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Objective Head injuries are an important problem in pediatric emergency care. The majority of head injuries are mild. Even when abnormalities are noted on computed tomography (CT), most patients have good outcomes. We aimed to evaluate the clinical course of pediatric patients who had head injuries and Glasgow Coma Scale (GCS) scores of 15, in whom abnormal findings were noted on head CT, to determine the impact of radiographic features on the need for hospitalization and clinical progression. Methods We retrospectively examined patients under 15 years of age with isolated mild head injuries, GCS scores of 15, and abnormal CT findings, and visited the emergency department between September 2011 and March 2019. Results Ninety-nine patients were included in the study. The median age was 2 years (0–15 years), and 61 (62%) patients were male. Eighty-six (87%) patients were hospitalized, and the median hospital stay was 1 day (1–10 days). Sixty-eight (69%) patients underwent repeat CT, and 12 (18%) patients showed signs of radiographic progression. These 12 patients had subdural or epidural hematomas, and surgical intervention was required for two patients (2%). In patients with isolated skull fracture or subarachnoid hemorrhage alone, no deterioration was noted radiographically or clinically. Conclusion Pediatric head injuries with GCS scores of 15 may rarely require surgical intervention, even when CT shows abnormalities. In particular, patients diagnosed with isolated skull fracture or subarachnoid hemorrhage on CT may not require routine hospitalization. A validation study is needed to confirm the findings of this study.

Purpose Coronavirus disease 2019 (COVID-19) has placed a great burden on critical care services worldwide. Data regarding critically ill COVID-19 patients and their demand of critical care services outside of initial COVID-19 epicenters are lacking. This study described clinical characteristics and outcomes of critically ill COVID-19 patients and the capacity of a COVID-19-dedicated intensive care unit (ICU) in Kobe, Japan. Methods This retrospective observational study included critically ill COVID-19 patients admitted to a 14-bed COVID-19-dedicated ICU in Kobe between March 3, 2020 and June 21, 2020. Clinical and daily ICU occupancy data were obtained from electrical medical records. The last follow-up day was June 28, 2020. Results Of 32 patients included, the median hospital follow-up period was 27 (interquartile range 19–50) days. The median age was 68 (57–76) years; 23 (72%) were men and 25 (78%) had at least one comorbidity. Nineteen (59%) patients received invasive mechanical ventilation for a median duration of 14 (8–27) days. Until all patients were discharged from the ICU on June 5, 2020, the median daily ICU occupancy was 50% (36–71%). As of June 28, 2020, six (19%) died during hospitalization. Of 26 (81%) survivors, 23 (72%) were discharged from the hospital and three (9%) remained in the hospital. Conclusion During the first months of the outbreak in Kobe, most critically ill patients were men aged ≥ 60 years with at least one comorbidity and on mechanical ventilation; the ICU capacity was not strained, and the case-fatality rate was 19%. Supplementary Information The online version contains supplementary material available at 10.1007/s00540-021-02897-w.

Aim Extracorporeal cardiopulmonary resuscitation (ECPR) is the emerging resuscitative strategy to save refractory ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) patients. We investigated whether the receiving hospitals’ ECPR capabilities are associated with outcomes in out-of-hospital cardiac arrest (OHCA) patients who have refractory VF or pulseless VT. Methods In a population-based cohort study performed in Kobe City, Japan, between 2010 and 2017, we identified all OHCA patients who had refractory VF or pulseless VT. Based on their ECPR capabilities, hospitals were categorised into ECPR facilities and conventional cardiopulmonary resuscitation (CCPR) facilities. We compared patient survivals between ECPR facilities and CCPR facilities by applying inverse probability weighting using a propensity score. Results Of all 10,971 OHCA patients, 518 had refractory VF or pulseless VT. The proportion of favourable neurologic outcomes was 43/188 (22.9%) in ECPR facilities and 28/330 (8.5%) in CCPR facilities. In the propensity analysis, hospitals’ ECPR capabilities were associated with favourable neurologic outcomes (adjusted risk difference [ARD], 9.7% [95% confidence interval [CI], 3.7%–15.7%]; adjusted risk ratio [ARR], 2.01 [95% CI, 1.31–3.09]), and overall survival (87/188 [46.3%] vs. 67/330 [20.3%]; ARD, 19.0% [95% CI, 11.1%–26.9%]; ARR, 1.88 [95% CI, 1.45–2.44]). Conclusions Hospitals’ ECPR capabilities were associated with favourable neurologic outcomes in OHCA patients who had refractory VF or pulseless VT. We should take each hospital’s ECPR capability into consideration when developing a regional system of care for OHCA.

