Showing papers in "Acute medicine and surgery in 2020"

Influence of the COVID-19 pandemic on an emergency medical service system: a population-based, descriptive study in Osaka, Japan.

Abstract: Aim Novel coronavirus infection (COVID-19) was confirmed in Wuhan, China in December 2019, and the COVID-19 pandemic has spread around the world. However, no clinical studies on the impact of the COVID-19 pandemic on emergency medical service (EMS) systems have been carried out. Methods This was a retrospective study with a study period from 1 January 2020 to 14 April 2020. We included the patients transported by ambulance for acute diseases and traffic accidents in Osaka city, Japan. The main outcome of this study was the difficulty in hospital acceptance. We calculated the rate of difficulty of hospital acceptance for each month for acute diseases and traffic accidents. Results Between 1 January and 14 April 2020, 36,981 patients were transported to hospitals by ambulance for acute diseases and 3,096 patients for traffic accidents. There was no difference in the proportion of the difficulty in hospital acceptance due to traffic accidents between 2019 and 2020, but there was an increase in the proportion of the difficulty in hospital acceptance due to acute disease after the 13th week (25-31 March) of 2020 compared to that of 2019. The odds ratio in April was 2.17 (95% confidence interval, 1.84-2.58) for acute disease. Conclusion We assessed the impact of the COVID-19 pandemic on the EMS system in Osaka City, Japan and found that, since April 2020, the EMS system in Osaka City has been facing difficulty in terms of hospital acceptance of patients transported to hospital for acute diseases.

Therapeutic strategies for ischemia reperfusion injury in emergency medicine

Abstract: Ischemia reperfusion (IR) injury occurs when blood supply, perfusion, and concomitant reoxygenation is restored to an organ or area following an initial poor blood supply after a critical time period. Ischemia reperfusion injury contributes to mortality and morbidity in many pathological conditions in emergency medicine clinical practice, including trauma, ischemic stroke, myocardial infarction, and post-cardiac arrest syndrome. The process of IR is multifactorial, and its pathogenesis involves several mechanisms. Reactive oxygen species are considered key molecules in reperfusion injury due to their potent oxidizing and reducing effects that directly damage cellular membranes by lipid peroxidation. In general, IR injury to an individual organ causes various pro-inflammatory mediators to be released, which could then induce inflammation in remote organs, thereby possibly advancing the dysfunction of multiple organs. In this review, we summarize IR injury in emergency medicine. Potential therapies include pharmacological treatment, ischemic preconditioning, and the use of medical gases or vitamin therapy, which could significantly help experts develop strategies to inhibit IR injury.

Adhesive small bowel obstruction - an update.

Abstract: Small bowel obstruction (SBO) accounts for 12-16% of emergency surgical admissions and 20% of emergency surgical procedures. Even with the advent of laparoscopic surgery, intra-abdominal adhesions remain a significant cause of SBO, accounting for 65% of cases. History and physical examination are essential to identify signs of bowel ischemia as this indicates a need for urgent surgical exploration. Another critical aspect of evaluation includes establishing the underlying cause for obstruction and distinguishing between adhesive and non-adhesive etiologies as adhesive SBO (ASBO) can be managed non-operatively in 70-90% of patients. A patient with a history of abdominopelvic surgery along with one or more cardinal features of obstruction should be suspected to have ASBO until proven otherwise. Triad of severe pain, pain out of proportion to the clinical findings, and presence of an abdominal scar suggest possible closed-loop obstruction. Computed tomography has higher sensitivity and specificity compared to plain films and is recommended by the Bologna guidelines. Correcting fluid and electrolyte imbalance is an initial crucial step to mitigate severe hypovolemia. Patients should proceed with surgery if symptoms of bowel compromise are present, or if symptoms do not resolve or have worsened. Surgery is indicated in patients with ischemia, strangulation, perforation, peritonitis, or failure of non-operative treatment. With advances in minimal access technology and increasing experience, laparoscopic adhesiolysis is recommended. Mechanical adhesion barriers are an effective measure to prevent adhesion formation.

Past, present, and future of palliative care in emergency medicine in the USA.

Abstract: The emergency department (ED) provides immediate access to medical care for patients and families in times of need. Increasingly, older patients with serious illness seek care in the ED, hoping for relief from symptoms and suffering associated with advanced disease. Until recently, emergency medicine (EM) clinicians have been ill-equipped to meet the needs of patients with serious illness, and palliative services have been largely unavailable in the ED. However, in the past decade, there has been growing recognition from within both the EM and palliative medicine communities on the importance of palliative care provision in the ED. The past 10 years have seen a surge in EM-palliative care training and education, quality improvement projects, and research. As a result, the practice paradigm within EM for the seriously ill has begun to shift to incorporate more palliative care practices. Despite this progress, substantial work has yet to be done in terms of identifying ED patients in need of palliative care, training EM clinicians to provide high-quality primary palliative care, creating pathways for ED referral to palliative care and hospice, and researching the outcomes and impact of palliative care provision on patients with serious illness in the ED.

