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Apart from saving the lives of coronavirus disease (COVID-19) patients on mechanical ventilation (MV), recovery from the sequelae of prolonged MV (PMV) is an emerging issue.c METHODS: We conducted a retrospective study among consecutive adult COVID-19 patients admitted to an intensive care unit (ICU) in Kobe, Japan, between March 3, 2020, and January 31, 2021, and received invasive MV. Clinical outcomes included in-hospital mortality and recovery from COVID-19 in survivors regarding organ dysfunction, respiratory symptoms, and functional status at discharge. We compared survivors' outcomes with MV durations of14 days and ≤14 days.We included 85 patients with a median age of 69 years (interquartile range, 64-75 years); 76 (89%) patients had at least 1 comorbidity, 72 (85%) were non-frail, and 79 (93%) were functionally independent before COVID-19 infection. Eighteen patients (21%) died during hospitalization. At discharge, 59/67 survivors (88%) no longer required respiratory support, 50 (75%) complained of dyspnea, and 40 (60%) were functionally independent. Of the survivors, 23 patients receiving MV for14 days had a worse recovery from COVID-19 at discharge compared with those on MV for ≤14 days, as observed using the Barthel index (median: 35 [5-65] vs. 100 [85-100]), ICU mobility scale (8 [5-9] vs. 10 [10-10]), and functional oral intake scale (3 [1-7] vs. 7 [7-7]) (P 0.0001).Although four-fifths of the patients survived and50% of survivors demonstrated clinically important recovery in organ function and functional status during hospitalization, PMV was related to poor recovery from COVID-19 at discharge.

Central nervous system (CNS) infections are often suspected in adult patients with fever-associated seizures. However, it is unclear whether lumbar puncture (LP) is routinely required in patients with fever-associated seizures. This study aimed to examine the prevalence of meningitis and encephalitis in adult patients with fever-associated seizures and to evaluate whether LP is routinely required.We retrospectively studied patients aged ≥16 years who presented to the emergency department with complaints of seizures and fever above 37.5 °C who were admitted to the hospital between January 2017 and December 2019. LP was performed when the emergency physician suspected meningitis or encephalitis. Neurologists assessed patients with normal cerebrospinal fluid (CSF) findings and those admitted without LP after hospitalization. A neurologist confirmed the diagnoses of meningitis and encephalitis.The study included 148 patients. Ninety-seven patients (65.5%) were male, and the median age was 60 years. LP was performed in 105 patients (70.9%), and 14 (13.4%) had CSF pleocytosis. Meningitis and encephalitis were diagnosed in nine patients (6.1%), of whom four (2.8%) had CNS infections. Patients diagnosed with meningitis and encephalitis were more likely to have Glasgow Coma Scale13 (P = 0.03) and less likely to have a history of seizures or epilepsy (P = 0.04) and had higher C-reactive protein levels than the other patients (P = 0.02).The prevalence of meningitis or encephalitis is relatively low in adult patients with fever-associated seizures. Lumbar puncture is considered unnecessary to be performed routinely, but its indication should be carefully considered with reference to the clinical course, comorbidities, and blood tests. Further validation studies with larger sample sizes are needed to confirm the findings of this study.

[BACKGROUND] We aimed to develop and externally validate a novel machine learning model that can classify CT image findings as positive or negative for SARS-CoV-2 reverse transcription polymerase chain reaction (RT-PCR). [METHODS] We used 2, 928 images from a wide variety of case-control type data sources for the development and internal validation of the machine learning model. A total of 633 COVID-19 cases and 2, 295 non-COVID-19 cases were included in the study. We randomly divided cases into training and tuning sets at a ratio of 8:2. For external validation, we used 893 images from 740 consecutive patients at 11 acute care hospitals suspected of having COVID-19 at the time of diagnosis. The dataset included 343 COVID-19 patients. The reference standard was RT-PCR. [RESULTS] In external validation, the sensitivity and specificity of the model were 0.869 and 0.432, at the low-level cutoff, 0.724 and 0.721, at the high-level cutoff. Area under the receiver operating characteristic was 0.76. [CONCLUSIONS] Our machine learning model exhibited a high sensitivity in external validation datasets and may assist physicians to rule out COVID-19 diagnosis in a timely manner at emergency departments. Further studies are warranted to improve model specificity.

