Association of fentanyl use in rapid sequence intubation with post-intubation hypotension

BACKGROUND

The anesthesia literature has reported that pre-intubation fentanyl use is associated with post-intubation hypotension which is a risk factor of poor post-emergency department (ED) prognosis. However, little is known about the relations between fentanyl use for intubation and post-intubation hypotension in the ED. We aimed to determine whether pretreatment with fentanyl was associated with a higher risk of post-intubation hypotension in the ED.

METHODS

We conducted a secondary analysis of data of ED airway management collected from a multicenter prospective study of 14 Japanese EDs from February 2012 through November 2016. We included all adult non-cardiac-arrest patients who underwent rapid sequence intubation for medical indication. Patients were divided into fentanyl and non-fentanyl groups. The primary outcome was post-intubation hypotension (systolic blood pressure ≤90mmHg) in the ED.

RESULTS

Of 1263 eligible patients, 466 (37%) patients underwent pretreatment with fentanyl. The fentanyl group had a higher risk of post-intubation hypotension (17% vs. 6%; unadjusted OR, 1.73; 95%CI, 1.01-2.97; P=0.048) compared to the non-fentanyl group. In the multivariable analysis adjusting for age, sex, weight, principal indication, sedatives, intubator's specialty, number of intubation attempts, and patient clustering within EDs, the fentanyl group had a higher risk of post-intubation hypotension (adjusted OR, 1.87; 95%CI, 1.05-3.34; P=0.03) compared to the non-fentanyl group. In the sensitivity analysis using propensity score matching, this association remained significant (OR, 3.17; 95%CI, 1.96-5.14; P<0.01).

CONCLUSION

In this prospective multicenter study of ED airway management, pretreatment with fentanyl in rapid sequence intubation was associated with higher risks of post-intubation hypotension.

WSES worldwide emergency general surgery formation and evaluation project

Optimal management of emergency surgical patients represents one of the major health challenges worldwide. Emergency general surgery (EGS) was identified as multidisciplinary surgery performed for traumatic and non-traumatic acute conditions during the same admission in the hospital. EGS represents the easiest viable way to provide affordable and high-quality level of care to emergency surgical and trauma patients. It may result from the association of different physicians with other specialties in a cooperative model. The World Society of Emergency Surgery (WSES) has been working on the EGS organization and implementation since its foundation believing in the need of common benchmarks for training and educational programs throughout the world. This is a plea in different languages to all World Prime Ministers and Presidents to support the creation in all nations of an organized hub-spoke system for emergency general surgery to improve standards of care and to save lives.

Verifying the validity and reliability of the Japanese version of the Face, Legs, Activity, Cry, Consolability (FLACC) Behavioral Scale

Background

Pediatric patients, especially in the preverbal stage, cannot self-report intensity of pain therefore several validated observational tools, including the Face, Legs, Activity, Cry, Consolability (FLACC) Behavioral Scale, have been used as a benchmark to evaluate pediatric pain. Unfortunately, this scale is currently unavailable in Japanese, precluding its widespread use in Japanese hospitals.

Objectives

To translate and verify the validity and reliability of the Japanese version of the FLACC Behavioral Scale.

Method

Back-translation was first conducted by eight medical researchers, then an available sample of patients at the University of Tsukuba Pediatric Intensive Care Unit (from May 2017 to August 2017) was enrolled in a clinical study. Two researchers evaluated the validity of the translated FLACC Behavioral Scale by weighted kappa coefficient and intraclass correlation coefficients (ICC). Observational pain was simultaneously measured by the visual analog scale (VAS obs) and reliability was evaluated by correlation analysis.

Result

The original author approved the translation. For the clinical study, a total of 121 observations were obtained from 24 pediatric patients. Agreement between observers was highly correlated for each of the FLACC categories (Face: κ = 0.85, Leg: κ = 0.74, Activity: κ = 0.89, Cry: κ = 0.93, Consolability: κ = 0.93) as well as the total score (Total: κ = 0.95,). Correlation analysis demonstrated a good criterion validation between the FLACC scale and the VAS obs. (r = 0.96)

Conclusion

Our Japanese version of the FLACC Behavioral Scale shows high validity and reliability.

Comparative Analysis of the Regulatory T Cells Dynamics in Peripheral Blood in Human and Porcine Polytrauma

Background

Severely injured patients experience substantial immunological stress in the aftermath of traumatic insult, which often results in systemic immune dysregulation. Regulatory T cells (Treg) play a key role in the suppression of the immune response and in the maintenance of immunological homeostasis. Little is known about their presence and dynamics in blood after trauma, and nothing is known about Treg in the porcine polytrauma model. Here, we assessed different subsets of Treg in trauma patients (TP) and compared those to either healthy volunteers (HV) or data from porcine polytrauma.

