Search

A 73-year-old man previously treated with rituximab for his mucosa-associated lymphoid tissue lymphoma suffered a suboptimal humoral immune response against an acquired SARS-CoV-2 infection. A detailed serological description revealed discrepant antigen-specific humoral immune responses. The titer of spike-targeting, “viral-neutralizing” antibodies remained below the detection level, in contrast to the anti-nucleocapsid, “binding” antibody response, which was comparable in both magnitude and kinetics. Accordingly, viral neutralizability and clearance was delayed, leading to prolonged RNAemia and persistent pneumonia. The present case highlights the need to closely monitor this unique population of recipients of B-cell-targeted therapies for their neutralizing antibody responses against SARS-CoV-2.

BackgroundHealthcare workers (HCWs) who care for patients with the novel coronavirus infectious disease (COVID-19) are at an increased risk and fear contracting the infection themselves. HCWs are chronically exposed to very intense stress, both and physically and mentally. Hospitals must reduce both the physical and mental burden of HCWs on the front lines and ensure their safety. No prospective study has focused on the physical health complaints among HCWs engaged in the care of critically ill COVID-19 patients. This study aimed to investigate the occupational risk among HCWs of experiencing physical symptoms during the current COVID-19 pandemic.MethodsA twice-weekly questionnaire targeting HCWs who care for COVID-19 patients was performed at Osaka City University Hospital from April 30 to May 31, 2020 using a shareable Research Electronic Data Capture tool. The demographic characteristics of the participants, frequency of exposure to at-risk care, and physical complaints were evaluated.ResultsA total of 35 doctors, 88 nurses, and 35 technicians were engaged in the care of these critically ill COVID-19 patients. 76 HCWs participated in this study, of whom 24 (31.6%) were doctors, 43 (56.6%) were nurses, and 9 (11.8%) were technicians. The frequency of experiencing any physical symptom was 25.0% among HCWs. Exposure to at-risk care was significantly higher among nurses than among doctors (p < 0.001); likewise, the frequency of experiencing physical symptoms was higher among nurses than among doctors (p < 0.01). The multivariate analysis revealed that nurses (odds ratio 8.29; p = 0.01) might be independently at risk of experiencing physical symptoms.ConclusionsOur results indicate that occupational health care at hospitals must be allocated to HCWs who are highly exposed to at-risk care, particularly nurses engaged in the care of COVID-19 patients.

Although the COVID-19 pandemic affects the emergency medical service (EMS) system, little is known about the impact of the COVID-19 pandemic on the prognosis of emergency patients. This study aimed to reveal the impact of the COVID-19 pandemic on the EMS system and patient outcomes. We included patients transported by ambulance who were registered in a population-based registry of patients transported by ambulance. The endpoints of this study were the incident number of patients transported by ambulance each month and the number of deaths among these patients admitted to hospital each month. The incidence rate ratio (IRR) and 95% confidence interval (CI) using a Poisson regression model with the year 2019 as the reference were calculated. A total of 500,194 patients were transported in 2019, whereas 443,321 patients were transported in 2020, indicating a significant decrease in the number of emergency patients transported by ambulance (IRR: 0.89, 95% CI: 0.88–0.89). The number of deaths of emergency patients admitted to hospital was 11,931 in 2019 and remained unchanged at 11,963 in 2020 (IRR: 1.00, 95% CI: 0.98–1.03). The incidence of emergency patients transported by ambulance decreased during the COVID-19 pandemic in 2020, but the mortality of emergency patients admitted to hospital did not change in this study.

Objectives The spread of COVID-19 has affected the incidence of other infectious diseases, but there are no reports of studies using comprehensive regional population-based data to evaluate the impact of COVID-19 on influenza incidence. We attempted to evaluate the impact of COVID-19 on influenza using the population-based ORION (Osaka Emergency Information Research Intelligent Operation Network) registry. Methods The ORION registry of emergency patients treated by emergency medical service (EMS) personnel was developed by the Osaka Prefecture government. From ORION, we included emergency patients with influenza using the ICD (International Statistical Classification of Diseases and Related Health Problems) 10 codes. Influenza incidence rate ratio (IRR) and associated 95% CI were calculated. Results The number of influenza patients transported by EMS decreased during the COVID-19 pandemic. The IRR showed a substantial decrease in influenza patients in 2020 (IRR 2020/2018 0.39, 95% CI 0.37–0.41). Conclusions A comprehensive regional analysis using the population-based ORION registry confirmed that from January 2020, when the first confirmed cases of COVID-19 infection were reported in Osaka, Japan, the number of influenza patients transported by EMS decreased dramatically.

BackgroundThe symptoms of severe COVID-19 are complex and wide-ranging even in intensive care unit (ICU) patients, who may successfully discontinue respiratory support in a short period or conversely require prolonged respiratory support. Damage in the lungs of COVID-19 patients is characterized pathologically as diffuse alveolar damage, the degree of which correlates with the severity of the disease. We hypothesized that the ventilatory ratio (VR), a surrogate parameter for the dead space fraction, might stratify the severity of COVID-19 and predict the successful discontinuation of respiratory support.MethodsForty COVID-19 patients in our ICU were enrolled in this study. Respiratory variables were collected from 2 hours (day 0) after the initiation of respiratory support. We monitored the longitudinal values of VR and other respiratory parameters for 28 days. Patients successfully discontinued from respiratory support by day 28 of ICU stay were defined as the successfully discontinued group, while those who died or failed to discontinue were defined as the failed to discontinue group. VR and other respiratory parameters were compared between these groups.ResultsExcept for advanced age, prolonged ventilation period, and higher mortality in the failed to discontinue group, there were no significant differences between the groups in terms of any other background or respiratory parameter at 2 hours (day 0) after initiation of respiratory support. Longitudinal VR monitoring revealed significantly higher VR values in the failed to discontinue group than the successfully discontinued group on day 4 of respiratory support. Upon predicting the failure to discontinue respiratory support, the area under the receiver operating characteristic curve of VR values on day 4 of respiratory support was 0.748. A threshold of 1.56 achieved the highest predictive performance with a sensitivity of 0.667 and a specificity of 0.762. This threshold enabled the prediction of the successfully discontinued outcome at 0.810 of the negative predictive value.ConclusionsElevated VR values on day 4 of respiratory support were predictive of successful discontinuation of respiratory support in patients with severe COVID-19. Longitudinal VR values after initiation of respiratory support can be used as a practical index to stratify severe COVID-19.