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.

Background: Although patients with severely impaired consciousness require a rapid response, it is commonly difficult to obtain detailed histories and perform accurate physical examinations of these patients. Therefore, this study examined the causes of patients with severely impaired consciousness and the clinical characteristics in prehospital settings that are useful for differential diagnosis. Methods: We conducted a single-center retrospective study using data from the Kobe City Fire Department database. We retrospectively examined patients aged ≥16 years with Japan Coma Scale III-digit codes during paramedic contact and transported them to our hospital between January 2018 and December 2018. Furthermore, we evaluated the age, systolic blood pressure (sBP), presence of airway obstruction, and mortality for each final diagnosis. Results: Overall, 227 patients were included in this study. One hundred and twelve patients (49.3%) were male, and the median age was 71 years (interquartile range 50–83 years). Stroke was the most common cause (30%). In addition, intoxication and psychiatric disorders were significantly more common in younger patients (P < 0.01). sBP was the highest inpatients with stroke. Airway obstruction was found most frequently in patients with stroke (73.5%), with a significant difference compared with other differential diseases,except for environmental disorders and cardiovascular diseases (P < 0.01). Mortality was the highest in stroke (55.9%), which was significantly higher than that for other differential diagnoses, except for environmental disorders and cardiovascular diseases.Among the patients with stroke, 45.6% had ocular abnormalities. Conclusion: Stroke was the most common cause of severely impaired consciousness. However, age, sBP, the presence of airway obstruction, and ocular abnormalities can be useful indicators for differential diagnosis in prehospital settings in patients with severe disturbance of consciousness.

BackgroundTrichloroethylene is a hydrocarbon commercially used as a degreasing solvent. It has gradually become obsolete due to is carcinogenic properties meanwhile, many industries still use it due to its cost effectiveness. Although there are reports and studies regarding chronic exposures to trichloroethylene there are very few acute cases reported that have caused altered mental status and required intensive care. This paper aims to report the course of an acute case of trichloroethylene intoxication with coma and summarize its characteristics.Case PresentationA 50-year-old male with no particular medical history presented with acute altered mental status due to inhalation of volatile trichloroethylene in a factory. He was given brief cardiopulmonary resuscitation for suspected cardiac arrest however was found to have a pulse when emergency medical services had intervened. On arrival to our emergency department, he showed marked central nervous system depression due to suspicion of acute trichloroethylene intoxication. Head computed tomography showed no signs of hypoxic ischemia encephalitis, however the possibility of loss of consciousness from a cardiac event could not be denied. The patient was intubated promptly, elicited by impending respiratory arrest and received supportive treatment. Trichloroethylene metabolite urinary concentrations were taken during admission. He regained consciousness readily, was extubated the next day and then discharged, showing full recovery on day 3.ConclusionWe reported a case of acute trichloroethylene intoxication which required intensive care but was discharged with full recovery and no neurological deficits. There have been few reports describing acute intoxication which needed intubation and its neurological outcomes. Furthermore, this report suggests urine metabolite concentration as a possible guide to predict clinical outcome.