Methods

Peripheral blood was withdrawn from 20 TP with injury severity score (ISS) ≥16 at the admittance to the emergency department (ED), and subsequently on day 1 and at day 3. Ten HV were included as controls (ctrl). The porcine polytrauma model consisted of a femur fracture, liver laceration, lung contusion, and hemorrhagic shock resulting in an ISS of 27. After polytrauma, the animals underwent resuscitation and surgical fracture fixation. Blood samples were withdrawn before and immediately after trauma, 24 and 72 h later. Different subsets of Treg, CD4+CD25+, CD4+CD25+FoxP3+, CD4+CD25+CD127-, and CD4+CD25+CD127-FoxP3+ were characterized by flow cytometry.

Results

Absolute cell counts of leukocytes were significantly increasing after trauma, and again decreasing in the follow-up in human and porcine samples. The proportion of human Treg in the peripheral blood of TP admitted to the ED was lower when compared to HV. Their numbers did not recover until 72 h after trauma. Comparable data were found for all subsets. The situation in the porcine trauma model was comparable with the clinical data. In porcine peripheral blood before trauma, we could identify Treg with the typical immunophenotype (CD4+CD25+CD127-), which were virtually absent immediately after trauma. Similar to the human situation, most of these cells expressed FoxP3, as assessed by intracellular FACS stain.

Conclusion

Despite minor percental differences in the recovery of Treg populations after trauma, our findings show a comparable decrease of Treg early after polytrauma, and strengthen the immunological significance of the porcine polytrauma model. Furthermore, the Treg subpopulation CD4+CD25+CD127- was characterized in porcine samples.

The Association between Cardiopulmonary Resuscitation in Out-of-Hospital Settings and Chest Injuries: A Retrospective Observational Study

OBJECTIVES

The aim of this study was to assess the risk of cardiopulmonary resuscitation (CPR) performed in out-of-hospital settings for chest injuries in patients with out-of-hospital cardiac arrest (OHCA).

METHODS

This retrospective, observational study was conducted in an emergency critical care medical center in Japan. Non-traumatic OHCA patients transferred to the hospital from April 2013 through August 2016 were analyzed. The outcome was defined by chest injuries related to CPR, which is composite of rib fractures, sternal fractures, and pneumothoraces. A multivariate logistic regression analysis was performed to assess the independent risk factors for chest injuries related to CPR. The threshold of out-of-hospital CPR duration that increased risk of chest injuries was also assessed.

RESULTS

A total of 472 patients were identified, of whom 233 patients sustained chest injuries. The multivariate logistic regression model showed that the independent risk factors for chest injuries were age and out-of-hospital CPR duration (age: AOR=1.06 [95% CI, 1.04 to 1.07]; out-of-hospital CPR duration: AOR=1.03 [95% CI, 1.01 to 1.05]). In-hospital CPR duration was not an independent risk factor for chest injuries. When the duration of out-of-hospital CPR extended over 15 minutes, the likelihood of chest injuries increased; however, this association was not statistically significant.

CONCLUSIONS

Long duration of out-of-hospital CPR was an independent risk factor for chest injuries, possibly due to the difficulty of maintaining adequate quality of CPR. Further investigations to assess the efficacy of alternative CPR devices are expected in cases requiring long transportation times. Takayama W , Koguchi H , Endo A , Otomo Y . The association between cardiopulmonary resuscitation in out-of-hospital settings and chest injuries: a retrospective observational study. Prehosp Disaster Med. 2018;33(2):171-175.

An unusual case of cavitating pulmonary nodules: Lemierre’s syndrome with isolated involvement of the external jugular vein

A 65-year-old female presented with symptoms of tonsillitis and sepsis. Despite initial treatment with i.v. fluid and antibiotics, her condition deteriorated and she became hypoxaemic. CT pulmonary angiography showed no filling defects in the pulmonary arteries, but there were multiple cavitating lung nodules, initially thought to represent metastases. A subsequent contrast-enhanced CT of the neck and thorax demonstrated thrombosis of the left external jugular vein (EJV), leading to a revised diagnosis of Lemierre’s syndrome (i.e. septic embolization from jugular thrombophlebitis). Noteworthy aspects of the case include the initial misdiagnosis of the cavitating lung nodules by the reporting radiologist and the isolated involvement of the EJV—Lemierre’s syndrome usually involves the internal jugular vein. The case highlights the importance of septic emboli in the differential diagnosis of cavitating lung nodules, and of assessment of the EJV as well as internal jugular vein in the context of oropharyngeal infection.