Clinical characteristics, prognostic factors, and outcomes of heat-related illness (Heatstroke Study 2017-2018)

Abstract: Aim Heat-related illness is common, but its epidemiology and pathological mechanism remain unclear. The aim of this study was to report current clinical characteristics, prognostic factors, and outcomes of heat-related illness in Japan. Methods We undertook a prospective multicenter observational study in Japan. Only hospitalized patients with heat-related illness were enrolled from 1 July to 30 September 2017 and 1 July to 30 September 2018. Results A total of 763 patients were enrolled in the study. Median age was 68 years (interquartile range, 49-82 years) and median body temperature on admission was 38.2°C (interquartile range, 36.8-39.8°C). Non-exertional cause was 56.9% and exertional cause was 40.0%. The hospital mortality was 4.6%. The median Japanese Association for Acute Medicine disseminated intravascular coagulation (JAAM DIC), Sequential Organ Failure Assessment (SOFA), and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores on admission were 1 (0-2), 4 (2-6), and 13 (8-22), respectively. To predict hospital mortality, areas under the receiver operating characteristic curves were 0.776 (JAAM DIC score), 0.825 (SOFA), and 0.878 (APACHE II). There were 632 cases defined as heatstroke by JAAM heat-related illness criteria, 73 cases diagnosed as having DIC. A total of 16.6% patients had poor neurological outcome (modified Rankin Scale ≥ 4) at hospital discharge. In the multivariate analysis, Glasgow Coma Scale and platelets were independent predictors of mortality. Type of heatstroke, Glasgow Coma Scale, and platelets were independent predictors of poor neurological outcome. Body temperature was not associated with mortality or poor neurological outcome. Conclusions In this study, hospital mortality of heat-related illness was <5%, one-sixth of the patients had poor neurological outcome. The APACHE II, SOFA, and JAAM DIC scores predicted hospital mortality. Body temperature was not associated with mortality or poor neurological outcome.

Veno-venous extracorporeal membrane oxygenation for severe pneumonia: COVID-19 case in Japan

Abstract: Background: Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is one of the ultimate treatments for acute respiratory failure. However, the effectiveness of ECMO in patients with novel coronavirus disease (COVID-19) is unknown. Case Presentation: A 72-year-old woman who was a passenger of a cruise ship tested positive for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) while in quarantine on board using throat swab. Three days after admission, her condition deteriorated, and she was subsequently intubated. On day 6, VV-ECMO was introduced. Lopinavir/ritonavir was given; continuous renal replacement therapy was also introduced. On day 10, her chest radiography and lung compliance improved. She was weaned off ECMO on day 12. Conclusion: Treatment of severe pneumonia in COVID-19 by ECMO should recognize lung plasticity considering time to ECMO introduction and interstitial biomarkers. In Japan, centralization of ECMO patients has not been sufficient. Thus, we suggest nationwide centralization and further research to respond to the crisis caused by COVID-19.

Personal Protective Equipment Use by Healthcare Workers in Intensive Care Unit During the COVID-19 Pandemic in Japan: Comparative Analysis With the PPE-SAFE Survey.

Abstract: Aim: We investigated personal protective equipment (PPE) use and its shortage, training, and adverse events among healthcare workers (HCWs) in the intensive care unit (ICU) during the coronavirus disease (COVID-19) pandemic in Japan and compared the results with an international survey that used the same methodology. Methods: This web-based survey was conducted from April 14 to May 6, 2020, in Japan and included HCWs directly involved in ICU management of COVID-19 patients. A survey invitation was emailed using the Japanese Society of Intensive Care Medicine's mailing list. Results: We analyzed 460 valid responses from among 976 responses. The N95/FFP2 mask (77%) was most frequently used than in the international study, although half of our respondents reported reuse of single-use N95/FFP2 masks. The median duration (1 hour) of uninterrupted PPE use per shift was less than that in the international study. The commonest PPE-related adverse event was experiencing intense heat (75%). Logistic regression analysis revealed that being a nurse was independently associated with experiencing intense heat. Conclusion: PPE shortage and frequent mask reuse were prevalent during the COVID-19 pandemic in Japan. Intense heat is the most significant symptom, especially for nurses, even with short-duration PPE use. Strategies to protect HCWs from dehydration and intense heat stroke are needed.

Comparison of high-flow nasal cannula oxygen therapy and non-invasive ventilation as first-line therapy in respiratory failure: a multicenter retrospective study.

