Associations of endurance, muscle strength, and balanced exercise with subjective sleep quality in sedentary workers: A cross-sectional study

BACKGROUND

The optimal exercise combination for improving sleep quality among sedentary workers is unclear.

OBJECTIVE

To reveal what combination of exercises contributes to good sleep quality.

METHODS

In this cross-sectional study, we enrolled 5,201 sedentary workers who underwent health examinations in 2019. Data on sleep quality, basic attributes, energy expenditure, and lifestyle aspects such as exercise and physical activity, supper time close to bedtime, and alcohol intake were obtained. The subjects reported their exercise habits by selecting up to three forms of exercise from a list of 182 options, which were classified into three types: endurance (e.g., jogging), muscle strength (e.g., bench pressing), and balanced types which combined both endurance and muscle strength characteristics. (e.g., walking). These forms were then categorized into eight combination patterns: endurance only; muscle strength only; balanced only; endurance and muscle strength; endurance and balanced; muscle strength and balanced; all types; and absence of any exercise habits. Binary logistic regression analysis was used to examine the associations between the exercise combination patterns and sleep quality.

RESULTS

Good sleep quality was significantly associated with "endurance" (OR = 1.419; 95% CI 1.110-1.814), "balanced only" (OR = 1.474; 95% CI 1.248-1.741), and "endurance and balance" (OR = 1.782; 95% CI 1.085-2.926) exercise patterns. No significant associations were found between the combinations that included muscle strength exercises and sleep quality.

CONCLUSION

The endurance or balanced-type exercises, or a combination of both, may help to improve the sleep quality of sedentary workers as part of occupational health management.

Effect of occupation on sleep duration among daytime Japanese workers: A cross-sectional study

Occupation is one of the factors contributing to the loss of sleep. Although many studies have investigated sleep loss due to irregular and nighttime shifts, the causes of sleep loss in daytime workers remain unknown. The aims of the present study were to determine whether occupation is a dependent factor for sleep duration and whether working status and lifestyle are related to sleep duration.We examined the health check results of 17,519 (9028 men and 8491 women) workers who had at least 1 health check between the fiscal years 2013 and 2019. We asked about the workers' occupation, bedtime, dinner time, overtime work, and commuting time, using a self-administered questionnaire at their health check. The occupations were classified into 4 categories: high white-collar, low white-collar, pink-collar, and blue-collar. We conducted a linear regression model and analysis of covariance to investigate the effect of occupation on sleep duration.As a result of linear regression analysis, bedtime, overtime work and occupation were significantly associated with decreased sleep duration in males, and bedtime, age, and occupation were significantly associated with decreased sleep duration in females. Analysis of covariance revealed that both male and female blue-collar tended to sleep for significantly shorter durations than those in the other occupations.The results of the current study indicate that sleep duration is affected by occupation. When determining the cause of loss of sleep, medical personnel should consider their patient's lifestyles and how they have been affected by their occupation.

Removal of toxic substances by a selective membrane plasma separator

We devised a method of plasma exchange with dialysis (PED), in which selective plasma exchange (sPE) is performed using a selective membrane plasma separator (EC-2A) with an albumin-sieving coefficient of 0.3 while the dialysate flows outside the hollow fibers, and reported the usefulness of the system for treating acute liver failure. Thereafter, EC-4A with an albumin-sieving coefficient of 0.6 was developed, which was expected to be even more effective for removing protein-bound substances. In order to examine whether or not EC-4A might be applicable to blood purification therapy against drug poisoning, we compared the efficacies of sPE, PED, and direct hemoperfusion (DHP) using an activated carbon column for the removal of phenobarbital and lithium. Subjects undergoing the extracorporeal circulation study were assigned to the sPE group, PED group, or DHP group, and the changes in the blood concentrations of phenobarbital and lithium were measured over 180 min. A significant decrease of the phenobarbital concentration over time was seen in the PED group, as compared to that in the sPE group (P < 0.0001), while no significant difference in the concentration was observed between the PED and DHP groups. The PED group showed a significant decrease of the lithium concentration over time, as compared to the DHP group (P < 0.0001), while no significant difference in the concentration was observed between the PED and sPE groups. Thus, PED was as effective as DHP for removing phenobarbital and was as effective as sPE for removing lithium. These results suggest that PED therapy using EC-4A may be a feasible modality for the treatment of drug poisoning.

Selective plasma exchange with dialysis in patients with acute liver failure

Selective plasma exchange with dialysis is a blood purification therapy in which simple plasma exchange is performed using a selective membrane plasma separator while the dialysate flows out of the hollow fibers. To evaluate the effect of plasma exchange with dialysis, biochemical examination of the blood, for example, the oxidative stress regulation system and interleukin 18 levels, was performed in patients with acute liver failure. We studied four patients with acute liver failure in whom the therapy was performed (nine times in total). The degree of hepatic encephalopathy and interleukin 18 levels decreased significantly after treatment. However, total protein levels did not change significantly. The level of reactive oxygen species and total antioxidant capacity did not change significantly. Plasma exchange with dialysis may be a useful blood purification therapy in cases of acute liver failure in terms of the removal of water-soluble and albumin-bound toxins.

Extracorporeal membrane oxygenation for 2009 influenza A(H1N1) severe respiratory failure in Japan

Purpose

To evaluate procedures and outcomes of extracorporeal membrane oxygenation (ECMO) therapy applied to 2009 influenza A(H1N1) severe respiratory failure patients in Japan.

Methods

This observational study used database information about adults who received ECMO therapy for H1N1-related severe respiratory failure from April 1, 2010 to March 31, 2011.

Results

Fourteen patients from 12 facilities were enrolled. Anti-influenza drugs were used in all cases. Before the start of ECMO, the lowest PaO₂/FiO₂ was median (interquartile) of 50 (40–55) mmHg, the highest peak inspiratory pressure was 30 (29–35) cmH₂O, and mechanical ventilation had been applied for at least 7 days in 5 patients. None of the facilities had extensive experience with ECMO for respiratory failure (6 facilities, no previous experience; 5 facilities, one or two cases annually). The blood drainage cannula was smaller than 20 Fr. in 10 patients (71.4 %). The duration of ECMO was 8.5 (4.0–10.8) days. The duration of each circuit was only 4.0 (3.2–5.3) days, and the ECMO circuit had to be renewed 19 times (10 cases). Thirteen patients (92.9 %) developed adverse events associated with ECMO, such as oxygenator failure, massive bleeding, and disseminated intravascular coagulation. The survival rate was 35.7 % (5 patients).

