Patients with heart failure often have difficulty in stopping cardiotonic drugs as the disease stage progresses, and long-term hospitalization is a factor that significantly reduces quality of life. To solve this problem, in September 2017, our hospital started an initiative to support overnight stays at home by using a portable precision infusion pump and continuously injecting cardiotonic drugs with the approval of the hospital’s medical ethics committee. Since there are few case reports of similar efforts in Japan, here we describe the use of drugs and the content of the intervention by pharmacists. The drug is administered via a peripherally inserted central venous catheter using an ambulatory precision infusion pump. The pharmacist calculates the drug dose and flow rate required during the at-home period using spreadsheet software, and proposes a prescription to the doctor. In addition, if multiple cardiotonics and diuretics are administered, the presence or absence of compounding changes is confirmed, and the feasibility of mixing should be examined, and then prepared aseptically on a clean bench on the day of administration. We started to administer catecholamine while in the hospital on the day before the stay at home. Then we prepared the catecholamine in a portable precision infusion pump and administered it during stay at home. To date, we have supported 8 cases in stays at home without emergency hospitalization or sudden death due to exacerbation of heart failure.

A man in his 70s was transported to our hospital for acute exacerbation of chronic kidney disease. After arrival, he began having visual hallucinations, which were attributed to cognitive decline. We subsequently found that he had been taking amantadine 100 mg/day prescribed by another hospital. We thought that the visual hallucinations were caused by overdose of amantadine and discontinued the drug. Since abrupt discontinuation of antiparkinsonian drugs has a risk of neuroleptic malignant syndrome, tapering the dosage is desirable in most cases. However, the half-life of amantadine in patients with severe renal dysfunction is estimated to be 7-10 days, and thus the blood concentration of amantadine can be inferred to decrease slowly. Therefore, we chose to discontinue amantadine without tapering in the expectation of rapid improvement of the visual hallucinations, considering that the risk of neuroleptic malignant syndrome would be lower than that in patients with normal renal function who discontinued amantadine immediately. After the discontinuation of amantadine, no increase in creatine kinase level or muscle rigidity was observed, and the visual hallucinations improved on day 7 after discontinuation.

BACKGROUND:Splenectomy in patients with liver cirrhosis (LC) is expected to become more common owing to its efficacy on portal hemodynamics. In this report we describe an alarming case of group B streptococcus (GBS) infection after splenectomy in a patient with LC. METHODS:A 72-year-old woman with a history of LC was admitted to our emergency department because of respiratory failure. The patient had received left lateral segmentectomy of the liver and splenectomy three months before admission. Pulmonary examination revealed significant wheezing during inspiration and expiration, but no crackles and stridor. Chest radiography and CT showed no infiltrates. A presumptive diagnosis of bronchial asthma caused by upper respiratory infection was made. Four days after admission, GBS infection was confirmed by blood culture and penicillin G was administered. Antibiotics were given intravenously for a total of 12 days. RESULTS:The patient was discharged on the 12th day after admission. CONCLUSIONS:Although efficacy of splenectomy in patients with LC has been reported, immune status should be evaluated for a longer period. Patients who have undergone splenectomy are highly susceptible to bacteria; moreover, LC itself is an independent risk factor for mortality in patients with sepsis. Since prophylaxis against GBS has not been established, immediate action should be taken. Emergency physicians should be aware of invasive GBS infection in the context of the critical risk factors related to splenectomy and LC, particularly the expected increase of splenectomy performed in LC patients.

A 73 year old female, who had suffered from serious bronchial asthma and had been taking prednisolone and theophylline, was treated with acupuncture and herbal medicine. Twenty points, which are so called effective points for bronchial asthma, were used for acupuncture, e. g. LU 1: Zhongij, LU 2: Yunmen, and CV 22: Tiantu, etc. As Ryoudouraku mesurments showed suppression of F3 (Kidny Meridian) and F5 (Gallbladder Meridian), the exciting points on those meridians (KI 7: Fuliu and GB 43: Xiaxi) were also mildly stimulated by acupuncture. The severity of asthmatic attack, the strength of cough and the amount of sputum were expressed by a scoring system, where the most sever one which had been experienced before was scored as 10.
At the initiation of acupuncture, the frequency of asthmatic attack was 5 times a day, the severity of asthmatic attack was 6/10, the strength of cough was 6/10 and the amount of sputum was 8/10. Recently prednisolone was successfully reduced from 20mg to 7.5mg per day with acupuncture and the severity of asthmatic attack, the strength of cough and the amount of sputum were improved to 2/10, 1/10 and 3/10, respectively.
On the other hand, % FVC, FEV 1.0% and blood gas analysis data were not improved.
In summary, we believe that acupuncture acts beneficially to reduce the subjective symptoms of asthma even when the dose of prednisolone were decreased.

On twenty patients and ten healthy adult volunteers, pain threshold was measured by a dolorimeter (Pain meter NYT-5) to clarify whether analgesic effects of electrical acupuncture on various body surface may be changed by acupuncture points or not.
Electrical acupuncture was performed to the traditional acupuncture points on the two meridians. A group is the combination of LI 10 (Shousanli) and LI 14 (Hoku) on the right side, the other is the combination of ST 36 (Tsusanli) and ST 40 (Liangchiu) on the right side.
Measured points of pain threshold are (1) face, (the point 2cm above from the center of both eyelids), (2) (3) left and right upper extremities (LI 11; Chuchih) and (4) (5) left and right lower extremities (ST 41; Chiehhsi).
In the Shousanli-Hoku group, pain thresholds of face, both upper extrimities increased significantly. However, those of both lower extremities were not significantly changed.
In the Tsusanli-Liangchiu group, pain thresholds of the upper and lower extremities on both sides increased significantly. However there were no significant changes in the forehead.
In comparison of two groups, increases of pain thresholds of both lower extremities were observed in significantly more cases with acupuncture to Tsusanli and Liangchiu points than those with Shousanli and Hoku points by the Chi-square test (p<0.01). From this fact, acupuncture of Tsusanli-Liangchiu points seems to be more effective on the lower extremities than that of the Shousanli-Hoku points.
Therefore, we conclude that effects on pain threshold by electrical acupuncture depend on various points on meridians and are not evenly shown on the whole body surface.

