The Keio journal of medicine
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Emergency Medicine is a relatively young specialty in the United States as well as in other parts of the world. It was only 36 years ago, in 1968, that the American College of Emergency Physicians was founded. Two years later, the University of Cincinnati in Cincinnati, Ohio, USA launched the first Emergency Medicine Residency Training Program. ⋯ Interpersonal skills are demanding as well, requiring leadership/management of the Emergency Department care team, immediate patient rapport, and dealing with patient/family grief. The Residency Review Committee of the Accreditation Council for Graduate Medical Education (ACGME) ensures that all programs have a structured curriculum complete with both didactic and bedside teaching, as well as structured methods for evaluation of both residents and faculty. According to manpower studies, a great need still exists for Emergency Physicians in many United States hospitals, particularly in rural communities.
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The patient is a 62-year-old man who was diagnosed with myasthenia gravis and invasive thymoma at the age of 45 years, and had received treatment by extended thymectomy and radiotherapy. At the age of 61, he had suffered from a myasthenic crisis, and been administered immunoadsorption therapy under managed ventilatory care. Treatment had then been continued with steroids; however, due to subsequent deterioration of his diabetic state, treatment was switched to the immunosuppressant drug tacrolimus. ⋯ Steroid pulse therapy was therefore initiated, however, 4 days later, the patient suddenly died. Autopsy examination revealed inflammatory cell infiltration with giant cells in the myocardium, diffuse myocardial degeneration, and polymyositis. The case was therefore considered as one with the syndrome of myasthenia gravis, polymyositis, giant cell myocarditis, and thymoma.
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The transdermal therapeutic system with fentanyl was released in Germany in 1995. Before and after the release several clinical trials were performed in our pain management unit and in other German pain centers, showing good efficacy after initial dose titration with intravenous patient-controlled analgesia or switching from pretreatment with oral morphine or other opioids. A sequential trial showed less use of laxatives with transdermal fentanyl compared to pretreatment with oral morphine. ⋯ In conclusion, experience with the transdermal therapeutic system with fentanyl has been gathered in clinical trials, a large nationwide survey and clinical practice since the release in 1995. The conversion table based on a conversion ratio of 100 : 1 was safe and efficient in trials and clinical practice. Transdermal fentanyl has become a wellknown and frequently used opioid in the treatment of chronic cancer and non-cancer pain in Germany.
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Comparative Study
Characteristics of elderly patients presenting to the emergency department with injury.
In Japan, emergency departments (ED) receive a large proportion of elderly patients each year. As such, injuries in the elderly are a common reason for presentation to the ED. Knowledge about the characteristics of injuries presenting to the ED would be invaluable in devising strategies to prevent injury in the elderly. ⋯ Elderly injury patients are a distinct group with distinctive demographics, mechanism of injury and outcomes. This information would be useful in the planning of injury prevention programs, with particular emphasis on elderly females and MVA-unrelated trauma.
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Case Reports
Lightning injury as a blast injury of skull, brain, and visceral lesions: clinical and experimental evidences.
The present study attempts to better understand the mechanism of injuries associated with direct lightning strikes. We reviewed the records of 256 individuals struck by lightning between 1965 and 1999, including 56 people who were killed. Basal skull fracture, intracranial haemorrhage, pulmonary haemorrhage, or solid organ rupture was suspected in three men who died. ⋯ Saline-soaked blotting paper was used to simulate wet clothing or skin, and an artificial lightning impulse was applied. The resultant lesions were consistent with our hypothesis that the blast was reinforced by the concussive effect of water vaporization. The concordance between the clinical and experimental evidence argues strongly for blast injury as an important source of morbidity and mortality in lightning strikes.