Conclusion

ECMO therapy for H1N1-related severe respiratory failure in Japan has very poor outcomes, and most patients developed adverse events. However, this result does not refute the effectiveness of ECMO. One possible cause of these poor outcomes is the lack of satisfactory equipment, therapeutic guidelines, and systems for patient transfer to central facilities.

Association of body temperature and antipyretic treatments with mortality of critically ill patients with and without sepsis: multi-centered prospective observational study

Introduction

Fever is frequently observed in critically ill patients. An independent association of fever with increased mortality has been observed in non-neurological critically ill patients with mixed febrile etiology. The association of fever and antipyretics with mortality, however, may be different between infective and non-infective illness.

Methods

We designed a prospective observational study to investigate the independent association of fever and the use of antipyretic treatments with mortality in critically ill patients with and without sepsis. We included 1,425 consecutive adult critically ill patients (without neurological injury) requiring > 48 hours intensive care admitted in 25 ICUs. We recorded four-hourly body temperature and all antipyretic treatments until ICU discharge or 28 days after ICU admission, whichever occurred first. For septic and non-septic patients, we separately assessed the association of maximum body temperature during ICU stay (MAX_ICU) and the use of antipyretic treatments with 28-day mortality.

Results

We recorded body temperature 63,441 times. Antipyretic treatment was given 4,863 times to 737 patients (51.7%). We found that treatment with non-steroidal anti-inflammatory drugs (NSAIDs) or acetaminophen independently increased 28-day mortality for septic patients (adjusted odds ratio: NSAIDs: 2.61, P = 0.028, acetaminophen: 2.05, P = 0.01), but not for non-septic patients (adjusted odds ratio: NSAIDs: 0.22, P = 0.15, acetaminophen: 0.58, P = 0.63). Application of physical cooling did not associate with mortality in either group. Relative to the reference range (MAX_ICU 36.5°C to 37.4°C), MAX_ICU ≥ 39.5°C increased risk of 28-day mortality in septic patients (adjusted odds ratio 8.14, P = 0.01), but not in non-septic patients (adjusted odds ratio 0.47, P = 0.11).

Conclusions

In non-septic patients, high fever (≥ 39.5°C) independently associated with mortality, without association of administration of NSAIDs or acetaminophen with mortality. In contrast, in septic patients, administration of NSAIDs or acetaminophen independently associated with 28-day mortality, without association of fever with mortality. These findings suggest that fever and antipyretics may have different biological or clinical or both implications for patients with and without sepsis.

Trial registration

ClinicalTrials.gov: NCT00940654

Catheter-related infections via temporary vascular access catheters: a randomized prospective study

Temporary vascular access catheters (VACs) are important devices used in acute blood purification therapies. The aim of this study was to determine whether a catheterization duration of 2 weeks increased the risk of nosocomial complications when compared with a 1-week duration. Fifty-six patients with 90 double lumen VACs were randomly chosen, and received either 1- or 2-week catheterizations from operators experienced in the placement of such catheters at three sites such as the internal jugular, subclavian, or femoral vein. The characteristics of the VACs, including the sites, procedures, and lengths, were similar in both groups. No significant difference in the rate of catheter colonization was observed between the groups (14.6% vs 26.2%, P = 0.1371). No significant difference in the rate of catheter-related bloodstream infections was observed between the groups (2.1% vs 4.8%, P = 0.5967). Two-week indwelling did not increase the risk of infection compared with 1-week indwelling at any of the sites in critically ill patients.

Serum aconitine concentrations after taking powdered processed Aconiti tuber

Processed Bushi powder for ethical dispensing, called TJ-3022, is a herbal drug of processed Aconiti tuber (Aconitum carmichaeli Debeaux) and TJ-3023 is newly developed to contain a higher proportion of diester alkaloid of aconitine (Aconitum carmichaeli Debeaux and Aconitum japonicum Thunberg). Safety of TJ-3022 and TJ-3023 was evaluated by measuring the level of aconitum alkaloids in healthy adult volunteers. Forty subjects were assigned to one of two groups (each 20 subjects): TJ-3022 group or TJ-3023 group. The subjects received the powdered processed Aconiti tuber 3 g/day and the blood concentrations of aconitum alkaloids were measured at 90 min and 72 h after taking the study drug. The serum concentrations of aconitum alkaloids after 90 min and 72 h in the TJ-3023 group were higher than those in the TJ-3022 group. As for the chronological changes in the serum concentration, a significant decrease was observed in the TJ-3022 group, while no significant decrease was seen in the TJ-3023 group, which suggests that an analgesic effect in TJ-3023 was stronger than in TJ-3022. Aconitum alkaloids, which always have been believed to have the blood concentration below the measurement limit in human, were detected for the first time, although the detected amounts were minute. The results suggest that TJ-3023 shows sufficient analgesic effect with smaller dose than TJ-3022.

A Case Report of Hepatorenal Syndrome Treated With Plasma Diafiltration (Selective Plasma Filtration with Dialysis)

Plasma diafiltration (PDF) (selective plasma filtration with dialysis) is blood purification therapy in which simple plasma exchange is performed using a membrane plasma separator (Evacure EC-2A) while dialysate flows outside of the hollow-fibers. A 74-year old man with hepatorenal syndrome underwent four sessions of PDF and three sessions of HDF. Finally he recovered from hepatorenal syndrome. In this therapy, the levels of total bilirubin, interleukin-18, creatinine, and cystatin C were significantly reduced. On the other hand, there were no significant differences in the total protein and albumin levels before and after PDF. PDF may be one of the most useful blood purification therapies for hepatorenal syndrome in terms of medical economics.