Seasonal differences in brown adipose tissue density and pulse rate variability in a thermoneutral environment

Background

Brown adipose tissue (BAT) is sympathetically activated and induces thermogenesis during cold exposure, thereby influencing energy expenditure and body fat levels. The very low frequency (VLF) components of pulse rate variability could be a form of thermogenic sympathetic nervous activity, but no clear relationship has yet been reported between VLF activity and BAT density. We therefore aimed to evaluate the association between them.

Methods

We enrolled 20 adults in winter and 20 matched adults in summer. We assessed BAT densities based on total hemoglobin concentrations ([total-Hb]) measured with near-infrared time-resolved spectroscopy. We calculated VLF activity from pulse rate variability measurements.

Results

BAT density ([total-Hb]; winter 70.5 ± 17.0 μM, summer 57.8 ± 18.3 μM) and VLF activity (winter 6.7 ± 0.8, summer 6.1 ± 0.9) were significantly higher in winter than in summer (P < 0.05). However, there was no significant correlation between VLF activity and BAT density in either season.

Conclusion

Each parameter exhibited seasonal variation, but we failed to observe any significant correlations.

Interleukin-18 Reduces Blood Glucose and Modulates Plasma Corticosterone in a Septic Mouse Model

BACKGROUND

Dysregulation of glucose metabolism, including hyperglycemia with insulin resistance, is commonly observed in critically ill patients. Interleukin-18 (IL-18) improves the insulin resistance associated with obesity, but the relationship between IL-18 and glucose metabolism in sepsis was unclear. The purpose of this study was to investigate the influence of IL-18 on hyperglycemia during sepsis.

METHODS

Sepsis was induced using cecal ligation and puncture (CLP) in wild-type (WT) mice, IL-18 knockout (KO) mice, and IL-18 KO mice pretreated with recombinant IL-18. Blood glucose and plasma insulin, glucagon, and corticosterone were measured. The mRNAs for gluconeogenic enzymes (g6pc, pck1) and activation of insulin signaling were also analyzed.

RESULTS

In both WT and IL-18 KO mice, CLP operation led to hyperglycemia that lasted longer (18 h) than after sham operation (6 h). Blood glucose levels in IL-18 KO mice were significantly higher than in WT mice, without alteration of insulin or glucagon levels. In IL-18 KO mice, insulin signaling in the liver and skeletal muscle was decreased during hyperglycemia as compared with WT mice without suppression of hepatic glucose production enzymes. Pretreatment with recombinant IL-18 reduced blood glucose levels after CLP. Additionally, corticosterone levels were higher after CLP in the presence of either endogenous or exogenous IL-18.

CONCLUSION

IL-18 may reduce blood glucose by modulating insulin signaling in the liver during sepsis-induced hyperglycemia. IL-18 is an important factor associated with alterations in blood glucose during sepsis.

Lipopolysaccharide interferes with the use of the human Cell Line Activation Test to determine the allergic potential of proteins

It was believed that high molecular weight molecules including proteins cannot penetrate the skin. However, protein penetration through disrupted/ruptured skin has been reported recently, thus carrying the potential for inducing an allergic response. We used the human Cell Line Activation Test (h-CLAT), an in vitro skin sensitization test, to assess the allergic potential of proteins by measuring levels of CD86 and CD54 in the human monocytic leukemia cell line THP-1. Six allergens including ovalbumin (OVA) and human serum albumin (HSA; negative control) upregulated CD86 and/or CD54; a false-positive result was obtained using HSA. This was caused by lipopolysaccharide (LPS) contamination. Naturally derived materials often include LPS at various concentrations and may influence protein induction of CD86 and CD54. Additionally, polymyxin B, an LPS inhibitor, could not completely overcome the effect of LPS. Therefore, if test proteins contain ≥0.1 EU/mL LPS, their allergenic potency will not be assessed accurately using h-CLAT. These data show that naturally occurring materials or those derived from living organisms should be evaluated for their LPS content. It is important to confirm the applicability of in vitro methods such as h-CLAT for assessing the allergenic potency of naturally occurring proteins; our findings can be a foundation for future studies.

Dermatologic surgery in children: an update on indication, anesthesia, analgesia and potential perioperative complications

BACKGROUND

Children undergoing dermatosurgical procedures require, unlike adults, particular attention; the administration of various analgesics, anesthetics or sedatives requires a thorough knowledge of drug pharmacokinetics and pharmacodynamics. Furthermore, there are concerns that drugs used for sedation/general anesthesia may result in anesthetic/analgesic complications in children undergoing surgery, with a risk of impaired mental development.

