potent anti-tumor effect on DMBA- and TPA-induced mouse skin papilloma and might be more useful for the clinical applications. [Copyright &y& Elsevier]

A tumor localizing radiation sensitizer, KADT-F10, in which two molecules of nitroimidazole fluorinate, KU2280, are bound to side chain residues of a tumor localizing Mn–porphyrin was synthesized and evaluated. Suppression of tumor growth was significantly higher in a group of mice in which a total 50 mg/kg KADT-F10 was administered before radiotherapy at 50 Gly (A: n=7) than in a group of mice in which radiotherapy alone was done (B: n=7). In group B, all mice died within 73 days after radiotherapy, while in group A, the tumor disappeared in five of seven mice, and three of seven mice completely recovered 120 days after radiotherapy. Clear magnetic resonance images of SCCVII tumor were obtained 1.5 h after KADTF-10 administration. [Copyright &y& Elsevier]

Retrograde menstruation is the backward movement of menstrual fluids. The underlying mechanisms remain unknown. The converse current itself is benign, but the result can be abdominal pain caused by peritoneal irritation and, eventually, endometriosis. The case was of a 25-year-old woman with lower abdominal pain accompanied by significant hemoperitoneum. Physical examination and inspection using abdominal ultrasonography and computed tomography failed to reveal a differential diagnosis. Detailed history taking revealed sexual activities during her menstrual period, which allowed for a diagnosis of retrograde menstruation. These findings emphasize the importance of extensive history taking. [ABSTRACT FROM AUTHOR]

This case report describes a 60-year-old man found unresponsive on the road. He was later admitted to our emergency department (ED) with consciousness disturbance and decorticate rigidity. Computed tomographic imaging revealed coexisting left putamen hemorrhage and Stanford type A acute aortic dissection. Decompressive craniectomy and hematoma evacuation were performed, but he died during his second hospital day. Morbid anatomy proved aortic dissection from the ascending aorta to left common iliac artery with pericardial effusion up to 500 mL. Brain hemorrhage and acute aortic dissection share several risk factors including hypertension and atherosclerosis, but few cases have been reported with brain hemorrhage and aortic dissection occurring simultaneously. Diagnosis for aortic dissection is difficult, especially when the patient has consciousness disturbance because of brain hemorrhage. Consequently, coexistence of these 2 conditions might be missed frequently in emergency settings. Therefore, wider knowledge of this case is important to inform others to suspect and investigate aortic dissection in cases of brain hemorrhage. [ABSTRACT FROM AUTHOR]

Anaerobiospirillum succiniciproducens is rarely associated with bacteremia but results in significant mortality. Almost all reported bacteremia cases have occurred in immunocompromised hosts, such as those with alcoholic liver disease, atherosclerosis, recent surgery, malignancies, or acquired immunodeficiency syndrome. We describe here, to our knowledge, the first clinical evidence for A succiniciproducens bacteremia in a healthy man. A 61-year-old man had fallen from a roof and was admitted to our emergency department with severe left flank pain without an external wound. He was given transcatheter arterial embolization for the left kidney injury on the same day, and his condition stabilized. Four days after admission, he had fever without gastrointestinal signs and symptoms. Spiral-shaped, gram-negative anaerobic bacteria were isolated from 2 sets of blood cultures, and the oxidase and catalase test results were negative. The isolated bacteria were different from the Campylobacter spp. On the next day, the bacteria were confirmed as A succiniciproducens by 16S rRNA sequencing. The patient responded to sulbactam/ampicillin. On day 13, the patient was discharged with a 7-day prescription for oral amoxicillin/clavulanate. Six months after admission, the patient was free of recurrent infection. A succiniciproducens bacteremia can occur in healthy adults. When large gram-negative spiral-shaped bacteria are detected, this bacterial species should be considered and differentiated from the Campylobacter spp because A succiniciproducens is often resistant to macrolide antibiotics. [ABSTRACT FROM AUTHOR]

Background: The relationship between hospital volume and outcome after traumatic brain injury (TBI) is not completely understood in a real clinical setting. We investigated whether patients admitted with TBI achieved better outcomes in high-volume hospitals than in low-volume hospitals using a national inpatient database in Japan.Methods: This retrospective cohort study used the Diagnosis Combination Procedure database in Japan. We included patients with TBI admitted to hospitals with a Japan Coma Scale (JCS) score ≥2 between April 1, 2013 and March 31, 2014. Hospital volume was defined as the annual number of all admissions with TBI in individual hospitals. The hospital volume was categorized into four volume groups: low (≤60 admissions per hospital), medium-low (61-120 admissions per hospital), medium-high (121-180 admissions per hospital) and high (≥181 admissions per hospital). The outcomes of interest included 28-day mortality and survival discharge with complete dependency defined as a Barthel Index score of 0 at discharge. We used multivariate logistic regression models fitted with generalized estimating equations to evaluate relationships between the hospital volume and the outcomes. The hospital volume was evaluated both as categorical variables defined above and as continuous variables.Results: The analysis dataset consisted of 20,146 eligible patients. Of these, 2,784 died within 28days (13.8%) and 3,409 were completely dependent among 16,996 patients discharged alive (20.1%). Multivariate analyses found that there was no significant difference between the high-volume and low-volume groups for 28-day mortality (adjusted odds ratio [OR] 0.79, 95% confidence interval [CI] 0.58-1.06 for the high-volume group) or complete dependency at discharge (adjusted OR 0.94, 95% CI 0.71-1.23 for the high-volume group). The results were the same when the hospital volume was evaluated as a continuous variable.Conclusions: Hospital volume did not appear to influence outcomes in patients with TBI. High-volume hospitals may not be necessarily beneficial for patients with TBI exhibiting impaired consciousness as a whole. [ABSTRACT FROM AUTHOR]