Study of safe usage of high-flow three-way stopcocks in a blood circuit

To examine the safety of using a high-flow three-way stopcock in a blood circuit during extracorporeal blood purification therapy, we studied the risk of development of hemolysis and clot formation in both ex vivo and in vivo extracorporeal circulation. In the ex vivo study, no significant difference was observed in the decrease in hematocrit (HCT) or increase in the potassium level between the three-way stopcock group and the control group. Nor was there a significant difference in the change in inlet pressure between the two groups. Thus, it was shown that the risk of hemolysis caused by the use of a high-flow three-way stopcock on both the outlet side and inlet side would be small. In the in vivo cases, there was no significant difference in the decrease in HCT or the increase in inlet pressure between the three-way stopcock group and control group, suggesting that it is clinically possible to incorporate a high-flow three-way stopcock into a blood circuit.

Extravascular Lung Water Measured Using Single Transpulmonary Thermodilution Reflects Perioperative Pulmonary Edema Induced by Esophagectomy

Pulmonary edema is the most frequent postoperative complication following esophagectomy for thoracic esophageal cancer. We enrolled 23 patients who underwent esophagectomy with extended lymph node dissection for thoracic esophageal cancer in a prospective observational clinical trial. We used the PiCCO device to measure extravascular lung water with the aim of determining whether it correlates with the respiratory index and whether it is predictive of pulmonary complications. Based on constant criteria, the tracheal tubes of 11 patients were removed on the morning of postoperative day 1 (extubation group), while 12 patients remained intubated (intubation group). These two groups significantly differed in that all patients in the extubation group recovered without any pulmonary complications, whereas 4 patients (33%) in the intubation group developed pulmonary complications. The extravascular lung water measured using PiCCO correlated significantly with the respiratory index. In the intubation group, both extravascular lung water and respiratory index were elevated 12 h after surgery and were even higher 24 h after surgery. The extravascular lung water measured using PiCCO reflects the level of postoperative pulmonary edema and predicts the pulmonary complications induced by esophagectomy with extended lymph node dissection.

Combining continuous endotoxin apheresis and continuous hemodiafiltration in the treatment of patients with septic multiple organ dysfunction syndrome

When septic multiple organ dysfunction syndrome (MODS) occurs as a result of endotoxemia, diverse chemical mediators are excessively produced, and the patient becomes seriously ill. Under such circumstances, it is difficult to improve the patient's condition by endotoxin apheresis alone and hemodiafiltration should be carried out to remove excessive chemical mediators. Series-parallel treatment combining continuous endotoxin apheresis and hemodiafiltration is recommended for patients with septic MODS.

The Dose of Nafamostat Mesilate During Plasma Exchange With Continuous Hemodiafiltration in the Series-Parallel Circuit

We studied nafamostat mesilate (NM) and interleukin (IL)-18 levels to determine whether the dose of NM is reduced during plasma exchange (PE) with continuous hemodiafiltration (CHDF) when the series-parallel circuit is used. The subjects of the current study included four patients with acute hepatic failure who underwent PE with CHDF. The four patients underwent a total 15 PE + CHDF procedures, and for each procedure, they were randomized to receive either a half-dose of NM or no NM in the CHDF circuit. Eight procedures were carried out with NM administration, and seven were carried out without NM administration. The dose of NM in the NM group was significantly higher than that in the non-NM group (P = 0.040). No significant differences were observed between the two groups in the inlet NM concentration, the outlet NM concentration, or the rate of IL-18 removal. No statistical correlation was observed between the IL-18 level and the NM dose, the inlet NM concentration, or the outlet NM concentration. There was no blood access difficulty such as catheter failure or clotting of the filter. Thus, it might be possible to carry out PE and CHDF with the series-parallel method without administration of NM in the CHDF circuit.

Effectiveness of combining plasma exchange and continuous hemodiafiltration in patients with postoperative liver failure

Nine patients with postoperative liver failure were treated with plasma exchange (PE) or PE and continuous hemodiafiltration (CHDF), and various biochemical parameters were determined before and after treatment. Although citrate levels increased significantly after treatment compared with pretreatment levels in both the PE group and the PE + CHDF group (P < 0.0001 and P < 0.0001, respectively), the percentage of the increase in citrate levels was significantly higher in the PE group than in the PE + CHDF group (P = 0.0051). Total bilirubin (T-Bil) levels were significantly lower after treatment in both the PE and PE + CHDF groups (P < 0.0001 and P = 0.0001, respectively). There were no significant differences in T-Bil levels between the two groups (P = 0.5181). There were no significant differences in interleukin (IL)-6 levels before and after treatment in both the PE and PE + CHDF groups (P = 0.1281 and P = 0.2273, respectively). IL-18 levels were significantly lower after treatment in both the PE and PE + CHDF groups (P < 0.0001 and P = 0.0002, respectively), but there were no significant differences in the removal rate of IL-18 in both the PE and PE + CHDF groups (P = 0.8749). These results indicate that combining PE and CHDF in a series-parallel circuit is an effective modality for suppressing the elevation of blood citrate levels. This finding may have important implications for the development of an effective treatment for patients with postoperative liver failure.

Correlation Between Serum Nafamostat Mesilate and Activated Coagulation Time During Continuous Hemodiafiltration

We analyzed the relationship between nafamostat mesilate (NM) level and activated coagulation time (ACT) as measured using an Actalyke MINI system vs. an ACTester system in patients with fulminant hepatitis undergoing continuous hemodiafiltration. The hemofilter was made with a polyacrylonitrile membrane, and NM was used as the anticoagulant. Significant correlation was found between the NM dose and the prehemofilter ACT measured by the Actalyke MINI system (r = 0.561, P = 0.0352, n = 14). However, no significant correlation was found between the NM dose and the prehemofilter ACT measured by the ACTester. Neither was a significant correlation found between the prehemofilter NM level and the prehemofilter ACT measured by either system. No significant correlation was found between the NM dose and the posthemofilter ACT measured by either system. The ACTester uses a test tube containing celite and a small amount of kaolin as a coagulation activator. The results of the present study suggest that the ACTester can adsorb NM and that this feature can affect ACT measurement. Considering this influence and the need to minimize the dose of NM in patients with fulminant hepatitis to avoid hemorrhagic tendencies, it is advisable to use the Actalyke MINI system.