Abstract: Aim To identify which subgroups of respiratory failure could benefit more from high-flow nasal cannula oxygen therapy (HFNC) or non-invasive ventilation (NIV). Methods We undertook a multicenter retrospective study of patients with acute respiratory failure (ARF) who received HFNC or NIV as first-line respiratory support between January 2012 and December 2017. The adjusted odds ratios (OR) with 95% confidence intervals (CI) for HFNC versus NIV were calculated for treatment failure and 30-day mortality in the overall cohort and in patient subgroups. Results High-flow nasal cannula oxygen therapy and NIV were used in 200 and 378 patients, and the treatment failure and 30-day mortality rates were 56% and 34% in the HFNC group and 41% and 39% in the NIV group, respectively. The risks of treatment failure and 30-day mortality were not significantly different between the two groups. In subgroup analyses, HFNC was associated with increased risk of treatment failure in patients with cardiogenic pulmonary edema (adjusted OR 6.26; 95% CI, 2.19-17.87; P < 0.01) and hypercapnia (adjusted OR 3.70; 95% CI, 1.34-10.25; P = 0.01), but the 30-day mortality was not significantly different in these subgroups. High-flow nasal cannula oxygen therapy was associated with lower risk of 30-day mortality in patients with pneumonia (adjusted OR 0.43; 95% CI, 0.19-0.94; P = 0.03) and in patients without hypercapnia (adjusted OR 0.51; 95% CI, 0.30-0.88; P = 0.02). Conclusion High-flow nasal cannula oxygen therapy could be more beneficial than NIV in patients with pneumonia or non-hypercapnia, but not in patients with cardiogenic pulmonary edema or hypercapnia.

Validation of chief complaints, medical history, medications, and physician diagnoses structured with an integrated emergency department information system in Japan: the Next Stage ER system.

Abstract: Aim Emergency department information systems (EDIS) facilitate free-text data use for clinical research; however, no study has validated whether the Next Stage ER system (NSER), an EDIS used in Japan, accurately translates electronic medical records (EMRs) into structured data. Methods This is a retrospective cohort study using data from the emergency department (ED) of a tertiary care hospital from 2018 to 2019. We used EMRs of 500 random samples from 27,000 ED visits during the study period. Through the NSER system, chief complaints were translated into 231 chief complaint categories based on the Japan Triage and Acuity Scale. Medical history and physician's diagnoses were encoded using the International Classification of Diseases, 10th Revision; medications were encoded as Anatomical Therapeutic Chemical Classification System codes. Two reviewers independently reviewed 20 items (e.g., presence of fever) for each study component (e.g., chief complaints). We calculated association measures of the structured data by the NSER system, using the chart review results as the gold standard. Results Sensitivities were very high (>90%) in 17 chief complaints. Positive predictive values were high for 14 chief complaints (≥80%). Negative predictive values were ≥96% for all chief complaints. For medical history and medications, most of the association measures were very high (>90%). For physicians' ED diagnoses, sensitivities were very high (>93%) in 16 diagnoses; specificities and negative predictive values were very high (>97%). Conclusions Chief complaints, medical history, medications, and physician's ED diagnoses in EMRs were well-translated into existing categories or coding by the NSER system.

COVID-19 first stage in Japan – how we treat ‘Diamond Princess Cruise Ship’ with 3700 passengers?

Abstract: Dear Editor We report the current situation regarding the case of multiple patients who tested positive via polymerase chain reaction (PCR) for the novel coronavirus infection and were transported from the Diamond Princess cruise ship, from the viewpoint of medical facilities in Yokohama City to serve as a reference for future development of emergency medical care systems in each region. Please note that the following numbers are preliminary (unconfirmed) and may change based on the counts determined by related organizations in the future. The Medical Control Council recognizes the importance of verifying the overall situation once the crisis has settled down. Please refer to reports from each organization to gain administrative perspectives. The present report is merely one of the documents that could be used to review regional emergency medical systems when large numbers of coronavirus disease (COVID-19) patients are observed in each region.

Perspectives on paralytic ileus

Abstract: Paralytic ileus is the condition where the motor activity of the bowel is impaired, usually not associated with a mechanical cause. Although the condition may be self-limiting, it is serious and if prolonged and untreated will result in death in much the same way as in acute mechanical obstruction. Management of paralytic ileus depends on the knowledge of the most likely cause and the perceived chance of resolution without operation. Postoperative ileus is the single largest factor influencing length of hospital stay after bowel resection, and has great implications for patients and resource utilization. Early diagnosis and correct management is essential in reducing complications. This article briefly outlined the plausible pathophysiological mechanisms and clinical implications of paralytic ileus.

Epidemiology and volume‐outcome relationship of extracorporeal membrane oxygenation for respiratory failure in Japan: A retrospective observational study using a national administrative database

Abstract: Aim To describe the epidemiology of patients on extracorporeal membrane oxygenation (ECMO) and investigate the possible association between outcomes for respiratory ECMO patients and hospital volume of ECMO treatment for any indications. Methods Using data from the Diagnosis Procedure Combination database, a nationwide Japanese inpatient database, between 1 July 2010 and 31 March 2018, we identified inpatients aged ≥18 years who underwent ECMO. Institutional case volume was defined as the mean annual number of ECMO cases; eligible patients were categorized into institutional case volume tertile groups. The primary outcome was in-hospital mortality. For ECMO patients with respiratory failure, the association between institutional case volume group and in-hospital mortality rate was analyzed using a multilevel logistic regression model including multiple imputation. Results Extracorporeal membrane oxygenation was carried out on 25,384 patients during the study period; of those, 1,227 cases were for respiratory failure. Respiratory cases were categorized into low- (<8 cases/year), medium- (8-16 cases/year), and high-volume groups (≥17 cases/year). The overall in-hospital mortality rate for respiratory ECMO was 62.5% in low-, 54.7% in medium-, and 50.4% in high-volume institutions. With reference to low-volume institutions, the adjusted odds ratios (95% confidence interval) of the medium- and high-volume institutions for in-hospital mortality were 0.72 (0.50-1.04; P = 0.082) and 0.65 (0.45-0.95; P = 0.024), respectively. Conclusions The present study showed that accumulating the experience of using ECMO for any indications could positively affect the outcome of ECMO treatment for respiratory failure, which suggests the effectiveness of consolidating ECMO cases in high-volume centers in Japan.