The prompt rollout of the coronavirus disease (COVID-19) messenger RNA (mRNA) vaccine is facilitating population immunity, which shall become more dominant than natural infection-induced immunity. At the beginning of the vaccine era, understanding the epitope profiles of vaccine-elicited antibodies will be the first step in assessing functionality of vaccine-induced immunity. In this study, the high-resolution linear epitope profiles of Pfizer-BioNTech COVID-19 mRNA vaccine recipients and COVID-19 patients were delineated by using microarrays mapped with overlapping peptides of the receptor binding domain (RBD) of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spike protein. The vaccine-induced antibodies targeting RBD had broader distribution across the RBD than that induced by the natural infection. Thus, relatively lower neutralizability was observed when a half-maximal neutralization titer measured in vitro by live virus neutralization assays was normalized to a total anti-RBD IgG titer. However, mutation panel assays targeting the SARS-CoV-2 variants of concern have shown that the vaccine-induced epitope variety, rich in breadth, may grant resistance against future viral evolutionary escapes, serving as an advantage of vaccine-induced immunity.ImportanceEstablishing vaccine-based population immunity has been the key factor in attaining herd protection. Thanks to expedited worldwide research efforts, the potency of messenger RNA vaccines against the coronavirus disease 2019 (COVID-19) is now incontestable. The next debate is regarding the coverage of SARS-CoV-2 variants. At the beginning of this vaccine era, it is of importance to describe the similarities and differences between the immune responses of COVID-19 vaccine recipients and naturally infected individuals. In this study, we demonstrated that the antibody profiles of vaccine recipients are richer in variety, targeting a key protein of the invading virus, than those of naturally infected individuals. Yet vaccine-elicited antibodies included more non-neutralizing antibodies than infection-elicited, their breadth in antibody variations suggested possible resilience against future SARS-CoV-2 variants. The antibody profile achieved by vaccinations in naive individuals pose important insight into the first step towards vaccine-based population immunity.

Background When children suffer sudden illness or injury, many parents wonder whether they should go to the hospital immediately or call an ambulance. In 2015, we developed a mobile app that allows parents or guardians to determine the urgency of their child’s condition or call an ambulance and that indicates available hospitals and clinics when their child is suddenly sick or injured by simple selection of the child’s chief complaints and symptoms. However, the effectiveness of medical apps used by the general public has not been well evaluated. Objective The purpose of this study was to clarify the use profile of this mobile app based on data usage in the app. Methods This study was a descriptive epidemiological study with a 4-year study period running from January 2016 to December 2019. We included cases in which the app was used either by the children themselves or by their parents and other guardians. Cases in which the app was downloaded but never actually used were excluded from this study. Continuous variables are presented as median and IQR, and categorical variables are presented as actual number and percentages. Results The app was used during the study period for 59,375 children whose median age was 1 year (IQR 0-3 years). The app was used for 33,874 (57.05%) infants, 16,228 (27.33%) toddlers, 8102 (13.65%) elementary school students, and 1117 (1.88%) junior high school students, with 54 (0.09%) having an unknown status. Furthermore, 31,519 (53.08%) were male and 27,329 (46.03%) were female, with sex being unknown for 527 (0.89%) children. “Sickness” was chosen for 49,101 (78.51%) patients, and “injury, poisoning, foreign, substances and others” was chosen for 13,441 (21.49%). For “sickness,” “fever” was the most commonly selected option (22,773, 36.41%), followed by “cough” (4054, 6.48%), and “nausea/vomiting” (3528, 5.64%), whereas for “injury, poisoning, foreign substances and others,” “head and neck injury” was the most commonly selected option (3887, 6.22%), followed by “face and extremities injury” (1493, 2.39%) and “injury and foreign substances in eyes” (1255, 2.01%). Conclusions This study clarified the profile of use of a self-triage app for pediatric emergency patients in Japan.

Blunt traumatic aortic injury (BTAI) patients are severely ill, with high mortality and morbidity. As 60% of BTAIs occur in the distal arch, left subclavian artery (LSCA) management is determined without knowing posterior cerebral or left arm circulation in emergent cases. Because we perform thoracic endovascular aortic repair (TEVAR) + debranching technique for thoracic BTAI, we assessed efficacy and safety of debranching TEVAR in BTAI patients. We retrospectively reviewed vital signs on arrival, injury mechanism, characteristics, clinical time-series, concomitant injuries, injury description, operative procedures, and results from patient records. We excluded patients in cardiopulmonary arrest on arrival. From April 2014 to December 2018, nine of 25 patients admitted with BTAI underwent TEVAR. Median Injury Severity Score was 34 (29–34) and probability of survival was 0.82 (0.16–0.94). Society for Vascular Surgery BTAI injury grade was III or IV in all patients. Three patients underwent simple TEVAR and six underwent debranching TEVAR (LSCA occlusion + left common carotid artery to LSCA bypass). Median operation time was 108 (75–157) min for simple TEVAR and 177 (112–218) min for debranching TEVAR. Concomitant injuries included intracranial hemorrhage (N = 1), intra-abdominal injuries (N = 3), pneumo- or hemothoraxes (N = 4) and pelvic/extremities fractures (N = 7). Only one complication of left-hand claudication occurred postoperatively in a patient with simple TEVAR with LSCA occlusion. Despite debranching TEVAR taking approximately 60 min longer than simple TEVAR, short-term results indicated it to be acceptable for BTAI in multiple trauma patients to avoid LSCA complications unless we fail to stop bleeding first.

Transesophageal echocardiography is mandatory if you do suspect infective endocarditis. By approaching via a small right thoracotomy, vegetectomy and mitral valvuloplasty following severe mediastinitis were successfully accomplished without any complications., The huge vegetation attached between the mitral annulus and left ventricular posterior wall (Yellow arrow).