The series-parallel circuit in the treatment of fulminant hepatitis

We developed a series-parallel treatment method for combined plasma exchange (PE) and continuous hemodiafiltration (CHDF) therapy in fulminant hepatitis. We then compared total serum bilirubin, citrate, and cytokine levels obtained by the new methods to those obtained with treatment by the single and reverse-parallel PE methods. Ten adult patients with fulminant hepatitis consented to participate. Plasma exchange was conducted 25 times by the single method (PE only), 16 times by the reverse-parallel method, and 37 times by the series-parallel method. The percentage of total bilirubin removed was highest with the single method followed in order by that with the series-parallel and reverse-parallel methods; the differences were significant. The percentage increase in citrate level was highest with the single method, followed in order by that with the series-parallel and the reverse-parallel methods; these differences were also significant. There was no significant difference in serum interleukin (IL)-6 levels after PE, by the single or the reverse-parallel methods. However, the IL-6 level decreased significantly following PE by the series-parallel method. The serum IL-18 level decreased significantly following PE by each of the three methods. Thus, removal of excess bilirubin, citrate, and cytokines by the series-parallel method, a simple maneuver with excellent removal rates, was considered effective.

Characteristics of self-immolation attempts in Akita Prefecture, Japan

Akita Prefecture has had the highest suicide rate in Japan for the past 9 years. To obtain further information on suicide attempts by self-immolation in Akita, we performed a statistical analysis of patients in this prefecture who attempted to burn themselves. Over the past 6 years, 541 patients suffering from burns were transferred to medical emergency units. Of these, 35 (6.5%) attempted self-immolation, most of whom were between 20 and 60 years of age. Women over 50 years of age outnumbered men in the same age group. All 35 patients sustained flame burns. The total burn surface area (TBSA), burn index (BI), rate of inhalation injury, and mortality rate were all significantly higher in the patients who attempted self-immolation than in those with nonsuicidal burns. Most (68.6%) of the self-immolation attempts were made indoors. Because the Japanese are not generally a very religious people, training to help them cultivate a philosophy of life and educating them in moral science to help them form a personal view of life and death may be necessary to prevent suicides.

Pharmacokinetics of nafamostat mesilate during continuous hemodiafiltration with a polyacrylonitrile membrane

We studied the pharmacokinetics of nafamostat mesilate (NM) used as an anticoagulant in continuous hemodiafiltration (CHDF) with a polyacrylonitrile (PAN) membrane used as the hemofilter. Six patients undergoing CHDF for multiple organ dysfunction syndrome (MODS) were chosen as subjects. The inlet NM concentration measured 24 h after the start of CHDF was significantly greater than that after 1 h (P = 0.0431). No significant difference was observed between the outlet NM concentration and the ultrafilter concentration at 1 h or 24 h after the start of CHDF. However, concentrations at 24 h differed significantly from concentrations at 1 h at all sites. Significant correlation was observed between the dose of NM and the outlet NM concentration (P = 0.0475). No statistical correlation was observed between the dose of catecholamines and the outlet NM concentration (P = 0.0985). This study is the first to disclose a mild but significant time-dependent serum NM concentration in patients with MODS.

IL-15 levels in patients with acute hepatic failure

Interleukin (IL)-15, an inhibitor of tumor necrosis factor (TNF)-alpha, causes liver injury in mice. We determined levels of IL-15, IL-6, and IL-18 by enzyme-linked immunosorbent assays in 20 patients with acute hepatic failure and examined relationship between these proinflammatory cytokines and IL-15. A significant correlation was observed between the levels of IL-18 and IL-15 (p = 0.0118). IL-15 levels in the nonsurvivors were significantly higher than those in the survivors (p = 0.0357). Our results suggest that IL-15 overexpression may cause liver injury in human.

Cl- channel blockers inhibit transition of quiescent (G0) fibroblasts into the cell cycle

Modulation of ion permeability during the cell cycle is one of the key events in cell cycle progression. We have compared the effects of K+ and Cl- channel blockers on the cell cycle in synchronous and asynchronous NIH3T3 cells. The Cl- channel blocker 5-N-2-(3-phenylpropylamino) benzoic acid (NPPB; 0.2 mM) inhibited entry into S phase in synchronous cells but not in asynchronous cells, while the K+ channel blocker 4-aminopyridine (4-AP) showed similar inhibitory effects in both conditions. In NIH3T3 cells synchronized by serum deprivation/replenishment, G0-to-G1 transition occurred within 8 h after serum addition, and the G1/S checkpoint at 10-14 h. NPPB applied only at 0-8 or 8-14 h after serum addition inhibited entry into S phase. Cl- permeability measured as 125I efflux increased at 4 and 10 h after serum addition. Ki-67-negative cells, which represent quiescent G0 phase cells, progressively decreased in number until 8 h after serum addition. The Cl- channel blockers (NPPB and 4,4'-diisothiocyanatostilbene-2,2'-disulfonic acid [DIDS]) but not the K+ channel blocker (4-AP) significantly decreased the rate of reduction in number of Ki-67-negative cells. These data indicate that an increase in Cl- permeability plays an important role in reentry of quiescent cells into the proliferating phase, in addition to the known effects on passage through the G1/S checkpoint.

Involvement of IL-18 and soluble fas in patients with postoperative hepatic failure

We measured the levels of tumor necrosis factor alpha (TNF-alpha), interleukins (IL)-6 and -18, and soluble Fas (sFas) in 11 patients with postoperative hepatic failure and assessed whether IL-18-mediated apoptosis is involved in the onset of liver dysfunction. The serum TNF-alpha, IL-18, and sFas levels were significantly higher in patients with sepsis as a complication than in those without sepsis. The TNF-alpha and IL-18 levels were significantly higher in nonsurvivors than in survivors. Significant correlations were observed between TNF-alpha and IL-6, between TNF-alpha and IL-18, and between TNF-alpha and sFas levels. These results showed that Fas-mediated hepatocyte apoptosis functions as an important mechanism responsible for the onset of postoperative hepatic failure in humans. They especially suggested that IL-18 and TNF-alpha function both as apoptosis-promoting factors and as apoptosis-inhibiting factors, depending on the conditions to which hepatocytes are subjected.