Background: Helicobacter cinaedi, a Gram-negative spiral bacterium, is a rare cause of bacteraemia in humans. It is increasingly reported in both immunocompetent and immunocompromised patients. Nevertheless, little is known about H. cinaedi infections in the emergency departments (ED). Our study aimed to describe the clinical features of H. cinaedi infections in the ED.Methods: We conducted the descriptive study at the ED of Kobe City General Hospital between November 2011 and December 2020. We included all ED patients with H. cinaedi infections, and all H. cinaedi were isolated in blood cultures. Following bacterial culture, clinical specimens with gram-negative spiral bacilli underwent polymerase chain reactions to confirm H. cineadi infection. We retrospectively obtained the patient data from the electronic medical records and described patient characteristics, clinical course, and management of H. cinaedi bacteraemia. Results: During the study period, 22 patients in the ED were diagnosed with H. cinaedi bacteraemia. The youngest patient was 32 years old, and the oldest was 91 (median: 65.5 [interquartile range, 49.3 to 63.3] years). Diabetes mellitus was the most common comorbidity (7/22, 31.8%), followed by haematological malignancy and solid tumour (5/22, 22.7%), recent chemotherapy (4/22, 18.2%), while 3/22 (13.6%) patients had no comorbidities. In our cohort, complicated cases were identified: vertebral osteomyelitis (three cases), infected aortic aneurysm (two cases), and infected cyst (renal cyst, and pancreatic cyst with concomitant empyema) (two cases). Tetracycline (minocycline) was most commonly prescribed; administered intravenously in 5/15 (33.3%) and orally in 9/20 (45.0%) patients. Only one (4.5%) patient required surgical interventions. None died in the hospital.Conclusions: We reported 22 cases of H. cinaedi bacteraemia in the ED, most of which were successfully treated with antibiotics, primarily tetracycline. This report gives an important insight into the presentation and management of such infections. We suggest that future studies are warranted to evaluate the optimal choice and route of antibiotic treatment in H. cinaedi infections.

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.

It may need to pay attention to the sustention of moderate cardiotoxicity and delayed elevation of plasma 10‐hydroxynortriptyline level in severe amitriptyline overdose case.

Background Visceral disseminated varicella zoster virus (VZV) infections frequently affect immunocompromised patients. Diabetes mellitus has been associated with VZV infection, and most cases of disseminated infection involve patients with poorly controlled blood glucose levels. It initially presents as severe abdominal pain, which is evaluated as an acute abdomen, however, the cause is typically unidentified due to unremarkable computed tomography (CT) findings. We report a case of visceral disseminated VZV infection in a patient with well-controlled diabetes mellitus with fat stranding around the celiac and superior mesenteric artery on CT. Case presentation A 61-year-old Japanese woman with well-controlled diabetes mellitus presented to the emergency department with severe abdominal pain that gradually worsened. She had stable vital signs and skin rashes, suggestive of varicella. Abdominal CT showed fat stranding around the celiac and superior mesenteric arteries. The patient tested positive for the VZV antigen and was diagnosed with a visceral disseminated VZV infection. Acyclovir was administered, and the patient was discharged on the 14th day. Conclusions Visceral disseminated VZV infection may affect patients with well-controlled diabetes mellitus and causes acute abdomen. Periarterial fat stranding on CT is associated with abdominal pain due to visceral disseminated VZV infection.

Introduction Tube thoracostomy is an important treatment for traumatic hemothorax and pneumothorax. The optimal tube diameter remains unclear. To reduce invasiveness, we use small-bore chest tubes (≤20 Fr) for all trauma patients for whom tube thoracostomy is indicated in our emergency department (ED). The aim of this study was to investigate the effectiveness and safety of small-bore tube thoracostomy for traumatic hemothorax or pneumothorax. Method We conducted a retrospective observational study at a single emergency medical center. This study included adult patients (≥18 years old) who had undergone tube thoracostomy for chest trauma in the ED during the 5 years from October 2013 to September 2018. We used 20 Fr chest tubes or 8 Fr pigtail catheters. The examined outcome was tube-related complications, such as tube obstruction, retained hemothorax, and unresolved pneumothorax. Results A total of 107 tube thoracostomies were performed in 102 patients. The mean Injury Severity Score of these patients was 17.8 (±9.6), and the mean duration of the tube placement period was 3.9 days (±1.8). Eight patients developed tube-related complications (7.8%) (retained hemothorax: 4 patients (3.9%), unresolved pneumothorax: 4 patients (3.9%)). None of these cases were caused by tube obstruction. Although the drainage itself was effective, they underwent definitive invasive interventions to stop bleeding or air leak. Conclusion Our study showed that the use of small-bore (≤20 Fr) chest tubes to treat traumatic hemothorax/pneumothorax achieved the purposes of tube thoracostomy. It might be possible to safely manage chest trauma with small-bore chest tubes.