Epidemiological profile of emergency medical services in Japan: a population-based descriptive study in 2016.

Abstract: Aim The aim of our study is to describe the characteristics of patients who use emergency medical services (EMS), EMS performance, and regional variations in Japan. Methods We undertook a nationwide, population-based, descriptive review of anonymized ambulance transport records obtained from the Fire and Disaster Management Agency in Japan. All emergency patients transported to emergency medical institutions by EMS personnel from January to December 2016 were enrolled in this study, excluding patients who were not transported. Results During the study period, 5,097,838 patients were transported to a hospital. Their median age was 69 years, 51.4% were male, and 56.5% were over 65 years old. Median durations from EMS call to EMS arrival on scene were similar among the regions, ranging from 7 to 9 min. However, the longest median duration from EMS call to hospital arrival was 38 min, and the shortest was 31 min across the regions. Among all patients, 350,865 (6.9%) were assessed as being in a severe condition, 14,410 (0.3%) were in very severe condition, and 74,780 (1.5%) were confirmed to be dead at the time of initial medical examination in the emergency department. Conclusions We described the characteristics of emergency patients and EMS performance in Japan. This registry serves as a basis for providing relevant information to improve prehospital emergency medical systems.

Optimal extracorporeal cardiopulmonary resuscitation inclusion criteria for favorable neurological outcomes: a single-center retrospective analysis.

Abstract: Aim Although age ≤75 years, witnessed arrest, shockable initial cardiac rhythm, and short cardiac arrest duration are commonly cited inclusion criteria for extracorporeal cardiopulmonary resuscitation (ECPR), these criteria are not well-established, and ECPR outcomes remain poor. We aimed to evaluate whether the aforementioned inclusion criteria are appropriate for ECPR, and estimate the improvements in prognoses associated with their fulfillment. Methods Between October 2009 and December 2017, we retrospectively examined consecutive out-of-hospital cardiac arrest patients who were admitted to our hospital and received ECPR. We established four ECPR inclusion criteria: age ≤75 years, witnessed arrest, shockable initial cardiac rhythm, and call-to-hospital arrival time ≤45 min, and also evaluated the relationship between these criteria and patient outcomes. Results During the study period, 1,677 out-of-hospital cardiac arrest patients were admitted to our hospital, and 156 (9%) with ECPR were examined. The proportion of favorable neurological outcomes was 15% (24/156). However, when the study population was limited to individuals who fulfilled all four criteria, 27% (15/55) had favorable neurological outcomes; only one patient had favorable outcomes when two or more criteria were fulfilled. There was a significant positive linear correlation between the proportion of cases with favorable neurological outcomes and fulfillment of the four criteria (P = 0.005, r = 0.975). Conclusion Fulfillment of at least three of the aforementioned criteria could yield improved ECPR outcomes.

Evaluation of appropriate indications for the use of sivelestat sodium in acute respiratory distress syndrome: a retrospective cohort study.

Abstract: Aim Sivelestat sodium, a selective neutrophil elastase inhibitor, is the only commercially available, specific therapy for acute respiratory distress syndrome (ARDS); however, its clinical efficacy is controversial. We aimed to evaluate appropriate indications for its use in ARDS. Methods We studied 66 patients with ARDS who were treated with sivelestat sodium. They were divided into survivors (n = 37) or non-survivors (n = 29) at 60 days, and clinical characteristics were analyzed. Results Patients' backgrounds evaluated with the Acute Physiology and Chronic Health Evaluation II (APACHE II) score and the sequential organ failure assessment (SOFA) score were significantly different between both groups (survivors versus non-survivors: APACHE II score, 14.7 ± 6.7 versus 20.5 ± 4.7, P Conclusion An APACHE II score ≤18, and a PaO2/FIO2 ratio >198 at 3 days after the use of sivelestat sodium predicted a good outcome.

Euglycemic diabetic ketoacidosis due to a strict low-carbohydrate diet during treatment with sodium-glucose cotransporter 2 inhibitors.

Abstract: Background Euglycemic diabetic ketoacidosis is a critical clinical presentation that can occur during treatment with sodium-glucose cotransporter 2 inhibitors. However, little is known regarding how a low-carbohydrate diet in combination with this treatment can increase the risk for this condition. Here, we report a case of euglycemic diabetic ketoacidosis in a patient treated with sodium-glucose cotransporter 2 inhibitors after initiation of a low-carbohydrate diet. Case presentation A 54-year-old woman who was taking canagliflozin was transferred to our hospital with severe dyspnea. She had been started on a strict low-carbohydrate diet for 6 days before admission. Laboratory evaluation revealed severe ketoacidosis and a blood glucose level of 196 mg/dL. After her symptoms improved, she was diagnosed with type 1 diabetes mellitus. Conclusion Although low-carbohydrate diets are recommended for patients with diabetes mellitus, physicians should exercise great caution in recommending low-carbohydrate diets to patients undergoing treatment with sodium-glucose cotransporter 2 inhibitors.