Background; Novel corona virus (COVID-19) outbreaks have spread worldwide. Although the COVID-19 pandemic affects the emergency medical service (EMS) system, which is one factor of primary care, little is known about its impact. This study aimed to reveal the impact of the COVID-19 pandemic on the EMS system and outcome of patients transported by ambulance.Methods; This was a retrospective study with a study period from 1 January 2020 to 31 May 2020. We included patients transported by ambulance who were registered in a population-based registry of patients transported by ambulance. The endpoints of this study were the incident number of patients transported by ambulance each month and the number of deaths among these patients admitted to hospital each month. We calculated the incidence rate ratio (IRR) and 95% confidence interval (CI) using a Poisson regression model with year 2019 as the reference.Results; From January to May 2019, 205,195 patients were transported, whereas from January to May 2020, 180,362 patients were transported, indicating a significant decrease in the number of emergency patients transported by ambulance (IRR: 0.88, 95% CI: 0.87–0.88). The number of deaths among emergency patients admitted to hospital was 5237 in January-May 2019 and remained unchanged at 5172 in January-May 2020 (IRR: 0.99, 95% CI: 0.95–1.03).Conclusion; The first surge of the COVID-19 pandemic had no adverse effect on the EMS system in Osaka Prefecture, Japan.

CAPA (COVID-19 associated pulmonary aspergillosis) is an important complication of COVID-19. It has been reported that the incidence of CAPA is as high as 19%-33% worldwide. However, its onset has not been reported in Japan. A 72-year-old Japanese man was diagnosed with COVID-19 and was transferred to our hospital due to deterioration of respiratory condition. Treatment with remdesivir, dexamethasone (DEXA), and antibiotics was performed under mechanical ventilation. Although the condition improved temporarily, a new shadow appeared in the lung, and Aspergillus fumigatus was cultured from sputum. The patient was clinically diagnosed with CAPA and treated with voriconazole. However, his progress deteriorated and he died. High-risk COVID-19 patients should be tested for Aspergillus to ensure early diagnosis of CAPA.

Background: Novel corona virus (COVID-19) outbreaks have spread worldwide. Although the COVID-19 pandemic affects the emergency medical service (EMS) system, which is one factor of primary care, little is known about its impact. This study aimed to reveal the impact of the COVID-19 pandemic on the EMS system and outcome of emergency patients transported by ambulance in Osaka Prefecture, Japan. Methods: This was a retrospective study with a study period from 1 January 2020 to 31 May 2020. We included patients transported by ambulance who were registered in a population-based registry of emergency patients transported by ambulance. The primary endpoints of this study were the incident number of patients transported by ambulance each month and the number of deaths among emergency patients admitted to hospital each month. We calculated the incidence rate ratio (IRR) and 95% confidence interval (CI) using a Poisson regression model with year 2019 as the reference. Findings: From January to May 2019, 205,195 patients were transported, whereas from January to May 2020, 180,362 patients were transported, indicating a significant decrease in the number of emergency patients transported by ambulance (IRR: 0.88, 95% CI: 0.87–0.88). The number of deaths among emergency patients admitted to hospital was 5237 in January-May 2019 and remained unchanged at 5172 in January-May 2020 (IRR: 0.99, 95% CI: 0.95–1.03). Interpretation: The first surge of the COVID-19 pandemic had no adverse effect on the EMS system in Osaka Prefecture, Japan. Funding: Japanese Society of the Promotion of Science KAKENHI (grant no. JP18H02902). Declaration of Interests: All authors of this manuscript declared that they have no conflicts of interest that relate to the content of this manuscript. Ethics Approval Statement: This study was approved by the Ethics Committee of Osaka University Graduate School of Medicine (approval no. 15003).

Aim To assess the impact of the Summit on Financial Markets and the World Economy held in Osaka City, Japan (G20 Osaka Summit) on the emergency medical services (EMS) system. Methods This study used the ORION database with its population-based registry of emergency patients comprising both ambulance and in-hospital records in Osaka Prefecture, Japan. The G20 Osaka Summit was held in Osaka City from 28 to 29 June, 2019. Changes in the EMS system and traffic regulations in Osaka were made during the period from 27 to 30 June, but we focused on the two summit days as the G20 period. The control periods comprised the same calendar days 1 week before and 1 week after the G20 period. We evaluated differences in the number of emergency transports, difficulties in obtaining hospital acceptance of patients, deaths among hospitalized emergency patients, and ambulance transport times between the two periods. Results In total, 2,590 cases in the G20 period and 5,152 cases in the control periods were registered. The relative risk of cases during the G20 versus control periods was 1.01 (0.96-1.05). Significant decreases were observed in the number of traffic accidents as ambulance calls (relative risk = 0.77; 95% confidence interval, 0.64-0.91). There were no significant differences in difficulties in obtaining hospital acceptance or deaths among hospitalized emergency patients between the G20 and control periods. In addition, ambulance transport times during the G20 period were not significantly longer than those in the control periods. Conclusion The G20 Osaka Summit did not adversely impact the provision of emergency medical care in the Osaka area.

Mass gatherings are events characterized by “the concentration of people at a specific location for a specific purpose over a set period of time that have the potential to strain the planning and response resources of the host country or community.” Previous reports showed that, as a result of the concentration of people in the limited area, injury and illness occurred due to several factors. The response plan should aim to provide timely medical care to the patients and to reduce the burden on emergency hospitals, and to maintain a daily emergency medical services system for residents of the local area. Although a mass gathering event will place a significant burden on the local health‐care system, it can provide the opportunity for long‐term benefits of public health‐care and improvement of daily medical service systems after the end of the event. The next Olympic and Paralympic Games will be held in Tokyo, during which mass gatherings will occur on a daily basis in the context of the coronavirus disease (COVID‐19) epidemic. The Academic Consortium on Emergency Medical Services and Disaster Medical Response Plan during the Tokyo Olympic and Paralympic Games in 2020 (AC2020) was launched 2016, consisting of 28 academic societies in Japan, it has released statements based on assessments of medical risk and publishing guidelines and manuals on its website. This paper outlines the issues and countermeasures for emergency and disaster medical care related to the holding of this big event, focusing on the activities of the academic consortium., This article describes medical problems, tasks, and topics at mass gathering events. It also introduces the current activities of the Academic Consortium on Emergency Medical Services and Disaster Medical Response Plan during the 2020 Tokyo Olympics (AC2020), consisting of 28 medical societies in Japan.