What is known and objective Amlodipine overdose is common; however, the dose and timing of intravenous lipid emulsion (ILE) therapy as a management strategy remain debatable. Case description A 73-year-old man received a single bolus (1.5 mL/kg) of ILE therapy following massive ingestion of multiple drugs, including amlodipine. After approximately 20 hours of ILE therapy, the serum amlodipine level that had decreased from 90.2 to 49.9 ng/mL increased to 70.8 ng/mL. What is new and conclusion A single bolus (1.5 mL/kg) of ILE therapy is probably insufficient to completely capture and partition serum amlodipine following amlodipine overdose.

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.

Few studies have assessed the duration of the postictal state after a generalized convulsion (GC) in adults. This study aimed to investigate the postictal duration after a GC and the factors associated with it.Patients aged ≥16 years who presented to the emergency department of a community general hospital with an unprovoked GC from January 2015 through December 2016 were evaluated retrospectively. A GC was defined as a bilateral convulsion with apparent impaired consciousness including a generalized tonic-clonic seizure.We evaluated 209 consecutive GCs (median age, 42 years) with the median postictal duration of 0.75 h. The univariate analyses indicated that the median duration of the postictal state was significantly longer: in elderly patients (aged ≥65 years) than in younger patients (aged65 years) (2 h vs. 0.7 h, p = 0.0005); in patients with higher modified Rankin scale (mRS) scores (≥3) at baseline than in those with lower scores (≤2) (2.5 h vs. 0.7 h, p 0.0001); in patients with longer seizure duration (≥30 min) than in those with shorter duration (55 h vs. 0.7 h, p 0.0001); in patients who were given emergency antiepileptic drugs than in those who were not (16 h vs. 0.6 h, p 0.0001); and in patients who were intubated than in those who were not (63.5 h vs. 0.75 h, p = 0.0009). Multiple linear regression analyses indicated that older age, higher mRS scores at baseline, longer seizure duration, and administration of emergency antiepileptic drugs were independently associated with longer postictal duration.Age, baseline functional disability, and seizure duration were factors associated with the duration of the postictal state after a GC.

We retrospectively examined the differences between paramedic triage and final diagnosis in the cases that were transported to our hospital between May 2016 and March 2019. About 30% of the patients with suspected stroke were diagnosed other than stroke. Some of the patients without suspected stroke were diagnosed with large vessel occlusion and were treated with mechanical thrombectomy. The time from arrival at the hospital to treatment was significantly longer in the patients without suspected stroke than with suspected stroke. To achieve a better prehospital care, we need to accept a wide range of stroke mimics, and to continuously feedback the paramedics about the importance of paralysis, cortical symptoms in stroke.

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.

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.