Basic point-of-care ultrasound framework based on the airway, breathing, and circulation approach for the initial management of shock and dyspnea.

Abstract: Ultrasound (US) carried out and interpreted by clinicians at the bedside is now called point-of-care US (POCUS). Clinical studies on POCUS have been carried out based on the ideas of "creation", "extraction", and "combination". "Creation" refers to findings for the upper airway and lung being obtained at the bedside. "Extraction" refers to findings suitable for POCUS being extracted from comprehensive US, including echocardiography, abdominal US, and whole-leg US. "Combination" refers to these POCUS applications being combined for the comprehensive assessment of patients with trauma, shock, or dyspnea. Emergency and critical care physicians have many opportunities to encounter trauma or non-trauma patients with shock, dyspnea, or both. Furthermore, the scope of POCUS includes many diseases and injuries that present with both shock and dyspnea. Therefore, we propose a basic POCUS framework based on the systematic airway, breathing, and circulation approach for the initial management of shock and dyspnea in adult patients. In this article, we update and review each application of POCUS and their combination in this framework. Furthermore, we propose the practical usage of the framework based on clinical presentations to improve the management of shock and dyspnea.

First report based on the online registry of a Japanese multicenter rapid response system: a descriptive study of 35 institutions in Japan.

Abstract: Aim Although the concept of a rapid response system (RRS) has been gradually accepted in Japan, detailed information on the Japanese RRS is not well known. We provide the first report of the RRS epidemiological situation based on 4 years of RRS online registry data. Methods This is a prospective observational study. All patients registered between January 2014 and March 2018 were eligible for this study. Data related to RRS including physiological measurements were recorded. The mortality rates after rapid response team/medical emergency team (RRT/MET) intervention and after 30 days were recorded as outcomes. Results In total, 6,784 cases were registered at 35 facilities. Cancer (23.1%) was the most common existing comorbidity. Limitation of medical treatment was identified in 12.7% of the cases. The respiratory category was most frequently activated in 41.3% of the cases. Only two institutions had received more than 15 calls per 1,000 admissions. During RRT/MET intervention, death occurred in 3.6% and transfers to intensive care units occurred in 28.2% of the cases. After 30 days, the mortality rate was significantly higher in the night than in the day shift (30.7% versus 20.4%, respectively, P < 0.01). Conclusions We report the first epidemiological study of RRS in Japan. Japanese facilities had a very low rate of RRT/MET calls and a higher mortality rate in the night than in the day shift. Further promotion to increase the number of calls and implementation of a 24-h RRT/MET is required.

Preventing thrombosis in a COVID-19 patient by combinatorial therapy with nafamostat and heparin during extracorporeal membrane oxygenation.

Abstract: Background: Extracorporeal membrane oxygenation (ECMO) can be life-saving in cases of coronavirus disease (COVID-19); however, circuit thrombosis is a complication. This report describes a COVID-19 patient treated with nafamostat and heparin to prevent circuit thrombosis during ECMO support. Case presentation: A 63-year-old man was transferred to our hospital with respiratory failure due to COVID-19 pneumonia. He was provided venous-venous ECMO to maintain oxygenation. During ECMO support, occlusive circuit thrombosis developed despite systemic anticoagulation therapy with heparin. He was subsequently administered combination therapy with nafamostat and heparin. Although the combination therapy could prevent circuit thrombosis, it was converted to heparin monotherapy because of hyperkalemia and hemothorax. After tracheostomy and a gradual improvement in oxygenation, ECMO was discontinued. He was transferred to another hospital for further rehabilitation. Conclusion: Combination therapy with nafamostat and heparin can prevent circuit thrombosis during ECMO. However, bleeding can still develop with this combination therapy during ECMO.

Traumatic brain injury-related inflammatory projection: beyond local inflammatory responses.

Abstract: Acute neuroinflammation induced by microglial activation is key for repair and recovery after traumatic brain injury (TBI) and could be necessary for the clearance of harmful substances, such as cell debris. However, recent clinical and preclinical data have shown that TBI causes chronic neuroinflammation, lasting many years in some cases, and leading to chronic neurodegeneration, dementia, and encephalopathy. To evaluate neuroinflammation in vivo, positron-emission tomography has been used to target translocator protein, which is upregulated in activated glial cells. Such studies have suggested that remote neuroinflammation induced by regional microglia persists even after reduced inflammatory responses at the injury site. Furthermore, unregulated inflammatory responses are associated with neurodegeneration. Therefore, elucidation of the role of neuroinflammation in TBI pathology is essential for developing new therapeutic targets for TBI. Treatment of associated progressive disorders requires a deeper understanding of how inflammatory responses to injury are triggered, sustained, and resolved and how they impact neuronal function. In this review, we provide a general overview of the dynamics of immune responses to TBI, from acute to chronic neuroinflammation. We discuss the clinical significance of remote ongoing neuroinflammation, termed "brain injury-related inflammatory projection". We also highlight positron-emission tomography imaging as a promising approach needing further development to facilitate an understanding of post-TBI inflammatory and neurodegenerative processes and to monitor the clinical effects of corresponding new therapeutic strategies.