Cytokine removal by plasma exchange with continuous hemodiafiltration in critically ill patients

The effectiveness of plasma exchange (PE) with continuous hemodiafiltration (CHDF) in the treatment of critically ill patients was evaluated based on changes in cytokine levels. Twenty-six patients with acute hepatic failure were treated with PE (PE group) or PE and CHDF (PE+CHDF group), and the levels of cytokines such as tumor necrosis factor (TNF)-alpha, interleukin (IL)-6, and IL-8 were determined before and after treatment. Bilirubin levels were significantly lower after treatment in both the PE and PE+CHDF groups. There were no significant differences in TNF-alpha levels before and after treatment in the PE group, but the TNF-alpha level was significantly lower after treatment in the PE+CHDF group. There were no significant differences in the IL-6 levels before and after treatment in both the PE and PE+CHDF groups. There were no significant differences in IL-8 levels before and after treatment in the PE group, but the IL-8 level was significantly lower after treatment in the PE+CHDF group. PE with CHDF therapy was given to 5 patients with acutely aggravated autoimmune diseases, 2 patients with hemorrhagic shock and encephalopathy syndrome, and 3 patients with thrombotic microangiopathy. The results suggested that PE with CHDF therapy are useful in critically ill patients with suspected hypercytokinemia.

M phase-specific expression and phosphorylation-dependent ubiquitination of the ClC-2 channel

Cl(-) channel activities vary during the cell cycle and are thought to play various roles including regulation of cell volume. We have shown previously that ClC-2 channels are directly phosphorylated and functionally regulated by the M phase-specific cyclin-dependent kinase p34(cdc2)/cyclin B. We investigate here to determine whether the expression levels of ClC-2 channel protein vary during the cell cycle. Immunoblot and immunocytochemical analyses of cells cycle-synchronized by serum depletion/replenishment reveal that ClC-2 channel protein is expressed predominantly at M phase in cells with two nuclei and a clear constriction ring, whereas RNA blot analysis shows that ClC-2 mRNA expression does not change during the cell cycle. Ubiquitin assays reveal that the ClC-2 channels are ubiquitinated at M phase, whereas the magnitude of ubiquitination is suppressed by incubation with olomoucine, an inhibitor of p34(cdc2)/cyclin B, and it is almost completely abolished in ClC-2 channels having an S632A mutation, which cannot be phosphorylated by p34(cdc2)/cyclin B, indicating that ubiquitination of ClC-2 channels requires phosphorylation by M phase-specific p34(cdc2)/cyclin B. Regulation at the post-transcriptional level, including phosphorylation-dependent ubiquitination, may contribute to M phase-specific expression of ClC-2 channels. Cell cycle-dependent regulation of expression at the protein level in addition to the regulation of function suggests that the ClC-2 channel plays a physiological role in the cell cycle.

A cross-cultural comparison of critical care delivery: Japan and the United States

OBJECTIVE

To compare the utilization and outcomes of critical care services in a cohort of hospitals in the United States and Japan.

DESIGN

Prospective data collection on 5,107 patients and detailed organizational characteristics from each of the participating Japanese study hospitals between 1993 and 1995, with comparisons made to prospectively collected data on the 17,440 patients included in the US APACHE (acute physiology and chronic health evaluation) III database.

SETTING

Twenty-two Japanese and 40 US hospitals.

PATIENTS

Consecutive, unselected patients from medical, surgical, and mixed medical/surgical ICUs.

MEASUREMENTS

Severity of illness, predicted risk of in-hospital death, and ICU and hospital length of stay (LOS) were assessed using APACHE III. Japanese ICU directors completed a detailed survey describing their units.

MAIN RESULTS

US and Japanese ICUs have a similar array of modalities available for care. Only 1.0% (range, 0.56 to 2.7%) of beds in Japanese hospitals were designated as ICUs. The organization of the Japanese and US ICUs varied by hospital, but Japanese ICUs were more likely to be organized to care for heterogeneous diagnostic populations. Sample case-mix differences reflect different disease prevalence. ICU utilization for women is significantly lower (35.5% vs 44.8% of patients) and there were relatively fewer patients > or = 85 years old in the Japanese ICU cohort (1.2% vs 4.6%), despite a higher per capita rate of individuals > or = 85 years old in Japan. The utilization of ICUs for patients at low risk of death significantly less in Japan (10.2%) than in the United States (12.9%). The APACHE III score stratified patient risk. Overall mortality was similar in both national samples after accounting for differences in hospital LOS, utilizing a model that was highly discriminating (receiver operating characteristic, 0.87) when applied to the Japanese sample. The application of a US-based mortality model to a Japanese sample overestimated mortality across all but the highest (> 90%) deciles of risk. Significant variation in expected performance was noted between hospitals. Risk-adjusted ICU LOS was not significantly longer in Japan; however, total hospital stay was nearly twice that found in the US hospitals, reflecting differences in hospital utilization philosophies.

CONCLUSIONS

Similar high-technology critical care is available in both countries. Variations in ICU utilization reflect differences in case-mix and bed availability. Japanese ICU utilization by gender reflects differences in disease prevalence, whereas differences in utilization by age may reflect differences in cultural norms regarding the limits of care. Such differences provide context from which to assess the delivery of care across international borders. Miscalibration of predictive models applied to international data samples highlight the impact that differences in resource use and local practice cultures have on outcomes. Models may require modification in order to account for these differences. Nevertheless, with large databases, it is possible to assess critical care delivery systems between countries accounting for differences in case-mix, severity of illness, and cultural normative standards facilitating the design and management such systems.