In this study, we merged the telephone triage data set with the ORION data set and revealed the profile and outcome of patients transported by ambulance after telephone triage. Most of the patients who were transported by ambulance after telephone triage returned home after visiting the emergency department, and cerebral infarction was the most common diagnosis among the patients who were hospitalized., Aim Details such as diagnosis and outcome of patients transported by ambulance after telephone triage have not been fully revealed. The aim of this study was to reveal profile and outcome about patients transported by ambulance via telephone triage with dataset of telephone triage and population‐based registry for emergency patients. Methods This retrospective descriptive study with a one‐year study period from January 1, 2016 to December 31, 2016 included patients selected from the telephone triage dataset who were transported by ambulance. Key parameters such as age, sex and date and time of ambulance dispatch were used to identify patient data from the ORION registry. We assessed the profile and outcome of the patients in a descriptive epidemiological analysis. Results We included 4,293 patients in the selected datasets whose data were merged, of whom 2,998 patients (69.8%) returned home from the emergency department, 1,255 (29.2%) were hospitalized, 32 (0.7%) were transferred to other hospitals, and 8 (0.2%) died. The most common diagnosis in the emergency departments was “infectious gastroenteritis and colitis, unspecified [A09] (219, 5.1%)”. Among the 1,255 hospitalized patients, 905 patients (72.1%) were discharged home, 254 patients (20.2%) remained hospitalized, 52 patients (4.1%) were transferred to other hospitals, 38 patients (3.0%) died, and 5 patients (0.5%) had missing data. The most common diagnosis was “cerebral infarction [I63.0‐I63.9] (138, 11.0%)”. Conclusion This study revealed the profile and outcome of patients transported by ambulance after telephone triage.

Background When resuscitating patients with hemorrhagic shock following trauma, fluid volume restriction and permissive hypotension prior to bleeding control are emphasized along with the good outcome especially for penetrating trauma patients. However, evidence that these concepts apply well to the management of blunt trauma is lacking, and their use in blunt trauma remains controversial. This study aimed to assess the impact of vasopressor use in patients with blunt trauma in severe hemorrhagic shock. Methods In this single-center retrospective study, we reviewed records of blunt trauma patients with hemorrhagic shock and included patients with a probability of survival Results Forty patients admitted from April 2014 to September 2019 were included. Median Injury Severity Score in survivors vs non-survivors was 41 (36–48) vs 45 (34–51) (p = 0.48), with no significant difference in probability of survival between the two groups (0.22 [0.12–0.48] vs 0.21 [0.08–0.46]; p = 0.93). Despite no significant difference in patient characteristics and injury severity, non-survivors were administered vasopressors significantly earlier after admission and at significantly higher doses. Total blood transfusion amount administered within 24 h after admission was significantly higher in survivors (8430 [5680–9320] vs 6540 [4550–7880] mL; p = 0.03). Max catecholamine index was significantly higher in non-survivors (2 [0–4] vs 14 [10–18]; p = 0.008), and administered vasopressors were terminated significantly earlier (12 [4–26] vs 34 [10–74] hours; p = 0.026) in survivors. Although the variables of severity of the patients had no significant differences, vasopressor use (Odds ratio [OR] = 21.32, 95% confident interval [CI]: 3.71–121.6; p = 0.0001) and its early administration (OR = 10.56, 95%CI: 1.90–58.5; p = 0.005) indicated significant higher risk of death in this study. Conclusion Vasopressor administration and high-dose use for resuscitation of hemorrhagic shock following severe blunt trauma are potentially associated with increased mortality. Although the transfused volume of blood products tends to be increased when resuscitating these patients, early termination of vasopressor had better to be considered.

Aim Management of traumatic pancreatic injury is challenging, and mortality and morbidity remain high. Because pancreatic injury is uncommon and strong recommendations for pancreatic injury management are lacking, management is primarily based on institutional practices. We propose our strategy of pancreatic injury management. Methods We retrospectively reviewed patients with pancreatic injury and evaluated our strategy and outcomes. Results From January 2013 to December 2019, 18 patients were included with traumatic pancreatic injury. The median Injury Severity Score was 22 (25–75% interquartile range, 17–34) and probability of survival was 0.87 (25–75% interquartile range, 0.78–0.93). Patients were grouped according to the American Association for the Surgery of Trauma injury grades: grade I, n = 3 (16.7%); II, n = 6 (33.3%); III, n = 7 (38.9%); and IV, n = 2 (11.1%). All patients underwent endoscopic pancreatic ductal evaluation within 1–2 days after admission. Abbreviated surgery because of hemodynamic instability and subsequent open abdominal management were undertaken in one patient with pancreas head injury and two patients with pancreas body/tail injury. Management was by laparotomy for closed suction drain insertion with main ductal endoscopic drainage in six patients, endoscopic ductal drainage only in six patients, and distal pancreatectomy with closed suction drainage and endoscopic drainage in five patients. One patient with grade I injury underwent observation only. Median length of closed suction drainage was 12 days and that of hospital stay was 36 days. The observed mortality during the study period was 0%. Late formation of pseudo‐pancreatic cyst was observed in two patients (11.1%). Conclusion Our uniform, simplified strategy offers good outcomes for any pancreatic injury site and any concomitant injuries, even in hemodynamically unstable patients., Because pancreatic injury is uncommon and strong recommendations for pancreatic injury management are lacking, management is primarily based on institutional practices. We propose our strategy of pancreatic injury management with acceptable outcome, and no unexpected complications or critical delays in treatment were observed.

Aim Blunt injuries to visceral organs have the potential to lead to delayed pseudoaneurysm formation or organ rupture, but current trauma and surgical guidelines do not recommend repetitive imaging. This study examined the incidence and timing of delayed undesirable events and established advisable timing for follow‐up imaging and appropriate observational admission. Methods Patients with blunt splenic (S), liver (L), or kidney (K) injury treated with non‐operative management (NOM) in our institution were included and retrospectively reviewed. Results From January 2013 to January 2017, 57 patients were admitted with documented blunt visceral organ injuries and 22 patients were excluded. Of 35 patients (L, 10; S, 17; K, 6; L & S, 1; S & K, 1) treated with NOM, 14 (L, 4; S, 9; K, 1) patients underwent transcatheter arterial embolization. Delayed undesirable events occurred in four patients: three patients with splenic pseudoaneurysm on hospital day 6–7 and one patient with splenic delayed rupture on hospital day 7. The second follow‐up computed tomography scan carried out 1–2 days after admission did not show any significant findings that could help predict undesirable results of delayed events. The patients with delayed events had longer continuous abdominal pain than that of event‐free patients (P = 0.04). Conclusions Undesirable delayed events were recognized on follow‐up computed tomography scans in 11.4% of NOM patients at hospital day 6–7 and tended to be associated with high‐grade splenic injuries and continuous symptoms. Repetitive screening of these patients 6–7 days after injury might be warranted because of the potential risk of delayed events.