Evaluations of intravascular fluid volume are considered to be one of the most important assessments in emergency and intensive care. Focusing on pulse-induced variation of the internal jugular vein (IJV) area, i.e., cardiac variation, we investigated its correlation with various hemodynamic indices using newly developed software. Software that automatically can track and analyze the IJV during ultrasonography was developed. Eleven healthy patients were subjected to an exercise load to increase their stroke volume (SV) and a dehydration load to decrease their central venous pressure (CVP). The cardiac variation in the area of the IJV, CVP, the SV and the respiratory variation in the inferior vena cava (IVC) were evaluated. The exercise protocol increased the patients' mean SV by 14.5 ± 3.7 mL, and the dehydration protocol caused their mean CVP to fall by 3.75 ± 0.33 cm H2O, which resulted in the collapse index (max IJV area - min IJV area/max IJV area) changing from 0.32 ± 0.04 to 0.44 ± 0.06 and 0.49 ± 0.04, respectively (p < 0.05). The SV exhibited a strong positive correlation with the collapse index (r = 0.59, p = 0.006), and CVP showed a strong positive correlation with the body height-adjusted mean area of the IJV (r = 0.72, p < 0.001). Cardiac variation in the area of the great veins is considered to be induced by venous return to the right atrium under negative pressure. It is possible that intravascular dehydration can be detected and hemodynamic indices, such as CVP and SV, can be estimated by evaluating cardiac variation in the area of the IJV. [ABSTRACT FROM AUTHOR]

For the rational seismic design of railway embankments considering seismic risk, high-strength geomaterials and reinforcements should be used in areas with high seismic probability, and low-strength geomaterials and reinforcements should be used in areas with low seismic probability. In this study, a seismic probabilistic risk estimation of Japanese railway embankments was conducted using publicly available information on seismic hazards in Japan and previously estimated seismic-fragility curves for Japanese railway embankments. To determine the required average friction angle of backfill soil and average reinforcement tensile strength for satisfying the prescribed allowable seismic risk, a sensitivity analysis of the railway embankment was conducted by changing the average friction angle of the backfill soil and the average reinforcement tensile strength. Using the sensitivity-analysis results, the required average friction angle of the backfill soil and average reinforcement tensile strength of the railway embankment satisfying the prescribed allowable seismic risk considering the occurrence probability of earthquakes were analytically obtained. • The seismic probabilistic risk estimation of Japanese railway embankments is conducted. • Seismic hazard and fragility analyses are conducted. • Calculated geomaterial and reinforcement strength parameters are estimated, satisfying the prescribed allowable seismic risk. [ABSTRACT FROM AUTHOR]

Abstract: Objective: The prevalence of epilepsy in patients with Down syndrome (DS) is 5–13%, which is higher than the prevalence in the general population. Transient hyperammonemia is often observed following seizure, but it typically resolves within a day. Here, we describe the case a 37-year-old woman who had DS and a history of adult-onset epilepsy and was admitted to our hospital with recurrent seizures. After admission, her ammonia levels fluctuated without any apparent cause, and dynamic computed tomography revealed a portosystemic shunt. The findings suggest that her seizures possibly precipitated from hyperammonemia secondary to a portosystemic shunt, and we reviewed the relevant literature. Methods: We conducted PubMed, Web of Science, and EMBASE searches without language restrictions for articles published between 1970 and February 2013. Results: In addition to the present case, 7 cases were ultimately included in this review. Four patients were newborns, 2 patients were 1month old, and 1 patient was 3years old. No adult cases were described until now. Conclusion: Adult patients with DS diagnosed with epilepsy are not routinely assessed for portosystemic venous shunts. Measuring ammonia levels in patients with DS the day after admission would help detect portosystemic shunts, even if the patients have been previously diagnosed with epilepsy. Practice Implications: If ammonia levels fluctuate without any apparent cause after seizure, dynamic computed tomography should be performed, especially for patients with DS, whether or not they have been previously diagnosed with epilepsy. [Copyright &y& Elsevier]

Summary: A fluorescence endoscopic system, PDS-2000, enabled observation of color auto-fluorescence from the human body. We performed a clinical study to determine whether color auto-fluorescence bronchoscopy using PDS-2000 improved the accuracy of central type lung cancer diagnosis, as compared to white light bronchoscopy. White light bronchoscopy followed by auto-fluorescence bronchoscopy was performed in 71 subjects with either bronchogenic cancer, previous lung cancer, bloody sputum or who were at a high risk of developing lung cancer. Findings of white light bronchoscopy and auto-fluorescence bronchoscopy were classified into three categories. Two hundred eighty-eight biopsy specimens were taken from all sites which were considered to be abnormal by white light bronchoscopy as well as by auto-fluorescence bronchoscopy. The pathological findings were classified into nine categories. The sensitivity of only white light bronchoscopy (WLB) regarding the detection of severe dysplasia and cancer was compared with that of only auto-fluorescence bronchoscopy (AFB) and that of WLB+AFB. We quantified color endoscopic fluorescence images and compared the red/green signal intensity ratio (R/G ratio) according to the pathological diagnosis. The pathological diagnosis was normal in 123, inflammation, hyperplasia or metaplasia in 120, mild or moderate dysplasia in 8, severe dysplasia in 14 and cancer in 23. The sensitivity of WLB, AFB and WLB+AFB regarding the detection of severe dysplasia or cancer was 54.1%, 81.1% and 89.2%, respectively. The R/G ratio was significantly increased in the areas with severe dysplasia and cancer. [Copyright &y& Elsevier]