OBJECTIVES

Based on our clinical experience and a literature review, we illustrate the most commonly used analgesic, anesthetic and sedative drugs in pediatric dermatosurgery, and identify risk factors and complications following dermatosurgical procedures.

RESULTS

Topical anesthetics can be used in children for superficial dermatologic procedures or prior to infiltration anesthesia. Maximum recommended doses based on body weight should be calculated in order to avoid overdosage of local anesthetics. General anesthesia in dermatosurgery is considered safe and has a low rate of side effects. However, caution is advised in children under the age of one due to potential long-term neurological side-effects. NSAIDs and opioids play a significant role in analgesia for children.

CONCLUSIONS

This article reviews currently available data on analgesia, anesthesia and complications that may arise in pediatric dermatosurgery. These data may be useful in optimizing the safety and quality of care and in improving parent counseling.

Trigger Criteria: Big Data

Electronic medical records can be used to mine clinical data (big data), providing automated analysis during patient care. This article describes the source and potential impact of big data analysis on risk stratification and early detection of deterioration. It compares use of big data analysis with existing methods of identifying at-risk patients who require rapid response. Aggregate weighted scoring systems combined with big data analysis offer an opportunity to detect clinical changes that precede rapid response team activation. Future studies must determine if this will decrease transfers to intensive care units and cardiac arrests on the floors.

Radiological classification of retroperitoneal hematoma resulting from lumbar vertebral fracture

PURPOSE

Lumbar vertebral fracture (LVF) infrequently produces massive retroperitoneal hematoma (RPH). This study aimed to systematically review the clinical and radiographic characteristics of RPH resulting from LVF.

METHODS

For 193 consecutive patients having LVF who underwent computed tomography (CT), demographic data, physiological conditions, and outcomes were reviewed from their medical records. Presence or absence of RPH, other bone fractures, or organ/vessel injury was evaluated in their CT images, and LVF or RPH, if present, was classified according to either the Orthopaedic Trauma Association classification or the concept of interfascial planes.

RESULTS

RPH resulting only or dominantly from LVF was found in 66 (34.2%) patients, whereas among the others, 64 (33.2%) had no RPH, 38 (19.7%) had RPH from other injuries, and 25 (13.0%) had RPH partly attributable to LVF. The 66 RPHs resulting only or dominantly from LVF were radiologically classified into mild subtype of minor median (n = 35), moderate subtype of lateral (n = 11), and severe subtypes of central pushing-up (n = 13) and combined (n = 7). Of the 20 patients with severe subtypes, 18 (90.0%) were in hemorrhagic shock on admission, and 6 (30.0%) were clinically diagnosed as dying due to uncontrollable RPH resulting from vertebral body fractures despite no anticoagulant medication.

CONCLUSIONS

LVF can directly produce massive RPH leading to hemorrhagic death. A major survey of such pathology should be conducted to establish appropriate diagnosis and treatment.

Resuscitative endovascular balloon occlusion of the aorta: rupture risk and implications for blind inflation

Background

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a torso hemorrhage control technique. To expedite deployment, inflation is frequently performed as a blind technique with minimal imaging, which carries a theoretical risk of aortic injury. The objective of this study was to examine the relationship between balloon inflation, deformation and the risk of aortic rupture.

Methods

Compliant balloon catheters were incrementally inflated in segments of cadaveric swine aorta. Serial longitudinal and circumferential measurements were recorded, along with the incidence of aortic rupture.

Results

Fourteen cadaveric swine aorta segments were tested with mean (±SD) baseline aortic diameter (mm) of 14.2±3.4. Rupture occurred in three aortas. The mean baseline diameters (mm) of the aortic segments that were ruptured were significantly smaller than those that did not rupture (8.9±1.2 vs 15.6±1.9; P<0.001). The maximal circumferential stretch ratios were significantly higher in the aorta segments that ruptured compared with those that did not (1.9±0.1 vs 1.5±0.1; P<0.001). The maximal amount of balloon longitudinal deformation was 80 mm (116% longer than the intended working length).

Conclusions

Inflation of aortic balloon catheters carries an inherent risk of aortic injury, which may be minimized through an understanding of the intrinsic characteristics of the aorta and compliant balloons. Smaller diameter aortic segments undergoing overinflation, particularly beyond a circumferential stretch ratio of 1.8, are at risk of aortic rupture.

Level of evidence

Level II.