Impact of non-pharmaceutical interventions for the COVID-19 pandemic on emergency department patient trends in Japan: a retrospective analysis.

Abstract: Aim The coronavirus disease (COVID-19) pandemic massively impacted emergency department (ED) visits. The unavailability of specific therapies or vaccines has made non-pharmaceutical interventions (NPIs) an alternative strategy for COVID-19. We assessed the impact of NPIs (nationwide school closures and state of emergency) on ED visits during the COVID-19 pandemic in Japan. Methods This retrospective study compared the trends in ED visits from 1 January to 25 May, 2020 (during the pandemic) with the average during 2015-2019 (before the pandemic). The primary end-point was the change in the number of ED visits during the COVID-19 pandemic with those from before the pandemic, with the NPI application stratified across four periods in 2020: Period 0 (1-15 January), no COVID-19 cases detected in Japan; Period I (16 January-1 March), initial COVID-19 outbreak; Period II (2 March-15 April), nationwide school closures; Period III (16 April-25 May), state of emergency. Results Compared with before the pandemic, the number of walk-in ED visits significantly decreased by 23.1%, 12.4%, and 24.0% (4,047 versus 3,111; 3,211 versus 2,813; and 3,384 versus 2,573; P < 0.001 for all) in Periods I, II, and III, respectively. The number of ambulance ED visits during the pandemic significantly increased by 8.3% in Period I (1,814 versus 1,964, P = 0.002), whereas there was no significant change in Periods II and III with 2.7% and -3.1% (1,547 versus 1,589 and 1,389 versus 1,346; P = 0.335 and P = 0.284, respectively). Conclusions The application of an NPI during the COVID-19 pandemic could have significantly reduced patient attendance in the ED.

Nationwide system to centralize decisions around extracorporeal membranous oxygenation use for severe COVID-19 pneumonia in Japan

Abstract: Dear Editor, The novel coronavirus disease (COVID-19) is spreading in Japan. The number of patients who need extracorporeal membranous oxygenation (ECMO) is expected to increase; however, the clinical characteristics of the patients who require and will benefit from ECMO are unclear. On 15 February 2020, the Japanese Society of Intensive Care Medicine, the Japanese Association for Acute Medicine, the Japanese Society of Respiratory Care Medicine, and the Japanese Society of Percutaneous Cardio Pulmonary Support/ECMO launched “Japan ECMOnet for COVID-19” as a telephone consultation, treatment support, and webbased real-time nationwide registry and surveillance system to discuss COVID-19 patients from over 400 hospitals who could be candidates for ECMO. The initiative is led by more than 20 ECMO experts (Japan ECMOnet for COVID19) from all over Japan. As of 15 March 2020, 26 patients had been placed on ECMO based on deliberation of the group. Sixteen of the 26 (61.5%) have been weaned off and six have been extubated and on rehabilitation, while the rest remain on ECMO. A few of these patients who have been weaned off ECMO still need treatment for other organ failure. We report the data from first 14 cases. The median age of the patients is 71 years (range, 45–81 years). The median number of days between intubation and ECMO was 3 days (range, 0–9 days). The median PaO2/FIO2 ratio, positive end-expiratory pressure (PEEP), mean airway pressure, and lung compliance before initiation of ECMO were 70 (range, 52–147), 15 cmH2O (range, 10–18 cmH2O), 21 cmH2O (18–27 cmH2O), and 28 mL/cmH2O (range, 13.6–70 mL/ cmH2O), respectively. Selected laboratory data of the patients on admission were: median serum KL-6 (a marker of interstitial pneumonia) was 333 U/mL, lactate dehydrogenase (LDH) was 460 IU/L, and procalcitonin was 0.12 ng/ mL. With regard to ECMO settings, the median blood flow was 4 L/min (range, 2.5–5.3 L/min), the median size of the draining cannula was 24 Fr (range, 21–25 Fr), and the median size of the infusing cannula was 20 Fr (range, 16– 21 Fr). For antiviral treatment, lopinavir was used for 13/14 (93%) patients. All patients received empirical antibiotics (carbapenems or third/fourth generation cephalosporins). Ciclesonide, a glucocorticoid inhaler, was used for 4/13 (31%) of the cases. The effectiveness of any of the medications cannot be assessed at this time. Experts within Japan ECMOnet for COVID-19 identified two phenotypes of patients with severe pneumonia: one associated with low lung compliance and the other with preserved lung compliance. Oxygenation of patients with preserved lung compliance did not improve with higher PEEP. For these patients, serum KL-6, SP-D (another marker of interstitial pneumonia), and LDH were not elevated on admission. These findings suggest that lung fibrosis was not severe for this subgroup of patients. The adoption of a platform for realtime discussion to guide the use of a scarce resource such as ECMO has been valuable to the Japanese doctors who are caring for critically ill patients with COVID-19 infection. A central near-real-time data repository is optimal to undertake justin-time epidemiologic studies and to develop algorithms that can inform clinical decision-making.