Pneumatic stabilization for flail chest injury: an 11-year study

The use of prolonged mechanical ventilation in the treatment of flail chest injury may increase the incidence of pulmonary morbidity. The aim of this study was to examine the results of performing internal pneumatic stabilization in our hospital. A retrospective review of the medical records of 59 patients with flail chest injury who presented within an 11-year period was conducted. During the second half of the period examined, we routinely adopted three characteristic procedures in the treatment of flail chest injury, namely, pressure support on spontaneous breathing, continuous positive airway pressure via a mask, and respiratory physical therapy by physical therapists. We compared the background, prognosis, and methods of treatment for flail chest injury before and after the introduction of these three procedures. A marked decline in the duration of endotracheal intubation and controlled mechanical ventilation, and in the frequency of pulmonary morbidity, was evident following the introduction of the above procedures.

Effects of milrinone on platelet aggregation in swine with pulmonary hypertension

PURPOSE

The purpose of this study was to investigate whether the effect of milrinone on platelet aggregation was related to the selectivity of vasodilation vasculature in a swine model with PH.

MATERIALS AND METHODS

To induce pulmonary hypertension, we injected two sets of acid-washed glass beads in 15 swine, which were divided into two groups (those receiving milrinone or not) and compared with each other.

RESULTS

The induction of pulmonary hypertension decreased the platelet count and increased the plasma levels of thromboxane B2 and 6-keto-prostaglandin F1alpha.

CONCLUSION

A locally high concentration of prostaglandin I2, at least in part, may produce selectivity of vasodilation in the pulmonary vasculature.

Milrinone improves arterial oxygenation in dogs with acute lung injury induced by oleic acid

The aim of the study was to investigate effects of milrinone on pulmonary permeability in dogs with acute lung injury induced by oleic acid. To induce acute lung injury, we administered 0.08 mg/kg of oleic acid to 19 adult mongrel dogs and then measured hemodynamic parameters and performed blood gas analysis. An injection of oleic acid depressed the mean arterial pressure, cardiac index, and arterial oxygenation. Dogs were divided into three groups: six received a bolus of milrinone (50 microg/kg) followed by a continuous (0.5 microg/kg/min, low-dose), seven received a bolus (100 microg/kg) followed by a continuous (1.0 microg/kg/min; i.e., a low-dose twice; high-dose), and six no milrinone (control). Milrinone administration improved the cardiac index and arterial oxygenation and simultaneously depressed the intrapulmonary shunt fraction and the extravascular thermal lung water as extravascular water content of the lung. These changes produced by milrinone are different according to the doses. In conclusion, milrinone acts on the capillary endothelium and inhibits an accumulation in the extravascular water content of the lung, which may induce an improvement in arterial oxygenation. Milrinone may also improve arterial oxygenation through an inhibition of platelet aggregation and chemical mediators that are released from platelets. The latter mechanism also may improve arterial oxygenation, and the exact property responsible for causing the effect of milrinone has not yet been identified.

Cost containment: the Pacific. Japan

The Japanese healthcare system is structured to provide universal healthcare access to the entire Japanese population via a constitutional guarantee. Increasing costs within the Japanese healthcare system are largely attributable to the country's rapidly aging population. Intensive care services are provided primarily in large tertiary care hospitals by a relatively small cadre of dedicated critical care physicians. Triage pressure is high in many Japanese hospitals due to a relatively small proportion of ICU beds. As a result, few patients are admitted to the ICU at low risk of adverse outcome or monitoring. Costs associated with providing critical care are poorly understood because of current hospital cost accounting systems. Critical care costs have only recently become an area of concern. Nevertheless, critical care physicians are taking steps to more fully understand severity of illness, clinical outcome, and utilization of resources in order to effectively guide healthcare policy and resource allocation decisions impacting Japanese critical care.

Changes in the parameters of oxygen metabolism in a clinical course recovering from potassium cyanide

Poisoning with potassium cyanide is usually fatal because of the inhibition of cytochrome oxidase. The parameters of oxygen metabolism in a patient with cyanide poisoning who was admitted in a coma with seizures was monitored. The administration of amyl nitrite and sodium thiosulfate led to a rapid improvement: the parameters reflecting oxygen metabolism improved and the plasma level of cyanide decreased. The patient revived 1 1/2 hours after treatment. The arterial ketone body ratio (AKBR), which is the ratio of acetoacetate to beta-hydroxybutyrate in arterial blood and which reflects the redox state in liver mitochondria, improved dramatically following treatment. Because the AKBR changes in relation to electron transport in liver mitochondria, it seems to be a logical parameter for evaluating the effect of potassium cyanide poisoning on electron transport. The AKBR also reflects the efficacy of treatment for cyanide poisoning.

Effects of milrinone on lung water content in dogs with acute pulmonary hypertension

To evaluate the effects of milrinone (MIL) on hemodynamics and lung water content, we used 10 mongrel dogs with pulmonary hypertension (PH). To induce pulmonary hypertension, we administered two injections of glass beads stirred in saline to dogs. Mean pulmonary arterial pressure (PAP) and pulmonary vascular resistance significantly increased following induction. Milrinone, which inhibits cyclic AMP phosphodiesterase-(PDE) demonstrated pulmonary vasodilation, indicated a reduction in these two parameters. To clarify the drug mechanism, we measured lung water content as extravascular lung thermal volume (ETVL) using a thermo/sodium double-indicator dilution method. The induction of pulmonary hypertension produced a transient reduction in extravascular lung thermal volume. The parameter remained constant following milrinone administration, whereas the control showed a gradual increase. Of the 10 dogs, five were killed to measure gravimetrically the volume of lung water content as a comparison with extravascular lung thermal volume. We concluded that milrinone produced pulmonary vasodilation which induced a reduction in the transmural capillary pressure gradient according to Starling's hypothesis. This study suggests that the reduction in the transmural pressure gradient induced by milrinone may also prevent the re-elevation in extravascular lung thermal volume. Milrinone increases the cyclic AMP level in the endothelium and in the platelet which may affect either directly or indirectly the permeability of capillary endothelium.