Aim To evaluate whether vital signs can predict whether hypoglycemia can be eliminated as the cause of impaired consciousness in prehospital settings. Methods We extracted the data of patients who underwent blood glucose measurements by paramedics in Kobe City, Japan from April 2015 to March 2019. We used receiver operating characteristic curves and calculated the area under the curve (AUC) to evaluate the validity of the vital signs in distinguishing hypoglycemia. We also calculated stratum‐specific likelihood ratios to examine the threshold at which hypoglycemia becomes less likely for each vital sign. Results Of the 1,791 patients, 1,242 were eligible for analysis. Hypoglycemia was observed in 324 patients (26.1%). Significant differences in each vital sign were noted between the hypoglycemic and non‐hypoglycemic groups. Body temperature was moderately accurate in differentiating between the two groups (AUC, 0.71; 95% confidence interval, 0.68–0.74). Furthermore, in patients with systolic blood pressure, Body temperature was moderately accurate in differentiating hypoglycemia and non‐hypoglycemia in the prehospital setting. If there is a high temperature or hypotension, it is less likely that hypoglycemia is the cause of impaired consciousness.

Noninvasive positive pressure ventilation (NPPV) may be attempted for treatment of acute respiratory failure during asthma attacks. However, it is necessary to shift to respiratory management under tracheal intubation without hesitation if the asthma attack worsens rapidly. There is currently insufficient evidence that NPPV is effective for severe asthma attacks according to previous RCT studies.

Aim Extracorporeal cardiopulmonary resuscitation (ECPR) is an evolving resuscitative method for refractory cardiopulmonary arrests. However, considering the substantial healthcare costs and resources involved, there is an urgent need for a full economic evaluation. We therefore assessed the cost-effectiveness of ECPR for refractory ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT). Methods We developed a decision model to estimate lifetime costs and outcomes for out-of-hospital cardiac arrest patients with VF/pVT who received either ECPR or conventional cardiopulmonary resuscitation. Quality-adjusted life-years (QALY) was used as the main outcome measure. This model was a combination of a decision tree model for the acute phase based on a prospective observational study (SAVE-J study), together with a Markov model for long-term follow-up periods extrapolated from published data. To evaluate the robustness of this model, we conducted a comprehensive deterministic sensitivity analysis (DSA) and a probabilistic sensitivity analysis (PSA). Results ECPR was cost-effective, with an incremental cost of ¥3,521,189 (Є30,227), an incremental effectiveness of 1.34 QALY, and an incremental cost-effectiveness ratio of ¥2,619,692 (Є22,489) per QALY gained. DSA revealed that the present model was most sensitive to probability of Cerebral Performance Category 1 after ECPR (¥2,153,977/QALY to ¥3,186,475/QALY), patient age (¥2,170,112/QALY to ¥3,334,252/QALY), and long-term medical cost for modified Rankin Scale 0 (¥2,280,352/QALY to ¥2,855,330/QALY). PSA indicated ECPR to be cost-effective and below the willingness-to-pay threshold of ¥5,000,000 with an 86.7 % possibility. Conclusions ECPR was an economically acceptable resuscitative strategy, and the results of the present study were robust even when considering the uncertainty of all parameters.

Background and aims: Vibrio vulnificus causes an infectious disease that has extremely poor convalescence and leads to necrotic fasciitis. In this study, we sought to define the characteristic epidemiology of V. vulnificus infection and clarify its diagnosis at the global level. Methods: Over a period of 10 years, we investigated the appearance of symptoms, underlying conditions, treatment, and mortality in 12 patients (eight men, four women; >50 years old; average age, 66 years,) infected with V. vulnificus. Results: The development of symptoms occurred primarily between June and September, a period during which seawater temperature rises and the prevalence of V. vulnificus increases. All patients had underlying diseases, and seven patients reported a history of consuming fresh fish and uncooked shellfish. The patients developed sepsis and fever with sharp pain in the limbs. Limb abnormalities were observed on visual examination. All patients underwent debridement; however, in the survival group, the involved limb was amputated early in 80% patients. The mortality rate was 58.3%. Conclusion: Recognition of the characteristic epidemiology and clinical features of this disease is important, and positive debridement should be performed on suspicion. When the illness reaches an advanced stage, however, amputation should be the immediate treatment of choice. Keywords: Vibrio vulnificus, Cellulitis/phlegmon, Necrotic fasciitis, Amputation

Nasal pillows can be useful for patients with obstructive sleep apnea syndrome requiring continuous positive airway pressure ventilation at high pressures. Nasal pillows have been successfully adapted for use in patients with obstructive sleep apnea syndrome and comorbid chronic obstructive pulmonary disease, which enables effective facilitation of activities of daily living.