Previous studies on status epilepticus (SE) in the elderly were conducted in tertiary centers. We aimed to delineate the features and outcomes of elderly SE patients by comparing them to those of younger patients in a comprehensive community hospital providing primary to tertiary care.We retrospectively investigated 197 consecutive adult SE patients admitted to our hospital. The clinical, electroencephalography, and diffusion-weighted imaging (DWI) findings of 112 elderly patients (aged ≥65 years) were compared to those of 85 younger patients (aged65 years).Compared to that in younger patients, SE in elderly patients more frequently presented de novo (68.8% vs. 52.9%, p = 0.02); was less likely to be tonic-clonic (55.4% vs. 83.5%, p 0.001) but more likely to be focal motor (36.6% vs. 12.9%, p 0.001); and was more frequently refractory (30.4% vs. 14.1%, p = 0.008), particularly refractory nonconvulsive SE (13.4% vs. 4.7%, p = 0.04). Lateralized periodic discharges on electroencephalography (20.9% vs. 4.8%, p = 0.001) and SE-associated hyperintensities on DWI (27.8% vs. 13.6%, p = 0.03) were more common in the elderly than in the younger SE patients. The mortality rates did not significantly differ between the groups (6.3% vs. 3.5%, p = 0.52). The percentage of poor functional outcomes did not significantly differ between the groups in cases with acute symptomatic etiology (52.0% vs. 45.7%, p = 0.63), but was higher in elderly patients with remote symptomatic and cryptogenic etiologies (33.3% vs. 12.0%, p = 0.006).SE in the elderly differed from that in younger adults in the semiology, refractoriness, electroencephalography and DWI findings, and functional outcome. Outcomes were better than previously reported.

Background Metformin has been widely used as a first-line agent to treat type 2 diabetes mellitus. Lactic acidosis is a rare but serious adverse effect in patients treated with metformin. Recent studies noted a correlation between metformin accumulation and lactic acidosis. Continuous renal replacement therapy for the treatment of metformin-associated lactic acidosis has been documented in some case reports; however, there is currently no specific treatment for metformin-associated lactic acidosis. Case presentation A 70-year-old Japanese woman with type 2 diabetes mellitus presented to an emergency room with metformin-associated lactic acidosis. She was found to be hypotensive and laboratory examinations revealed severe lactic acidosis: pH 6.618, partial pressure of carbon dioxide in arterial blood 17.3 mmHg, bicarbonate 1.7 mmol/L, and lactate 18 mmol/L. Severe acidemia persisted despite supportive care including intravenously administered fluids, sodium bicarbonate, antibiotics, and vasopressors. Continuous renal replacement therapy was initiated in our intensive care unit. After dialysis for 3 days, her lactate level and pH value completely normalized. The concentration of metformin detected was 77.5 mg/L, which is one of the highest in metformin-associated lactic acidosis successfully treated without overdose. Conclusions The present case had one of the highest metformin concentrations in metformin-associated lactic acidosis successfully treated with continuous renal replacement therapy, and serum metformin concentrations may be useful for the diagnosis of metformin-associated lactic acidosis. Metformin-associated lactic acidosis is a rare but important etiology of lactic acidosis. Continuous renal replacement therapy is advantageous for the treatment of hemodynamically unstable patients with metformin-associated lactic acidosis.

Background Spontaneous pneumomediastinum is defined as the presence of free air in the mediastinum without any apparent concomitant factors or disease. It is uncommon but usually benign and self-limiting. Generally, patients with spontaneous pneumomediastinum are admitted to hospital, and occasionally, prophylactic antibiotics are administered to prevent mediastinitis. The purpose of this study was to describe practices concerning the feasibility of outpatient treatment and follow-up of spontaneous pneumomediastinum and the necessity of prophylactic antibiotics. Methods We conducted this study in a single emergency medical center located in Kobe, Japan. We retrospectively evaluated patients with spontaneous pneumomediastinum from January 2007 to December 2014. Spontaneous pneumomediastinum was defined as cases in which pneumomediastinum did not occur in the setting of positive pressure ventilation or severe trauma. All case records were carefully reviewed considering the demographic data, symptoms, precipitating events, diagnostic workup performed, use of prophylactic antibiotics, length of hospital stay, and complications. Results Thirty-four patients who satisfied the inclusion criteria were identified. Twenty-three patients (67.6%) were followed up on an outpatient basis, and 11 patients (32.4%) were admitted to the hospital, with a mean length of stay of 3.4 days. Prophylactic antibiotics were orally administered to 2 patients. None of the patients developed complications, such as tension pneumomediastinum, delayed pneumothorax, airway compromise, and mediastinitis. Conclusion Spontaneous pneumomediastinum is a benign condition presenting primarily in young adults, with an uneventful recovery. Therefore, patients may recover from this condition without admission or the need for prophylactic antibiotics.