Purpose This study aimed to investigate incidence, risk factors, and outcomes for sepsis-associated delirium (SAD) in mechanically ventilated patients. Materials and methods We performed a retrospective post-hoc analysis of the DExmedetomidine for Sepsis in Intensive care unit Randomized Evaluation (DESIRE) trial. Outcomes included 28-day mortality, ventilator-free days, length of ICU stay, self-extubation, and re-intubation. Multivariable analysis was performed to identify variables independently associated with SAD. Results We retrospectively divided the patients into two groups: delirium group (n = 89) and non-delirium group (n = 98). There were no significant differences between the groups in 28-day mortality, self-extubation, and re-intubation. The number of ventilator-free days was significantly less in the delirium vs. non-delirium group (17 vs. 22 days, p = .006), and the length of ICU stay was significantly longer in the delirium group (10 vs. 5 days, p = .04). Multivariable analyses revealed that emergency surgery, more doses of midazolam, and fentanyl were independent predictors for SAD. Conclusions SAD was associated with a less number of ventilator-free days and longer length of ICU stay. Emergency surgery, more doses of midazolam, and fentanyl may be independent risk factors for SAD in mechanically ventilated patients with sepsis.

Background Disseminated intravascular coagulation (DIC) associated with multiple organ dysfunction syndrome (MODS) plays pivotal roles in severe sepsis. Objectives We performed a multicenter, prospective data collection study and retrospectively analyzed the data to confirm the role of DIC in severe sepsis. Methods Eligible patients were ICU patients who met the definitions of severe sepsis, and 1013 patients were included. DIC scores as well as disease severity and the development of MODS on the day of the diagnosis of severe sepsis (day 0) and at day 3 were evaluated. The primary outcome was hospital mortality, and MODS on days 0 and 3 was the secondary outcomes. Results The overall mortality rate of severe sepsis was 21.5%, and the prevalence of DIC was 50.9% (516/1013). DIC patients were more seriously ill and exhibited a higher prevalence of MODS (32.0% vs. 13.1%) on day 0 and worse mortality rate (24,8% vs. 17.5%) than non-DIC patients. DIC patients also showed a lower survival probability than non-DIC patients (Log rank p = 0.028). Logistic regression analyses after propensity score adjustment for potential confounders confirmed a significant association between DIC and MODS and hospital death in the patients with severe sepsis. The new development of DIC and persistent DIC from days 0 to 3 were associated with a high incidence of MODS and low survival probability. Conclusions The mortality rate of severe sepsis has been improved; however, DIC is still associated with the poor prognosis of these patients. Evaluating the dynamic changes in the DIC status may improve the prediction capability.

Background: Blunt vertebral artery injury (VAI) is uncommon, but it can cause neurologic deficits. Early diagnosis and treatment before the onset of neurological sequelae are important. The Advanced Trauma Life Support® (ATLS) program has published screening criteria for VAI. The major treatments of VAI are anticoagulation therapy and endovascular therapy, but the management of VAI remains controversial. Methods: We retrospectively investigated the patients with blunt cervical spine injury treated at the trauma and critical care center in Osaka City University Hospital and analyzed the efficiency of the ATLS screening criteria and the treatment of VAI. Results: One hundred fourteen patients were diagnosed as having cervical spine injury. Contrast-enhanced whole-body computed tomography was performed in 82 patients, and 13 patients were diagnosed as having VAI. Among the 114 patients, 73 patients met the ATLS screening criteria for investigating VAI, and 12 of the 13 (92.3%) VAI patients met the ATLS screening criteria. Among these 13 patients, antithrombotic therapy was performed in 9 patients but was not performed in the other 4 patients due to other injuries. Seven patients required urgent surgery. Prophylactic coiling to completely occlude the injured vertebral artery was performed before the operation or reduction in 4 patients. Two of the 13 VAI patients showed subsequent cerebellar infarction; both of them was not received antithrombotic therapy and had bilateral VAIs. Conclusion: ATLS screening criteria have high sensitivity for the diagnosis of VAI. Bilateral VAI and no antithrombotic therapy are risk factors for subsequent cerebellar infarction. Coiling of the obstructed vertebral artery might be effective in preventing infarction, but a randomized controlled study would be required to evaluate the efficacy of this endovascular treatment.

BackgroundRecently, interest has increased in surgical fixation for severe thoracic wall injury with good short-term outcomes. However, few reports have evaluated long-term outcomes or complications. This study aimed to assess long-term quality of life and implant-related complications after rib fixation for flail chest and multiple rib fractures.MethodsWe interviewed patients who had undergone rib fixation from January 2014 to December 2019 about their current ability to work and their usual life.ResultsTwenty-two patients underwent rib fixation during the study period. Two patients with flail chest had already died after the surgery due to senescence; thus, follow-up information was obtained from 20 patients (91%), with a follow-up duration of 47.5 (IQR 22–58) months. The most undesirable event occurring during the study period was irritation caused by a palpable plate (n=2, 10%), probably due to the thin skin of patients over 70 years old. Eighteen patients were able to return to their usual life or same work as in the premorbid state with no complaints. Two patients are still undergoing rehabilitation due to concomitant extremities fractures. The median EQ-5D-5L index score was 0.89 (IQR 0.84–0.93). There were no implant-related complications requiring plate explantation.DiscussionWe concluded that rib fixation offers good long-term benefits, with the ability of the patient with flail chest or multiple rib fractures to return to activity in the premorbid state. Elderly patients especially with thin, soft tissue may complain of irritation caused by the plate and should be informed of this prior to surgery.Level of evidenceLevel IV therapeutic care/management.