Transplacental lidocaine intoxication

Neonatal seizures are frequent in neonatal intensive care and the most common cause is perinatal asphyxia. Among other causes, toxin exposure is rare.We present a boy with an uneventful vaginal birth, who presented one hour after birth with apnea, hypotonia, mydriasis, tongue fasciculation, and tonic seizures. There was no hypoxic ischemic encephalopathy and brain imaging was normal. Toxicology screening revealed a toxic concentration of lidocaine in his blood. The intoxication was transplacental, as a cord blood sample confirmed the toxic level. This was probably due to maternal perineal nerve block with lidocaine.Perineal local infiltration of lidocaine is not without risk for the newborn. Toxicology screen remains an important tool in the work-up of neonatal seizures and sudden unexpected postnatal collapse.

Ruptured gastric artery aneurysms: two cases and emergency imaging findings

A ruptured gastric artery aneurysm is a rare but important possible cause of massive intra-abdominal or gastrointestinal haemorrhage, and carries a high risk of mortality. Although aneurysms of the gastric arteries are uncommon, emergency radiologists and clinicians should be familiar with the clinical presentation, imaging findings and pathophysiology. We present two cases of massive intra-abdominal haemorrhage and haemodynamic shock secondary to acute rupture of previously occult gastric artery aneurysm and review the relevant anatomy, imaging findings and pathophysiology of gastric and other visceral artery aneurysms. By virtue of its location in the lesser omentum, a ruptured gastric artery aneurysm may result in a typical pattern and distribution of adjacent haematoma in the upper abdomen. Our description of imaging findings highlights a characteristic epicentre of intraperitoneal haemorrhage, and its typical mass effect displacement of surrounding viscera, to aid the emergent diagnosis of gastric artery aneurysm rupture.

Medical equipment deployment in pediatric emergency prehospital medical units in Japan

The deployment status of pediatric emergency equipment in ambulances in Japan is unknown. To investigate the status of and issues associated with prehospital emergency medical care for pediatric patients, we conducted a descriptive epidemiological study. We carried out a Web-based survey of 767 fire defense headquarters in Japan, of which 671 responded (valid response rate, 88%). Most of the fire defense headquarters equipped all of their ambulances with oxygen masks (82%), bag-valve masks (for neonates, 83%; for children, 84%), straight laryngoscope blades (for neonates, 47%; for children 68%), blood pressure cuffs for children (91%), oximeter probes (78%), and stiff neck collars (91%); but despite the need for other equipment such as nasopharyngeal and oropharyngeal airways, and Magill forceps, they were insufficiently deployed. In Japan, prehospital emergency medical equipment deployment does not meet the needs of pediatric patients. Minimum equipment standards need to be established for pediatric prehospital care.

Traumatic Injury

Traumatic injury as one of the world's most relevant but neglected health concerns results in modulated inflammasome activity, which is closely linked to the development of post-injury complications. Cytokine-producing capacity of cells is important for the appropriate immune response to trauma and requires not only synthesis and transcription of inflammasome components but also their activation. Unfortunately, the precise role of inflammasome in trauma is still largely unknown. However, in the following chapter, we provide an overview on the best described inflammasomes in the various settings of trauma, introducing the recent findings on the up-to-date best described NLRP inflammasomes and underlying cytokines in the inflammatory response to trauma.

Knowledge, Attitude, and Perceived Confidence in the Management of Medical Emergencies in the Dental Office: A Survey among the Dental Students and Interns

Aims and Objectives

Many situations in the dental office can provoke medical emergencies. Lack of training and inability to overcome the medical emergencies can lead to serious consequences and legal actions. The aim of the study is to investigate and assess the knowledge, attitude, and perceived confidence of dental students and interns in the management of medical emergency.

Materials and Methods

A self-administered structured questionnaire was distributed to 153 of the undergraduate dental students and interns in Qassim province. Questionnaire consisted of nineteen questions pertaining to knowledge and awareness regarding syncope, cardiopulmonary resuscitation (CPR), intravenous drugs, measuring vital signs, and handling situation of aspiration of a foreign body, bleeding, and choking. Data were analyzed by Statistical Package for Social Sciences (SPSS) version 21.0.

Results

Fifty-seven percent was the response rate received from the questionnaire. Eighty-nine percent and 30% of the participants inquired about the medical history and vital signs before dental treatment, respectively. Only 37% of participants were confident to handle any medical emergency in the dental office. Seventy percent knew the correct location of chest compression and 67% were familiar about the right compression ventilation ratio showing significant difference between academic years and interns (P = 0.003). Females were significantly more aware about the management of bleeding after extraction than the males (65%, and 47%, respectively; P = 0.035). Thirty-five percent and 53% chose the correct management to relieve choking in responsive and unresponsive adult or child, respectively. A total of 28% of the participants reported syncope as the most common emergency situation.