Activities of daily living status and psychiatric symptoms after discharge from an intensive care unit: a single-center 12-month longitudinal prospective study.

Abstract: Aim In post-intensive care syndrome (PICS), long-term survivors of critical illness present various physical and mental symptoms that can persist for years after discharge. Post-intensive care syndrome in Japan has not been well described, so this study aims to elucidate its epidemiology. Methods We undertook a single-center prospective longitudinal cohort study in a mixed intensive care unit (ICU) in a Japanese tertiary hospital. Adult patients emergently admitted to the ICU were eligible for inclusion in the study. To assess activity of daily living (ADL) status and psychiatric symptoms, we posted a questionnaire at 3 and 12 months after discharge from the ICU. We evaluated ADL status, anxiety, depression, and post-traumatic stress disorder symptoms using the Barthel index, Hospital Anxiety and Depression Scale, and Impact of Event Scale - Revised, respectively. Results Enrolled in this study were 204 patients. We received responses from 117/147 (80%) and 74/98 (76%) patients at 3 and 12 months, respectively. At 3 months, the prevalence of ADL disability, anxiety, depression, and post-traumatic stress disorder symptoms was 32%, 42%, 48%, and 20%, respectively. At 12 months, the prevalence was 22%, 33%, 39%, and 21%, respectively. The prevalence of any symptoms was 66% at 3 months and 55% at 12 months. Barthel index score at 12 months was improved significantly from that at 3 months. Hospital Anxiety and Depression Scale and Impact of Event Scale - Revised scores at 12 months showed no improvement. Conclusions At 3 and 12 months after ICU discharge, over half of our Japanese patients suffered ADL disability and/or psychiatric symptoms. The ADL disability improved at 1 year, but psychiatric symptoms did not.

Heatstroke management during the COVID-19 epidemic: Recommendations from the experts in Japan.

Abstract: Fever and hyperthermia are the main symptoms of COVID-19 and heatstroke, it is difficult to distinguish them. We came to think that there is a need to discuss safe prevention and medical treatment for heatstroke. In view of the above issues, the Japanese Association for Acute Medicine "Committee on Heatstroke and Hypothermia" established a "Working group on heatstroke medical care given the COVID-19 epidemic" jointly with the Japanese Society for Emergency Medicine that focuses on emergency medical personnel including paramedics and nurses, the Japanese Association for Infectious Diseases, an academic society of infectious disease, and the Japanese Respiratory Society, an academic organization on respiratory diseases. The precautions for prevention of heatstroke this summer during the coronavirus epidemic was summarized in "Proposals on heatstroke prevention based on the COVID-19 epidemic" as follows and was issued on June 1, 2020. Based on the above, we have determined that guidance in clinical practice is necessary not only from the viewpoint of heatstroke prevention, but also from the viewpoint of medical treatment. As such, we have created this guidance in the form of supplementary recommendation.

Environmental maintenance with effective and useful zoning to protect patients and medical staff from COVID-19 infection.

Abstract: Aim The coronavirus disease 2019 (COVID-19) pandemic has accelerated all over the world, and global health-care systems have become overwhelmed with potentially infectious patients seeking testing and care. It is essential to set up effective and useful zoning to prevent the spread of infection to and from medical staff or other patients with effective use of standard precautions with personal protective equipment (PPE). Methods We repurposed a general ward into an acute care unit for severe COVID-19 patients taking into consideration airflow, the direction of movement of medical staff, and prevention of the spread of infection to medical staff and other patients. We checked the daily condition and body temperature of all medical staff for 60 days. Results There was no evidence of COVID-19 infection in any medical staff or other patients during the period thanks to effective and useful zoning with PPE. Conclusion Special wards and rooms should be set up for future protection of medical staff and other patients, and prevent the explosion of COVID-19 infection with effective and useful zoning with PPE.

Anticoagulant therapy for septic coagulopathy and disseminated intravascular coagulation: where do KyberSept and SCARLET leave us?

Abstract: The use of antithrombin and thrombomodulin to restore impaired anticoagulant pathways in septic coagulopathy has been shown to significantly increase the resolution rate of disseminated intravascular coagulation. In KyberSept and SCARLET, two large, international, randomized controlled trials in patients with sepsis, these anticoagulants have not shown significantly reduced mortality. The aim of this assessment was to compare the heterogeneity in responses to treatment in the two trials according to different patient phenotypes. Results of the KyberSept and SCARLET trials reported in original and post-hoc publications were analyzed and directly compared for treatment effects in various patient subgroups. In both KyberSept and SCARLET, the septic coagulopathy phenotype that benefited most from endogenous anticoagulant supplementation showed markers of excessive activation of coagulation. Interaction between concomitant thromboprophylactic heparin and the endogenous anticoagulants abrogated the efficacy of both antithrombin and thrombomodulin. In both trials, higher disease severity was associated with better treatment outcome. In conclusion, in two landmark studies of endogenous anticoagulants in patients with sepsis, similar findings of beneficial effects in the coagulopathy phenotype and interactions with heparin comedication and disease severity support the potential roles that thrombomodulin and antithrombin might play in treating septic coagulopathy and disseminated intravascular coagulation. Further prospective validation is warranted. Future trial designs to definitively establish the therapeutic relevance of antithrombin and thrombomodulin in septic coagulopathy should focus on involvement of patients characterized by coagulopathy and disease severity as well as interactions between endogenous anticoagulants and exogenous heparin.