The prediction of pulmonary deterioration in patients with smoke inhalation injury is important because this influences the strategy for patient management. We hypothesized that narrowing of the luminal bronchus due to bronchial wall thickening correlates to respiratory deterioration in smoke inhalation injury patients.In a prospective observational study, all patients were enrolled at a single tertiary trauma and critical care center. In 40 patients, chest computed tomographic images were obtained within a few hours after smoke inhalation injury. We assessed bronchial wall thickness and luminal area % on chest computed tomographic images. Airway wall thickness to total bronchial diameter (T/D) ratio, percentage of luminal area, and clinical indices were compared between patients with smoke inhalation injury and control patients.The T/D ratio of patients with smoke inhalation was significantly higher than that of control patients (p0.001), and the luminal area of these patients was significantly smaller than that of control patients (p0.001). The number of mechanical ventilation days correlated with the initial infusion volume, T/D ratio, and luminal area %. ROC analysis showed a cut-off value of 0.26 for the T/D ratio, with a sensitivity of 79.0% and specificity of 73.7%, and a value of 23.4% for luminal area %, with a sensitivity of 68.4% and specificity of 84.2%.These data revealed the utility of computed tomography scanning on admission to show that the patients with smoke inhalation injury had airway wall thickening compared to control patients without smoke inhalation injury. Airflow narrowing due to airway wall thickening was related to the development of pneumonia and the number of mechanical ventilation days in patients with smoke inhalation injury. Airflow narrowing is one important factor of respiratory deterioration in smoke inhalation injury.

Case A 47-year-old man was admitted after a car collision in shock with cardiac tamponade. After his circulation was stabilized by pericardial drainage, we treated him conservatively. Abnormal laboratory data and initial electrocardiogram (ECG) were suggestive of myocardial injury. However, echocardiography and cardiac computed tomography could not reveal the cause of the tamponade or the site of cardiac injury. ECG-gated cardiac magnetic resonance images were acquired. Outcome The cardiac magnetic resonance black-blood T2-weighted images showed hyperintense signals in the interventricular septum, whereas the late gadolinium enhancement images showed no enhancement in this region. We could accurately diagnose cardiac contusion of the anteroseptal area, which would explain the initial ECG abnormality seen in this patient. Conclusion Cardiac magnetic resonance imaging may be especially useful in the evaluation of non-operative management of blunt cardiac injury and could explain the initial ECG abnormality seen in our patient.

ObjectivesAfter the 2011 Great East Japan Earthquake, the resource utilization of and the problems encountered with communication devices were examined.MethodsA questionnaire survey was submitted to disaster medical assistance teams (DMATs) that were at the primary sites of destruction after the earthquake.ResultsWe collected data from 196 teams. During the first 4 days after the earthquake, the use of mobile phones, laptop computers, and landline phones was rated as poor to moderate, and satisfaction was very low, while satisfaction with satellite phones was rated as good to moderate (50%). The degree of satisfaction continued to increase gradually over time. Satellite phones, however, had several problems: poor reception, line instability, voice call use only, and inability to send large amounts of data.ConclusionsTo ensure effective communication during the acute phase in the aftermath of large disasters, a new satellite communication device is needed that not only is portable, battery powered, and able to send large volumes of data, but also offers stable communication. (Disaster Med Public Health Preparedness. 2014:0:1–4)

Aim We examined recent relevant prognostic factors for the outcome of open surgical treatment of ruptured abdominal aortic aneurysm. Methods Between 2006 and 2012, 35 patients received emergency open surgical treatment for ruptured abdominal aortic aneurysm at our institute. We reviewed ambulance activity logs and clinical records of 34 infrarenal ruptured abdominal aortic aneurysm patients retrospectively. Univariate and multivariate logistic regression analyses were carried out to identify risk factors for surgical outcomes. Results Eight patients died during surgery or within a few hours following surgery completion. Through univariate analysis, body mass index, serum lactate level, arterial blood pH, base excess, platelet count, prothrombin time–international normalized ratio, activated partial thromboplastin time, type of ruptured aneurysm, response to i.v. fluid resuscitation within 2,000 mL in the initial therapy, and volume of blood loss during surgery were detected to be significant variants. Multivariate logistic regression analysis revealed the patients who were hemodynamically stabilized after primary volume loading had a 13.2 times higher possibility of survival. Body mass index, high serum lactate level, and volume of blood loss were also found to be independent risk factors of mortality. Conclusion The risk factors of open surgical ruptured abdominal aortic aneurysm repair, body mass index, lactate level, volume of intraoperative blood loss, and response to initial 2,000 mL fluid resuscitation were correlated to survival.

Background Mobile intra-aortic thrombus without atherosclerosis, aneurysm, or congenital coagulopathy is very rare, and there are few reports especially in young or middle-aged patients. Furthermore, there are presently no established guidelines or common strategies for the treatment of mobile intra-aortic thrombus. In this case report, we describe the first case of intra-aortic thrombus caused by secondary erythrocytosis and describe the recommended treatment strategy for intra-aortic thrombus. Case presentation We report a case of an independent 40-year-old Asian man with a current history of heavy cigarette smoking who had sudden onset of abdominal and lumbar pain. Contrast-enhanced computed tomography revealed partial renal and splenic infarction, and he was transferred to our hospital. He also had a large mural thrombus in his thoracoabdominal aorta. Blood analysis on admission showed a hemoglobin level of 19.4 g/dL and hematocrit of 54.3 %; his international normalized ratio of prothrombin time, fibrin degradation products, and activated partial thromboplastin time levels were 1.02, 2.8 μg/ml, and 26.9 seconds respectively. We could find no abnormalities in protein C and protein S activity levels. Lupus anticoagulant and anti-cardiolipin antibody were both negative. He had no past medical history of arrhythmia and we found no signs of an arrhythmic event during admission. We promptly started anticoagulant therapy, but as the thrombus seemed at high risk of causing further critical infarction, we performed emergency aortic thrombectomy using partial extracorporeal circulation. To prevent dissemination of the thrombus during extracorporeal circulation, we first clamped his proximal and distal aorta on either side of the thrombus just before initiating extracorporeal circulation. After the aortotomy we removed a 14-cm length of intra-aortic thrombus without residual lesion. He was discharged from our hospital 20 days after surgery. From the results of his blood analysis, we considered the only cause of this thrombus was secondary erythrocytosis, which was probably induced by his current heavy cigarette smoking. Conclusion We are the first to report such a thrombosis caused by secondary erythrocytosis and conclude that once the diagnosis of intra-aortic thrombus with systemic embolism is clear, emergency surgical removal of such a thrombus must be considered to prevent further embolic complications.