This study was performed to clarify whether local anesthesia or sympathetic ganglion block abolishes the effects of electrical acupuncture (EA) on the autonomic nervous system or not.
Twelve healthy adult volunteers and 24 patients are divided into the following three experimental groups of each 12. EA was performed to the traditional acupuncture points on the meridians (H7; SHENMEN and CX4; HSIMEN). (1) In control group, only EA was performed. (2) In stellate ganglion block (SGB) group, EA was performed after unilateral SGB. (3) In local anesthesia (LA) group, EA was performed after local anesthesia on the same acupuncture points. The measured parameters on the autonomic nervous system functions were heart rates, R-R intervals in ECG, blood pressure and deep tissue temperature.
Results are as follows; Means of heart rate decreased significantly by EA in both control and SGB groups. Systolic blood pressure, diastolic blood pressure and RR-CV showed no significant changes by EA in all groups. Deep tissue temperature of the anterior forearm ipsilateral to the stimulation side decreased significantly by EA in SGB group. Deep tissure temperature of the anterior forearm contralateral to the stimuli decreased significantly by EA in both control and SGB groups. In LA group, however, all parameters were not changed by EA.
In summary, the effects of electrical acupuncture on the autonomic nervous system were not much different between control and SGB groups. It seems that one side of stellate ganglion block dose not interfere with the effects of acupuncture. On the other hand, any changes on the autonomic nervous system by electrical acupuncture were not observed in LA group. The fact showed that local anesthesia abolishes the effects of acupuncture on site. Local anesthesia blocks peripheral nerves and nerve endings. Therefore, we conclude that the effects of acupuncture on the autonomic nervous system are transmitted through the peripheral nerves, especially through the sensory nerves.

Previously we reported that acupuncture to the stellate ganglion stimulates the parasympathetic nervous system as well as the sympathetic nervous system. We measured effects of laser acupuncture to the stellate ganglion (SGL) or electrical acupuncture to the same (SGA) on R-R intervals, deep tissue temperature and blood presure by using 45 patients; 12 in SGL-group and 33 in SGA-group.
Results are as follows; (1) Means of heart rate (HR) decreased with 2bpm in the SGL-group, 3bpm in the SGA-group. (2) Coefficient of variation (CV) of R-R intervals increased with 1% in the SGA-group only. (3) Deep tissue temperature of the ipsilateral anterior forearm of the stimulation did not increase significantly after SGA, while deep tissue temperature increased with 0.3-0.5°C after SGL. Deep tissue temperature of the contralateral anterior forearm showed no significant change in the both groups. (4) Systolic blood pressure increased with 2-4mmHg after SGA and 4-5mmHg after SGL, respectively.
It is suggested that SGL increases deep tissue temperature by affecting autonomic nervous system, but not directly.

Previously we reported effects of acupuncture to the stellate ganglion on measurements of skin electroconductivity by a Neurometer.
By using 8 healthy adults and 23 patients, we measured effects of electrical acupuncture to the stellate ganglion on carotid blood flow, deep tissue temperature, blood pressure and pulse rate in order to clarify the influence on functions of the autonomic nervous system.
After electrical acupuncture to the right stellate ganglion (SGA), the right and left carotid blood flow decreased with 4-9% and 7-12%, respectively. Deep tissue temperature of the right anterior forearm after SGA showed a little increase (with no significance), while the temperature increased with 0.4-0.7°C after the right stellate ganglion block (SGB). Deep tissue temperature of the left anterior forearm showed no significant change after SGA, while it increased with 0.1-0.3°C significantly after SGB. Systolic blood pressure increased with 2-4mmHg after SGA and this also increased with 9-11mmHg after SGB. Those increases were significant. While the pulse rate decreased (2bpm) significantly after SGA, it increased (4-6bpm) significantly after SGB.
Except the decreased pulse rate after SGA, the other data did not support a common hypothesis that electrical acupuncture to the stellate ganglion suppresses the sympathetic system as SGB.

Previously we reported that acupuncture to the stellate ganglion stimulates sympathetic nervous system while it decreases heart rate.
As it is said that R-R intervals in electrocardiogram (ECG) reflect functions of parasympathetic nervous system, we measured effects of electrical acupuncture to the stellate ganglion (SG) or traditional acupuncture points (AP) on the meridians (H7: SHENMEN and P4: HSIMEN) on R-R intervals in ECG by using 24 patients; 12 each in SG-group and AP-group.
Results are as follows; (1) Means of heart rate (HR) decreased with 1-3bpm in the both groups; (2) Coefficients of variation (CV) of HR increased with 1-2% in the both groups; (3) Means of R-R intervals prolonged with 39-47msec in the SG-group and 20-44msec in the AP-group, respectively; (4) CV of R-R intervals increased with 1% in the SG-group only.
It is suggested that acupuncture stimulates not only sympathetic nervous system, but also parasympathetic nervous system.