[Clinical course of asthmatics with severe asthma attack]

This study was conducted on 39 patients whose severe attacks of bronchial asthma with disturbance of consciousness required admission to the ICU of our hospital between 1984 and 1989. Among the 39 patients, there were 16 deaths. Most patients collapsed suddenly at home and were taken to our hospital. Arterial blood gas analysis at the time of admission to the ICU revealed that the PaO2 levels were as high as 252.6 +/- 57.6 (mean +/- S.E.) Torr in non-survivors and 221.0 +/- 29.7 Torr in survivors, with no significant difference because of prior oxygen therapy in almost all cases. Systolic blood pressure was 14.8 +/- 10.8 (mean +/- S.E.) mmHg, with marked circulatory disturbance in the fatal cases. Most patients displayed marked disturbance of consciousness, but maintenance of blood pressure led to recovery without sequelae despite marked disturbance of consciousness in most patients.

An initial comparison of intensive care in Japan and the United States

OBJECTIVE

The objective of this study was to compare the utilization of, and outcome from, critical care services in selected medical centers providing secondary and tertiary care in the United States and Japan.

DESIGN

Prospective data collection on 1,292 patients from each of the participating Japanese study hospitals in 1987 to 1989 and compared with the 5,030 patients in the United States 1982 Acute Physiology and Chronic Health Evaluation (APACHE II) database used to develop the APACHE II equation. Detailed organizational characteristics of the participating ICUs and hospitals were also obtained.

SETTING

Data collection took place in the ICUs of 13 U.S. hospitals and six Japanese hospitals.

PATIENTS

Data were collected on consecutive, unselected patients from medical, surgical, and mixed medical/surgical critical care units, with a spectrum of medical and surgical diagnoses.

MEASUREMENTS AND MAIN RESULTS

U.S. and Japanese ICUs have a similar array of diagnostic and therapeutic modalities. Only 2% (range 0.6 to 3.5) of beds in Japanese hospitals were designated to intensive care. The organization of the Japanese and U.S. ICUs varied by hospital. There were significantly fewer women admitted to Japanese ICUs and a substantially lower proportion of low-risk-of-death patients. Despite a rapidly aging population, there were relatively fewer elderly patients with chronic health ailments in the Japanese ICU population (8%) compared with the U.S. cohort (18%).

CONCLUSIONS

In this sample of hospitals, similar high-technology critical care is available in the United States and Japan. Variations in utilization between the two countries represent differences in case mix and bed availability. The APACHE II equation stratified patients in the Japanese patient cohort across the full spectrum of increasing severity of illness.

Comparative effects of dopamine and dobutamine on the pulmonary haemodynamic response to hypoxia in dogs ventilated with a hypoxic gas mixture

1. The effects of dopamine and dobutamine on the pulmonary haemodynamic response to hypoxia were studied in nine anaesthetized dogs under hypoxaemia induced by ventilation with hypoxic gas mixture. 2. From the present study, only dopamine infusion reduced arterial oxygenation during hypoxic hypoxaemia, whereas catecholamine maintained it at the same level during normoxaemia. 3. A redistribution of perfusion to the pulmonary vasculature may be related to a reduction of arterial oxygenation with dopamine infusion during hypoxic hypoxaemia. 4. It is presumed that an increase in pulmonary blood flow would emphasize an inhibition of hypoxic pressor response in the pulmonary vasculature, which may not be a direct effect of dopamine.

[Improving effect of the synthetic protease inhibitor E-3123 on experimental DIC in dogs]

Disseminated intravascular coagulation (DIC) is a severe syndrome associated with generalized, intractable bleeding and multiple organ failure. Synthesized protease inhibitors such as gabexate mesilate and nafamostat mesilate show an improving effect on DIC, which develops by a chain reaction involving the coagulation, fibrinolysis, complement and kallikrein systems. Experimental DIC was developed in Beagle dogs by infusion of 150 U/kg tissue thromboplastin (Group I), and the improving effect of a new synthetic protease inhibitor, E-3123, was examined. The following groups of animals were treated with drugs: Group II (n = 4) was given with 5 mg/kg/hr of E-3123; group III (n = 4) was given 10 mg/kg/hr of E-3123; and group IV was given 6 mg/kg/hr of gabexate mesilate (GM). Although improvement of the hemodynamics or peripheral circulation was not apparent, a slight, but insignificant, improvement of lactate/pyruvate was noted in the treated groups. On the other hand, the hemostatic abnormalities such as prolongation of prothrombin time and activated thromboplastin time; decreases of platelet count, fibrinogen and alpha 2-antiplasmin; and increases of fibrin degradation products were significantly improved in the treated groups. These results indicate that E-3123 is effective for improving experimental DIC, and it is suggested that E-3123 is applicable for the treatment of clinical DIC.

Changes in hemodynamics and myocardial metabolism following discontinuation of a dopamine or dobutamine infusion

Hemodynamics and myocardial metabolism were studied in 20 anesthetized dogs following discontinuation of a dopamine (DA) or dobutamine (DB) infusion. Both groups showed significant decreases in HR, AP, dP/dt, CI, MBFI, and MVO2. Discontinuation of DA decreased lactate extraction, whereas this did not occur with DB. The arteriocoronary venous differences in reduction-oxidation electrical potential (delta Eh) decreased significantly immediately following an abrupt discontinuation of the DA infusion, whereas DB maintained delta Eh at a constant level during and following infusion. Thus, aerobic metabolism was maintained following the discontinuation of DB, and anaerobic metabolism in the myocardium was accelerated immediately following discontinuation of the DA infusion. Although the mechanism that produces the differences observed between DA and DB following discontinuation is not understood, it may result from stimulation of alpha 1-receptors in the myocardium, produced by the residual high level of myocardial tissue norepinephrine (NE) following the termination of DA. A high tissue level of NE combined with a low plasma level of DA may cause an oxygen imbalance of the myocardium, demonstrated by an increase in myocardial oxygen demand and by a reduction in coronary blood flow. It is speculated that this mechanism of oxygen imbalance is a possible explanation for the anaerobic metabolism observed following DA discontinuation.