Patients with acute exacerbation of tuberculosis can now be treated successfully with noninvasive ventilation (NIV) [1]. NIV is effective not only in cases of rapidly progressive mycobacterial tuberculosis but also in chronic cases where the disease has exacerbated. NIV use may reduce the high demand for intensive care unit (ICU) beds [2]. This is the first study to assess clinically the risk of spread of mycobacterial tuberculosis infection by droplet or aerosol during NIV.

Acute abdominal aortic thrombosis is a rare but potentially fatal condition. The patient was a 56-year-old man who developed lower back pain and arrived at our emergency room in a state of shock. He was alert, but could not move his legs. Cardiac echo revealed abnormal movement of the heart, and acute myocardial ischaemia was suspected as a differential diagnosis. Emergency coronary angiography and aortography together with percutaneous cardiopulmonary support were attempted. Both femoral arteries were punctured, but the guide wire could not be advanced from the bifurcation to the aorta. Heart stoppage occurred and lifesaving treatment was ineffective. A large thrombus from the abdominal aorta to both common iliac arteries was observed by aortography. To reduce mortality in acute abdominal aortic thrombosis, the disease must be recognised early based on clinical symptoms, followed by immediate contrast CT and surgical management by thrombectomy or re-establishment of the blood circulation.

A 37-year-old man was admitted to hospital for treatment of perineum damage and haematoma in the scrotum. His consciousness deteriorated after two intramuscular injections of pentazocine 15 mg. Faint low signals in the left putamin to frontal island and frontal lobe and obnubilation of the corticomedullary junction were apparent on head CT, which led to suspicion of cerebral infarction. MR angiography showed bilateral obstruction of the middle cerebral artery and moyamoya disease was diagnosed. Treatment with edaravone, argatroban and heparin was ineffective for opening the middle cerebral artery and serious after effects occurred. This case suggests that cerebrovascular accident should be suspected in a young patient with disturbance of consciousness but stable breathing and circulation, particularly if previous drug treatment has affected brain circulation. Moyamoya disease should be suspected based on medical or family history. In such a case, MR angiography is required for early diagnosis to facilitate treatment by re-establishment of blood circulation.

PURPOSE: For patients with acute respiratory failure due to lung edema or atelectasis, Surplus lung water that is not removed during an initial stay in the Intensive Care Unit (ICU) may be related to early ICU readmission. Therefore, we performed a retrospective study of patient management during the first ICU stay for such patients. MATERIALS AND METHODS: Of 1,835 patients who were admitted to the ICU in the 36 months from January, 2003 to December, 2005, 141 were patients readmitted, and the reason for readmission was lung edema or atelectasis in 21 patients. For these 21 patients, correlations were investigated between body weight gain at the time of initial ICU discharge (weight upon discharge from the ICU / weight when entering the ICU) and the time to ICU readmission, between body weight gain and the P/F ratio at ICU readmission, between the R/E ratio (the period using a respirator (R) / the length of the ICU stay after extubation (E)) and the time to ICU readmission, between the R/E ratio and body weight gain, and between body weight gain until extubation and the time to extubation. RESULTS: A negative linear relationship was found between body weight gain at the time of initial ICU discharge and the time to ICU readmission, and between body weight gain at the time of ICU discharge and the P/F ratio at ICU readmission. If body weight had increased by more than 10% at ICU discharge or the P/F ratio was below 150, readmission to the ICU within three days was likely. Patients with a large R/E ratio, a large body weight gain, and a worsening P/F ratio immediately after ICU discharge were likely to be readmitted soon to the ICU. Loss of body weight during the period of respirator support led to early extubation, since a positive correlation was found between the time to extubation and body weight gain. CONCLUSION: Fluid management failure during the first ICU stay might cause ICU readmission for patients who had lung edema or atelectasis. Therefore, a key to the prevention of ICU readmission is to ensure complete recovery from lung failure before the initial ICU discharge. Strict water management is crucial based on body weight measurement and removal of excess lung water is essential. In addition, an apparent improvement in respiratory state may be due to respiratory support, and such an improvement should be viewed cautiously. Loss of weight at the refilling stage of transfusion prevents ICU readmission and may decrease the length of the ICU stay.

Non-invasive ventilation (NIV) assists breathing and thus improves oxygenation in patients with Kyphoscoliosis. The benefits of short- and long-term intermittent nocturnal in such patients have been reported previously (improvement of vital capacity, total lung capacity, muscle strength, daytime oxygenation, exercise capacity, and pulmonary hypertension). We review this important study reporting patients with kyphoscoliosis and acute respiratory failure along with their long-term outcomes. We believe that this letter may provide important information regarding the prognosis and efficacy of NIV.