要旨 Noninvasive positive pressure ventilation（NPPV）が気管挿管を望まないdo–not–intubate（DNI）患者に対して使用される頻度は増加しているが，臨床的改善が乏しい場合にNPPVを継続することの妥当性に関するデータは乏しい。今回，DNI患者にNPPVを使用し，呼吸状態が改善しない場合の転帰について検討した。2011年4月から2013年8月に，急性呼吸不全に対してNPPVが6時間以上使用されたDNI患者19例について後方視的に検討した。改善の定義を，NPPV開始後6時間の時点でFIO2

Ingestion of large amounts of zinc chloride causes corrosive gastroenteritis with vomiting, abdominal pain, and diarrhea. Some individuals experience shock after ingesting large amounts of zinc chloride, resulting in fatality. Here, we present the results of an administrative autopsy performed on a 70-year-old man who ingested zinc chloride solution and died. After drinking the solution, he developed vomiting, abdominal pain, and diarrhea, and called for an ambulance. Except for tachycardia, his vital signs were stable at presentation. However, he developed hypotension and severe metabolic acidosis and died. The patient's blood zinc concentration on arrival was high at 3030μg/dL. Liver cirrhosis with cloudy yellow ascites was observed, however, there were no clear findings of gastrointestinal perforation. The gastric mucosa was gray-brown, with sclerosis present in all gastric wall layers. Zinc staining was strongly positive in all layers. There was almost no postmortem degeneration of the gastric mucosal epithelium, and hypercontracture of the smooth muscle layer was observed. Measurement of the zinc concentration in the organs revealed the highest concentration in the gastric mucosa, followed by the pancreas and spleen. Clinically, corrosive gastroenteritis was the cause of death. However, although autopsy revealed solidification in the esophagus and gastric mucosa, there were no findings in the small or large intestine. Therefore, metabolic acidosis resulting from organ damage was the direct cause of death.

Background: The optimal rate of feeding advancement after initiation of early enteral nutrition (EEN) for underweight, critically ill patients is unknown. Methods: We conducted a retrospective chart review in intensive care unit (ICU) patients with a body mass index (BMI) < 20.0 kg/m2. Patients were categorized into Group R, which reached the energy target within 3 days of EEN initiation, and Group S, which reached the energy target 4 or more days after EEN initiation. Results: A total of 65 patients with a median age of 73 years were included in the study. No significant differences were observed between the two groups for all-cause mortality, ICU-free days, or length of hospital stay. Ventilator-free days (VFDs) were significantly fewer in Group R than in Group S (18.0 [0.0 - 22.0] vs. 21.0 [16.3 - 24.8] days; P = 0.046). A significantly higher number of patients requiring mechanical ventilation (MV) at hospital discharge were observed in Group R than in Group S (29% vs. 8%; P = 0.030). Multivariable analyses with adjustment for confounders found that days required to reach target energy intake after EEN initiation were significantly and independently associated with the requirement for MV at hospital discharge, but not with VFDs. Conclusion: A slow rate of feeding advancement after initiation of EEN in critically ill patients having a BMI of

Case A 16-year-old primiparous girl in the 11th week of gestation presented to our hospital with a traumatic brain injury suffered during a motorcycle accident. She was comatose on arrival to the hospital and was admitted to the intensive care unit. From day 2, she developed intermittent episodes of tachycardia with tachypnea, fever, profuse sweating, and extensor posturing. She was diagnosed with paroxysmal sympathetic hyperactivity (PSH) and treated with morphine. However, paroxysmal sympathetic hyperactivity could not be controlled and her general condition deteriorated. Intrauterine fetal death was confirmed in the 16th week of gestation, on day 37 of hospitalization. P paroxysmal sympathetic hyperactivity increased each day until delivery and dramatically improved after delivery. Outcome The patient gradually regained consciousness and was discharged to a rehabilitation hospital on day 117 after hospitalization. Conclusion Pregnancy is a risk factor for paroxysmal sympathetic hyperactivity exacerbation, and delivery can result in resolution of the condition.