Conclusion

Participants were lacking confidence in handling medical emergencies even though the majority of them inquired the medical history. Most of them have a good knowledge regarding CPR, but regarding airway obstruction, the knowledge was not at an acceptable level. Annual basic life support and emergency courses should be mandatory in dental teaching curriculum.

Bath-related deaths: Preventive strategies and suggestions for general physicians

Bath-related deaths occur frequently in Japan, particularly in the elderly population; however, this fact is not sufficiently well known by the public. The advent of a super-aging society will expose general physicians to more cases of fatal and nonfatal bath-related accidents. As many of the victims have one or more lifestyle-related diseases, general physicians will play a more important role in preventing these fatalities in the future. In addition, general physicians may have to perform postmortem examinations in these cases. This review article addresses the latest studies on bath-related deaths from various medical departments, including forensic medicine, emergency medicine, and physiology. We also discuss preventive strategies based on the assumed mechanisms, and because Japan does not have a well-developed system of medical examiners, we also provide suggestions for physicians who will encounter bath-related deaths in the future.

Significance of blood pH value and automated external defibrillator shock in determining the outcomes of out-of-hospital cardiac arrest patients

Background:

The prognosis of out-of-hospital cardiac arrest is generally poor. It is known that the survival of out-of-hospital cardiac arrest patients depends on treatments delivered in a very short time frame. Identifying outcome-associated factors may provide valuable information for decision-making in clinical practices.

Aim:

The objective of the present study was to assess the associations between various factors (e.g. serum biomarker levels and prehospital factors) and outcomes in adult, non-traumatic out-of-hospital cardiac arrest patients.

Methods:

Data from 386 consecutive out-of-hospital cardiac arrest patients treated from January 2012 to December 2015 at Taoyuan Chang Gung Memorial Hospital (Taiwan, ROC) were collected. While performing cardiopulmonary resuscitation in the emergency room, the levels of creatinine, aspartate aminotransferase, sodium, potassium, troponin-I, hydrogen bicarbonate and haemoglobin were determined, blood pH and pCO2 were measured and the white blood cell count was calculated. The response time and scene time interval were also recorded.

Results:

Here we found that out-of-hospital cardiac arrest patients with blood pH values of <7.34 had a lower chance of survival to 24 h (Odds Ratio (OR) = 2.77), survival to discharge (OR = 7.06) and a good neurological outcome (OR = 64.59). Moreover, patients without an automated external defibrillator shock had a lower chance of being discharged (OR = 4.27) and enjoying good neurological outcomes (OR = 25.09).

Conclusion:

Our data suggest that the blood pH and an automated external defibrillator shockable rhythm are two easily measurable factors strongly associated with the outcomes of out-of-hospital cardiac arrest patients.

Effects of freshwater clam extract on fracture induced inflammation at early stage

The inflammatory process after traumatic fracture and soft tissue injury includes release of inflammatory cytokines and activated polymorph nuclear cells (PMN) that can cause subsequent affected limbs delayed healing and vital organ complications. Analgesics have good effect on relief of the symptom but may cause further burden for hepatic and renal metabolism. Freshwater clam extract (FCE) has been demonstrated to suppress the release of the pro-inflammatory cytokine tumor necrosis factor-α production after hemorrhagic shock, and decrease the level of liver injury marker in rats. The aim of the present study was to determine whether FCE is able to affect the inflammation induced by unilateral tibial fracture in a rat model. The rats were randomly divided into control, fracture, FCE and fracture with FCE groups. The fracture group received left tibia and fibula shaft fractures using a consistent three point bending method. For the fracture with FCE group, FCE (40 mg/kg) was administered orally after fracture. Their physiological changes were continuously monitored for 48 h. Blood samples were extracted from the femoral arterial catheter at 1, 3, 6, 9, 12, 18, 24 and 48 h after fracture. In comparison with fracture group, those whom were fed with FCE had more stable heart rate frequency, lower central temperature at the initial h, and lower serum level of the proinflammatory cytokines and muscle damage markers induced by fracture. FCE was also associated with decreased recruitment of inflammatory cells in the adjacent soft tissue. Thus, the present results suggest that FCE could decrease fracture induced inflammation reaction and have beneficial regulatory effect on post inflammatory response.

Postmortem computed tomography findings in cases of bath-related death: Applicability and limitation in forensic practice

PURPOSE

Bath-related deaths occur frequently in Japan, and many of these deaths are diagnosed as death from disease without autopsy in the current Japanese death-investigation system. Therefore, we aimed to examine the postmortem computed tomography (PMCT) findings of bath-related deaths to determine if PMCT can differentiate between real cases of drowning and sudden deaths not related to drowning.