The purpose of this study was to assess the effects of recent surgical rib fixation and establish its indications not only for flail chest but also for multiple rib fractures. Between 2007 and 2015, 187 patients were diagnosed as having multiple rib fractures in our institution. After the propensity score matching was performed, ten patients who had performed surgical rib fixation and ten patients who had treated with non-operative management were included. Categorical variables were analyzed with Fischer’s exact test and non-parametric numerical data were compared using the Mann–Whitney U test. Wilcoxon signed-rank test was performed for comparison of pre- and postoperative variables. All statistical data are presented as median (25–75 % interquartile range [IQR]) or number. The surgically treated patients extubated significantly earlier than non-operative management patients (5.5 [1–8] vs 9 [7–12] days: p = 0.019). The duration of continuous intravenous narcotic agents infusion days (4.5 [3–6] vs 12 [9–14] days: p = 0.002) and the duration of intensive care unit stay (6.5 [3–9] vs 12 [8–14] days: p = 0.008) were also significantly shorter in surgically treated patients. Under the same ventilating conditions, the postoperative values of tidal volume and respiratory rate improved significantly compared to those values measured just before the surgery. The incidence of pneumonia as a complication was significantly higher in non-operative management group (p = 0.05). From the viewpoints of early respiratory stabilization and intensive care unit disposition without any complications, surgical rib fixation is a sufficiently acceptable procedure not only for flail chest but also for repair of severe multiple rib fractures.

わが国では,1996年にトリアージタッグが標準化され,消防庁書式タッグが本邦のタッグとして広く用いられている。しかし,実際に訓練で使用すると,煩雑さのために記入漏れが多く,必ずしも満足のいく結果が得られていない。そこで,まずトリアージ方法の標準化を図り,一次トリアージはSTART (simple triage and rapid treatment)変法を,二次トリアージは「緊急度・重症度評価と病院選定基準」に基づいたトリアージ方法を採用したうえで,標準化タッグの自由裁量部分に改良を加えた新書式タッグを作製した。表面には,START変法による手順と判定基準を明記した。裏面には,生理学的指標,解剖学的指標と処置内容を時系列で記載できる欄を設け,さらに赤と判定すべき指標を明記した。今回われわれは,新書式タッグの有用性を検証するために救急救命士養成学校の学生80名を対象としたトリアージ訓練を行い,新書式タッグ群と消防庁書式タッグ群において,タッグへの記載内容,記載頻度,トリアージの正確性および訓練後のアンケート結果について比較検討した。一次トリアージでは,トリアージの判断根拠となった所見の記載率が,新書式タッグ群では高率であった。一方,二次トリアージでは,バイタルサインや意識レベルの記載が新書式タッグ群では全例行われていたが,消防庁書式タッグ群では低頻度であった。トリアージの正確性については,一次トリアージでは新書式タッグ群のほうがより高頻度に正答していたが,二次トリアージでは有意な差は認めなかった。訓練後のアンケートでは,新書式タッグの使用感の評価が高かった。今回の検討から,トリアージ方法を標準化したうえで新書式タッグを使用することによって,消防庁書式タッグに比べてより的確な重症度評価ができるようになり,さらにバイタルサインなどの傷病者情報の把握が容易となることが明らかとなった。

われわれは,傷病者のアンダートリアージを回避するために,2001年より泉州二次医療圏に米国外科学会の基準を一部改変した搬送先選定基準を導入した。今回,その導入が外傷死亡率に及ぼす効果について検討した。対象は,1999年1月より2003年8月の間に泉州医療圏内から当センターに搬入された鈍的外傷患者である。このうち,搬入時期が1999年1月から2000年12月までの2年間の症例を基準導入前群,救急隊員への周知が徹底した2001年9月から2003年8月までの症例を基準導入後群と群分けし,搬入経路,直送時間,重症度,トリアージ,死亡率の変化を検討した。搬送先選定基準の導入に伴い,各2年間に搬入された鈍的外傷の数は,基準導入前の270例から501例へと増加した。基準の導入により,現場での救急隊員のオーバートリアージは37.6%から55.9%へと増加し(p

Purpose: Effective hepatic blood flow (EHBF) is thought to reflect splanchnic perfusion and the metabolic state of the liver. This study was conducted to examine the relationship between cardiac output (CO) and EHBF using pulse dye-densitometry (PDD) in nonseptic and septic patients, and to assess the prognostic value of this relationship. Methods: The subjects were 33 critically ill patients, 16 of whom met the criteria for sepsis. Indocyanine green (ICG) was given via a central venous catheter to each patient. CO (l/min) and EHBF (l/min) were assessed with PDD. Results: CO and EHBF were significantly correlated in the nonseptic patients (r = 0.92, P < 0.001), but not in the septic patients (r = 0.38, P = 0.15). The ratio of EHBF to CO (EHBF/CO) in the septic patients was significantly lower than that in the nonseptic patients (0.08 ± 0.04 vs 0.22 ± 0.05; P < 0.001). Moreover, in the septic patients, the EHBF/CO ratios of nonsurvivors were significantly lower than those of survivors (0.06 ± 0.04 vs 010 ± 0.02; P < 0.01). Conclusions: In nonseptic patients, the EHBF decreased in relation to the CO. However, the EHBF/CO ratio of septic patients was lower than that of nonseptic patients, suggesting that inadequate splanchnic perfusion or metabolic change occurs in septic patients. Furthermore, the lower EHBF/CO ratio was related with a fatal outcome in septic patients. PDD could be a clinically useful method of assessing splanchnic conditions in critically ill patients.