要旨 【背景と目的】高齢者は，内服薬の種類が多いことや自己管理が困難になることがあり，定期処方の薬剤でも薬物中毒を引き起こし得る。今回，高齢者の急性薬物中毒の傾向について検討した。【対象と方法】2009年1月1日から2013年12月31日までの過去5年間に，当院救急外来で急性薬物中毒と診断した65歳以上の症例を対象とした。薬物依存症，診断が疑いの場合は，対象から除外した。自殺目的や誤ってなどで自ら過量服薬した故意的要素か，偶発的な事故的要素か，原因薬剤，主訴，転帰などを調査した。【結果】65歳以上の急性薬物中毒の総数は72例。84歳以下では故意による過量服薬が多かったが，超高齢者では定期内服による事故要素が多かった。原因薬物は，ベンゾジアゼピン系睡眠薬42例，フェノバルビタール8例，ジギタリス製剤8例，フェニトイン4例，カルシウム拮抗薬もしくはβ遮断薬4例，テオフィリン2例，抗うつ薬2例，サリチル酸1例，アシクロビル1例であった。主訴は意識障害が35例と最も多く，ショックを伴っていたのは8例で，家族や施設職員などにより発見されていた。【結語】高齢であるほど故意による薬物中毒は少なく，定期内服による中毒が多かった。高齢者では腎機能障害を有している例が多いと考えられ，抗てんかん薬，ジギタリスを含む抗不整脈薬，降圧薬の作用増強・遷延が起こりやすい。

Immune checkpoint inhibitors (ICIs) have demonstrated efficacy against various types of cancers. In addition to immune-related adverse events (irAEs) induced by ICIs, exacerbation of baseline autoimmune disease has been occasionally reported. This is the first report of autoimmune hemolytic anemia (AIHA) exacerbated by pembrolizumab. An 82-year-old Japanese male was diagnosed with lung adenocarcinoma 2 years ago. The patient had chronic anemia with positive direct and indirect Coombs test prior to initiating pembrolizumab therapy at a nearby hospital. However, a definitive diagnosis of AIHA was not made at that time. Seventeen days after the first dose of pembrolizumab, the patient was admitted to the Kobe City Medical Center General Hospital with severe hemolytic anemia (Hb 3.6 g/dL). After thorough examinations including bone marrow biopsy, the patient was diagnosed with pre-existing AIHA exacerbated by pembrolizumab therapy. Two weeks after treatment with prednisone, the levels of hemoglobin became stable with the reduced frequency of blood transfusion and improvements of hemolytic findings on blood tests and the patient was discharged from the hospital. This case report highlighted the importance of determining the patient’s pre-existing autoimmune status associated with chronic anemia prior to initiating treatment with ICIs.

Case A 22-year-old man was injured in a traffic accident and developed respiratory distress on his first day of admission. On postadmission day 3, he developed serious respiratory distress with a suddenly altered mental status. Chest computed tomography revealed a pulmonary embolism that had not been evident when he was admitted. The patient was intubated and a continuous heparin infusion was started to treat the pulmonary embolism. Palpebral conjunctival petechiae were noticed the following day, at which point the patient fulfilled Gurd's criteria for fat embolism syndrome. Within a few days, his respiratory status was improved. Brain magnetic resonance imaging also provided evidence of fat embolism syndrome. His femoral shaft fracture was repaired on day 20. Outcome The patient was discharged home on postadmission day 63. Conclusion Concomitant fat embolism syndrome and pulmonary embolism, although very rare, should be considered when a trauma patient's respiratory status worsens.