METHODS

Bath-related deaths were sampled from all autopsies conducted at the Tokyo Medical Examiner's Office from September 2015 to August 2016. A total of 90 bath-related deaths (77 drowning cases and 13 non-drowning cases) and 50 controls (sudden cardiac deaths non-related to bathing) were included in this study. We investigated factors contributing to drowning and measured PMCT parameters (presence/density of fluid in the maxillary sinus/trachea, distance between the lungs, lung patterns [ground glass opacities, consolidation], position of the right diaphragmatic dome, density in the right atrium, stomach volume, and density of the gastric/duodenal contents).

RESULTS

The analysis of the factors contributing to drowning showed that alcohol intoxication was the most frequent (n=25), followed by cardiac pathology (n=22), and psychotropic drug intoxication (n=6). Radiological evaluation showed that measurements of all parameters differed significantly between the drowning group and the controls. In addition, significant differences were observed between drowning and non-drowning cases in three radiological parameters (i.e., distance between lungs, stomach volume, and density of gastric contents).

CONCLUSIONS

Majority of bath-related deaths in this study showed signs of drowning at autopsy, and we observed a range of factors that contributed to drowning. By using several radiological parameters (e.g., the distance between the lungs, stomach volume, and the density of the gastric contents), PMCT for the investigation of bath-related deaths might indicate that drowning as opposed to other factors unrelated to drowning (e.g., sudden cardiac death) was the cause of death. This might allow for calculation of accurate mortality statistics on bath-related deaths.

Relationship between Bath-related Deaths and Low Air Temperature

Objective Bath-related sudden cardiac arrests occur frequently in Japan. Although previous studies have reported that most fatal events occurr in winter, the reason why such events exhibit a seasonal variation has not been elucidated. In this study, we hypothesized that the occurrence of bath-related deaths was correlated with a low air temperature. Methods This prospective cross-sectional observational study was conducted in the Tokyo Metropolitan area between October 2012 and March 2013. Data were collected for all cases involving the activation of the emergency medical system because of an accident or acute illness related to bathing that occurred in Tokyo during the study period. In particular, elderly (≥65 years) cardiac arrest victims who had been found in a bathtub filled with water were enrolled. The relationship between the daily number of cardiac arrest events and the lowest daily air temperature in Tokyo was studied using a nonlinear regression model. Results A total of 3,624 bath-related events were registered in this study. Among these events, 1,081 deaths of elderly individuals who had been found in a bathtub filled with water were recorded. A close correlation was observed between the daily number of events and the lowest daily air temperature. This correlation was described by the following equation: y=8.38e-0.07x, where y was the daily number of cardiac arrests and x was the lowest daily air temperature. Conclusion A low air temperature was closely correlated with the occurrence of bath-related cardiac arrest.

Initial Blood Ammonia Level Is a Useful Prognostication Tool in Out-of-Hospital Cardiac Arrest - Multicenter Prospective Study (SOS-KANTO 2012 Study)

BACKGROUND

Initial blood ammonia level is associated with neurologic outcomes in out-of-hospital cardiac arrest (OHCA). We tested the usefulness of blood ammonia for prediction of long-term neurological outcome of OHCA.

METHODS AND RESULTS

A total of 3,011 hospitalized adult OHCA patients were enrolled. Blood samples were obtained at the ED. Cut-offs (ammonia <100 μmol/L and lactate <12 mmol/L) were determined in a previous study. Neurological outcomes in survivors were assessed at 3 months. A logistic regression model with adjustment for within-hospital clustering and other risk factors was used to evaluate the association between biomarkers and outcomes. Of 3,011 patients, 380 (13.8%) had favorable neurological outcomes. Ammonia and lactate predicted neurological outcome with an AUC of 0.80 (95% CI: 0.76-0.84) and 0.77 (95% CI: 0.72-0.82), respectively. Adjusted OR for ammonia <100 μmol/L (4.55; 95% CI: 2.67-7.81) was higher than that for lactate <12 mmol/L (2.63; 95% CI: 1.61-4.28) and most other risk factors, such as cardiac etiology (3.47; 95% CI: 2.55-4.72), age<80 years (3.16; 95% CI: 2.17-4.61), bystander CPR (2.39; 95% CI: 1.70-3.38), and initial rhythm shockable (1.66; 95% CI: 1.16-2.37). The combination of ammonia and lactate had an increased predictive value (AUC, 0.86; 95% CI: 0.85-0.87) compared with that without biomarkers (AUC, 0.81; 95% CI: 0.80-0.82).