Background We experienced four Japanese patients with spontaneous retroperitoneal bleeding, a rare disease. We categorized the clinical characteristics of spontaneous retroperitoneal bleeding in these patients treated in our hospital and discuss the risk factors of spontaneous retroperitoneal bleeding. Case presentation Three of the 4 patients did not have a bleeding tendency as indicated by laboratory data obtained at the time of retroperitoneal bleeding. The causative blood vessels were the lumbar and superior gluteal arteries and the internal iliac artery. All patients were receiving an anticoagulant, heparin in one and nafamostat mesilate in the other three patients. Three patients were being treated with hemodialysis or continuous hemodiafiltration when the spontaneous retroperitoneal bleeding occurred. We achieved hemostasis with transcatheter arterial embolization in 3 patients and with surgical hemostasis in 1 patient. Conclusions We suggest that in patients receiving anticoagulant therapy in whom progressive anemia and unstable vital signs are present, spontaneous retroperitoneal bleeding should be considered as a possible cause. Nafamostat mesilate may be one of the risk factors for spontaneous retroperitoneal bleeding.

背景と目的:くも膜下出血に合併する低ナトリウム(Na)血症は,循環血液量の減少を伴い,遅発性脳血管攣縮の一因になるとされている。今回,厳重に輸液管理を行うことにより循環血液量の変動を最小限に押さえることで,血清Na濃度の変動に伴う遅発性脳血管攣縮を回避しうるか否かを検討した。対象と方法:26例の脳動脈瘤破裂によるくも膜下出血患者を対象とし,発症後24時間以内に動脈瘤クリッピング手術を施行し,術後は水分バランスをプラスに維持した。発症後2週間目までの脳血流速度,臨床的虚血症状,画像診断の所見をもとに対象をスパズム群(8例)と非スパズム群(18例)の2群に分類し,この間の血清Na濃度と水分・Naバランス,循環血液量の推移を検討した。結果:発症後2週間までの血清Na濃度の最高値と最低値は,非スパズム群では各々146±2.4mEq/l, 137±5.3mEq/lと正常域で推移しているのに対しスパズム群では各々150±8.7mEq/l, 132±10.3mEq/lとその変動が大きく,最低値は非スパズム群に比較し低値であった(p

A 62-year-old woman with severe tetanus was admitted to our medical center. Initial symptoms upon admission were trismus, risus sardonicus and opisthotonus. Endotracheal intubation and mechanical ventilation were performed, and the administration of diazepam and pancuronium bromide was initiated to enable sedation and muscle relaxation. On the third day of hospitalization, abrupt fluctuations in the patient's blood pressure appeared, suggesting that the diazepam and pancuronium bromide did not stabilize hemodynamics. Barbiturate therapy was selected to reduce the autonomic overactivity that was causing the blood pressure fluctuations. A continuous infusion of 1 to 8mg/kg/hr of thiamylal sodium following an intravenous injection of 5mg/kg was successful in suppressing the blood pressure fluctuations. Serum thiamylal concentrations were measured throughout the period of hospitalization, and electroencephalograms (EEG) were intermittently monitored. When a burstsuppression pattern appeared on the EEG, the serum thiamylal concentration was approximately 15-20μg/ml. When the blood pressure fluctuations were suppressed, the serum thiamylal concentration exceeded 25-30μg/ml and the burst-suppression intervals on the EEG were lengthened. Thus, the reticular activating system and the autonomic nervous system were suppressed by different degree. Furthermore, the serum thiamylal concentration was closely related to the burst-suppression interval. These results indicate that EEG monitoring should be used to determine the optimal barbiturate dosage during barbiturate therapy for severe cases of tetanus.

目的:頭部外傷後の高ナトリウム(Na)血症の病態は,ADH (antidiuretic hormone)の分泌異常により自由水を喪失した結果生じる高張性脱水である。われわれは高Na血症の治療においては,不足する体液量を補正することが不可欠であるとの仮説をたて,血清Na濃度と等濃度の輸液(等Na濃度輸液)を用いた体液量補正プロトコールを作成し,今回検討した。対象と方法:頭部外傷の治療経過中に低張尿の排出を認めた15例を対象とし,等Na濃度輸液を用いて水分バランスをプラスに維持するように管理した。低張多尿が持続する症例ではarginine vasopressin (AVP)を併用して尿量を減少させたうえで体液量補正を行った。この結果,15例中13例で高Na血症への進展を回避できた。そこで,対象を等Na濃度輸液の増量(volume replacement: VR)のみで高ナトリウム血症防止効果のあったVR有効群8例,AVPを併用しつつ体液量を補正し効果の認められたVR+AVP有効群5例,体液量補正にても血清Na濃度が上昇したVR無効群2例に分けて検討した。結果:等Na濃度輸液の開始後すべてのグループでマイナスに傾いていた水分バランスをプラスバランスに維持できた。体液量補正開始前後24時間でVR有効群(33±21 vs 123±21mEq/l, p

Although the suppressive effect of 3-hydroxybutyrate (3-OHB) on post-traumatic protein catabolism in traumatized patients is well documented, the oxidation of exogenously administered 3-OHB during catabolic stress has not been investigated. The present study was designed to evaluate, using radioactive isotopes, total body oxidation in rats with and without burn stress to which 3-OHB had been exogenously administered, in comparison with total body oxidation in such rats that had received glucose. The rats were divided into four groups, based on whether or not a 30% full-thickness burn was inflicted, and the type of infusate they received after the burn, namely, 3-OHB or glucose. The total exhaled CO2 was collected for 6h after the infusion was commenced, and 14CO2 was assayed in a liquid scintillation spectrometer. Oxidation of the infusate was calculated from the percentage of exhaled 14CO2 derived from the infused substrates. The plasma concentration of 3-OHB was significantly increased after the infusion in both the burned and non-burned rats. The total exhaled 14CO2 from the rats infused with glucose decreased from 48.2 +/- 2.4% to 40.8 +/- 3.7% (means +/- SD, P0.001) after thermal injury. However, the total exhaled 14CO2 from the rats infused with 3-OHB appeared sooner, and there was no difference in the total expired 14CO2 derived from 3-OHB between the burned and non-burned rats, at 68.1 +/- 2.7% vs 66.4 +/- 3.4%, respectively. These findings suggest that even under conditions of burn stress, 3-OHB can be oxidized normally if the plasma concentration of 3-OHB is elevated by exogenous administration.