Lactate and fibrinogen as good predictors of massive transfusion in postpartum hemorrhage.

Abstract: Aim This study aims to identify the clinical factors that can predict the requirement of massive transfusion among patients with postpartum hemorrhage (PPH). Methods Consecutive anonymized patients with PPH who were treated at the emergency department of our perinatal medical center were examined. Patients who had received transfusions before admission, those who had cardiac arrest on arrival, and those without history of blood gas analysis were excluded. Our primary outcome was the requirement of massive transfusion defined as packed red blood cells of ≥10 units/24 h. Univariable logistic analysis was carried out to identify the odds ratio and 95% confidence interval (CI) of the explanatory variables for the outcome. Results A total of 31 patients (massive transfusion, n = 19) were included in the main analysis. The crude odds ratio for fibrinogen per mg/dL and lactate per mmol/L were calculated as 0.98 (95% CI, 0.97-0.99) and 1.62 (95% CI, 1.08-3.02), respectively. The area under the curves for fibrinogen and lactate were 0.814 and 0.734, respectively, and optimal cut-off values for fibrinogen and lactate were 211 mg/dL and 4 mmol/L, respectively. Conclusion These findings suggest that lactate and fibrinogen can be predictors for the requirement of massive transfusion in patients with PPH.

Influence of mutual support and a culture of blame among staff in acute care units on the frequency of physical restraint use in patients undergoing mechanical ventilation.

Abstract: Aim Reducing the use of physical restraint in intensive care units is challenging, and little is known about the influence of culture on physical restraint use in this setting. The present study aims to verify the hypothesis that mutual support and a culture of blame among staff are associated with higher physical restraint use for mechanically ventilated patients. Methods We undertook a survey of nurses in intensive care units caring for mechanically ventilated patients in acute care units. The perceived frequency of physical restraint, mutual support, and culture of blame were measured. We predefined a high frequency physical restraint use group and compared the institutional characteristics, human resources, mutual support, and culture of blame between this group and the others (the control). Results Three hundred and thirty-three responses were analyzed. The mean number of beds per nurse was not significantly different between the groups; the mean and percentage of positive responses about mutual support and a culture of blame were significantly lower in the high frequency physical restraint use group. After adjusting variables in a multivariable regression analysis, a less positive response about the culture of blame was the only independent factor to predict high frequency physical restraint use. Conclusion The study suggests that changing the culture of blame, rather than increasing the number of nurses, is important for reducing physical restraint use.

Prediction of the neurological outcome using regional cerebral oxygen saturation in patients with extracorporeal cardiopulmonary resuscitation after out-of-hospital cardiac arrest: a multicenter retrospective cohort study.

Abstract: Aim To investigate the association between regional cerebral oxygen saturation (rSO2) and neurological outcomes in extracorporeal cardiopulmonary resuscitation (ECPR) patients after out-of-hospital cardiac arrest (OHCA). Methods We used data from the Japan-Prediction of Neurological Outcomes in Patients Post-Cardiac Arrest Registry. This registry included consecutive comatose patients after OHCA who were transferred to 15 hospitals in Japan from 2011 to 2013. Our primary end-point was a good neurological outcome (cerebral performance categories 1 or 2) at 90 days after OHCA. Results Among the enrolled patients, 121 (6.3%) received ECPR. Eleven (9.1%) had a good neurological outcome. Receiver operating characteristic curve analysis revealed the optimal cut-off value as >16%. Good neurological outcomes were observed in 19.6% (9/46) and 2.7% (2/74) of patients with rSO2 >16% and rSO2 ≤16%, respectively. Conclusion The neurological outcome of ECPR patients differed according to their rSO2 values. When considering ECPR, the rSO2 value could be important in addition to other criteria. Further studies that focus on ECPR patients and serial rSO2 values are needed.

Tick anaphylaxis triggered by pulling out the tick

Abstract: Background Reports of tick anaphylaxis are extremely rare in Asian countries, with poor awareness in these regions. Herein, we report a case of tick anaphylaxis that was triggered by pulling out the tick. Case presentation A 66-year-old man developed pruritus in his left toes after returning from a mountain. Three days later, he found a swollen tick biting at the skin between the second and third toes and pulled it out. Approximately 30 min after pulling out the tick, he started to feel a burning sensation in his chest and was brought to our hospital. He was diagnosed with anaphylactic shock (systolic blood pressure, 60 mmHg) and immediately received intramuscular adrenaline. Conclusion To our knowledge, this is the first case of tick anaphylaxis triggered by tick removal in an Asian country. A tick should be removed without pressure on its body, especially in patients with tick or bee allergy.