Vasodilatory effects of milrinone on pulmonary vasculature in dogs with pulmonary hypertension due to pulmonary embolism: a comparison with those of dopamine and dobutamine

1. The limited therapeutic role of pulmonary vasodilation reflects lack of their selectivity for the pulmonary vasculature, and many drugs have been evaluated for effectiveness; however, none has gained widespread clinical use. 2. Milrinone (MIL) is a newly synthetized phosphodiesterase inhibitor, which has potent positive inotropic and vasodilatory effects. 3. The present study shows the effects of MIL on the pulmonary circulation in dogs with pulmonary hypertension due to autologous muscle-induced pulmonary embolism, and also demonstrates a comparison with those of dopamine and dobutamine. 4. As MIL showed potent vasodilatory effects on the pulmonary vasculature, it had a potential clinical role in the treatment of pulmonary hypertension.

[Clinical results of selective treatment for flail chest]

A better understanding in pathophysiology of flail chest has brought an evolution to the principles of it's management. The methods of stabilization changed from surgical to pneumatic measures and now, a concept of conservative treatment is recognized. Adhering to our protocol for flail chest, which essentially limits mechanical ventilation, we have prospectively treated 36 patients since 1981. The patient were divided into two groups according to their need for mechanical ventilation. There were 16 patients (44.4%) in a group treated in conservative manner and with no mechanical ventilation (Group A). There were 20 patients (55.6%) in a group treated by mechanical ventilation (Group B). Group A had 6.2% incidence of pneumonia, 3.6 days average stay in ICU and mortality rate of 0%. Group B had 75% pneumonia, 22.5 days average in ICU and 15% mortality. Group B patients required respiratory support for 14 days average, which was not reduced by surgical stabilization. Restrictive pulmonary disturbance in group A was milder than that of group B, and this again was not affected by surgical stabilization. We conclude that 40% of flail chest are controllable without mechanical ventilation and that the result of this conservative therapy is superior to any other treatments.

Selective pulmonary vasodilatory effect of ZSY-27 in dogs with pulmonary hypertension due to pulmonary embolism

The pulmonary vasodilator effect of ZSY-27, a newly synthesized phosphodiesterase inhibitor, was studied in dogs with pulmonary hypertension resulting from autologous muscle-induced pulmonary embolism (PE). A bolus injection of ZSY-27 (1 mg/kg) significantly decreased mean pulmonary arterial pressure from 32 +/- 4 to 24 +/- 5 mm Hg and pulmonary vascular resistance index from 415 +/- 60 to 316 +/- 94 dyne.sec/cm5.m2. ZSY-27 did not change mean arterial pressure. The cardiac index was slightly increased and the systemic vascular resistance index was slightly decreased after ZSY-27 injection, but these changes were not statistically significant. This study suggests that ZSY-27 is a possible therapeutic agent for pulmonary hypertension secondary to PE.

Extracorporeal lung assist for patient with hypercapnia due to status asthmaticus

A 62-year-old female was brought to our emergency room in status asthmatics. She needed mechanical ventilation because of hypercapnia. However, effective mechanical ventilation was difficult because of severe airflow obstruction. Instead of conventional mechanical ventilation, we used extracorporeal lung assist (ECLA) to prevent barotrauma and lung tissue damage, and to reduce the doses of sedatives and muscle relaxants needed.

Impaired effect of dopamine on cardiac output during octopamine infusion

The hemodynamic effects of octopamine (OCT) were studied before and during dopamine (DA) infusion in six normal dogs. Before OCT infusion, DA significantly increased cardiac index (CI) from 3.24 +/- 0.20 to 4.90 +/- 0.30 L/min X m2 and significantly decreased systemic vascular resistance index (SVRI) from 3700.2 +/- 212.5 to 2618.3 +/- 156.6 dyne X sec/cm5 X m2, without changing heart rate. During OCT infusion, DA failed to increase CI or decrease SVRI; however, it significantly increased heart rate from 153.3 +/- 12.9 to 183.0 +/- 17.0 beat/min. This suppression of a DA-related increase in cardiac output may explain why DA is ineffective in those septic patients with elevated plasma OCT levels.

Effect of reduced glutathione on hemodynamic responses and plasma catecholamine levels during metabolic acidosis

The effects of reduced glutathione (GSH) on plasma catecholamine (CA) levels and hemodynamics were studied in seven severely acidotic dogs, before and after dopamine (DA) infusion. Seven other dogs, also acidotic, received lactated Ringer's solution instead of GSH. Although metabolic acidosis decreased cardiac index (CI) in both groups, the decrease was significantly less in the GSH group. The significantly increased systemic vascular resistance index (SVRI) in the control group was suppressed by GSH infusion, although similarly high plasma CA levels were maintained in both groups. This suggests that GSH has certain vasodilating effects not related to adrenosympathetic activity. CI did not improve and DA infusion significantly increased SVRI in the control group, whereas CI increased with a mild decrease of SVRI in the GSH group. The rise of plasma norepinephrine after DA infusion was low in the GSH group compared to the increase in the control group. This study suggests that during acidosis GSH improves hemodynamics and restores the effects of DA on cardiac output.

Plasma catecholamine levels and hemodynamic responses of severely acidotic dogs to dopamine infusion

Changes in plasma catecholamine (CA) levels and hemodynamic responses after a dopamine (DA) infusion of 20 micrograms/kg body weight per min were studied in dogs with a normal acid-base state (pH 7.4, PaCO2 40 torr) and in the same animals after induction of severe metabolic acidosis (pH 7.0, PaCO2 40 torr). DA increased plasma norepinephrine (NE) levels from .487 +/- .109 ng/ml to 3.077 +/- 0.357 ng/ml in the normal acid-base state, and from 1.762 +/- .521 ng/ml to 9.533 +/- 1.403 ng/ml in acidosis. Plasma epinephrine (E) levels in normal and acidotic states were also increased by DA infusion. In the normal acid-base state DA increased myocardial contractility and cardiac index (CI). DA also increased myocardial contractility during acidosis, but the response of CI to DA was abolished. DA significantly decreased systemic vascular resistance index (SVRI) in the normal acid-base state and significantly increased SVRI in acidosis. Acidosis appears to enhance the rate of conversion of DA to NE and E. The failure of DA to increase CI in acidosis may be a result of the increased afterload on the left ventricle.