CONCLUSIONS

Initial blood ammonia level is as useful as other traditional prognostic indicators such as lactate. Measurement of both initial blood ammonia and lactate helped accurately predict neurological outcomes after OHCA.

Longitudinal acquisition of endotracheal intubation skills in novice physicians

Little is known about the acquisition of intubation skills among novice physicians during their one-year clinical training. Our primary objective was to determine the changes in the intubation skills of novice physicians between prior to the clinical training and after completion of the clinical training. We used data of a prospective longitudinal multicenter data registry developed to investigate factors associated with the improvement of intubation skills among novice physicians. The study participants included 90 postgraduate year 1 physicians in 2015–2016. We used 4 simulation scenarios based on the devices used (direct laryngoscope [DL] and Airway scope [AWS]) and difficulty of intubation (normal and difficult scenarios). As a marker of the intubation skills, we used the force applied on the maxillary incisors and the tongue with each intubation. We compared the data obtained prior to clinical training with those obtained after completion of one-year clinical training. When using DL, compared to prior, significantly less force were applied on the maxillary incisors and the tongue after clinical training in the normal scenario (28.0 N vs 19.5 N, p < 0.001, and 11.1 N vs 8.4 N, p = 0.004). Likewise, when using AWS, compared to prior, significantly less force were applied on the tongue after clinical training in the normal scenario (22.0 N vs 0 N, p < 0.001). The force on the tongue decreased after clinical training but not significant. These associations persisted in the difficult airway scenario. These findings suggest that force applied on oral structures can be quantified as a marker of intubation skills by using high-fidelity simulators, and the assessment of procedural competency is recommended for all novice physicians prior to performing intubation in the clinical setting to improve the quality of emergency care.

Chest compression-related fatal internal mammary artery injuries manifesting after venoarterial extracorporeal membrane oxygenation: a case series

BACKGROUND

Cardiopulmonary resuscitation-related bleeding, especially internal mammary artery injuries, can become life-threatening complications after initiating venoarterial extracorporeal membrane oxygenation owing to the frequent involvement of concomitant anticoagulant treatment, antiplatelet treatment, targeted temperature management, and bleeding coagulopathy. We report the cases of five patients who experienced this complication and discuss their management.

CASE PRESENTATION

We retrospectively evaluated five patients with cardiopulmonary resuscitation-related internal mammary artery injuries who were treated between February 2011 and February 2016 at our institution. All five patients were Asian men, aged 56 to 68-years old, who had received concomitant intravenously administered unfractionated heparin (3000 units) with antiplatelet therapy. Four patients received targeted temperature management. The injuries and hematomas were detected using contrast-enhanced computed tomography in all cases. Three patients were treated using transcatheter arterial embolization within 6 hours following cardiopulmonary arrest, and two were resuscitated and received appropriate treatment following early recognition of their injuries. Two patients died of hemorrhagic shock with delayed intervention. Four of the five patients had excessively prolonged activated partial thromboplastin times before their interventions.

CONCLUSIONS

Computed tomography should be performed as soon as possible after the return of spontaneous circulation to identify injuries and consider appropriate treatments for patients who have experienced cardiac arrest. Delayed bleeding may develop after treating hypovolemic shock and relieving arterial spasms; therefore, transcatheter arterial embolization should be performed aggressively to prevent delayed bleeding even in the absence of extravasation. This approach may be superior to thoracotomy because it is less invasive, causes less bleeding, and can selectively stop arterial bleeding sooner. A 3000-unit intravenous bolus of unfractionated heparin may be redundant; heparin-free extracorporeal cardiopulmonary resuscitation may be a more appropriate alternative. Unfractionated heparin treatment can commence after the bleeding has stopped.

Traumatic Injury to the Portal Vein With Shock Bowel

A portal vein aneurysm is the dilatation of the portal vein due to a defect in the vein wall. This rare disease manifestation is difficult to predict and has the potential for severe complications. We describe the case of a 68-year-old man involved in a motor vehicle collision who presented with abdominal hemorrhage found on ultrasound, hypotension, and vague abdominal pain. The patient underwent an exploratory laparotomy to control bleeding. Surgery and a subsequent abdominal computed tomography revealed the presence of a portal vein pseudoaneurysm and shock bowel. This case highlights the importance of radiologists to consider the prospect of portal vein aneurysm in the differential diagnosis of hypotension following abdominal trauma.

Descending necrotizing mediastinitis after a trigger point injection

Descending necrotizing mediastinitis (DNM) is a rare form of mediastinal infection. Most cases are associated with esophageal rupture. DNM after a trigger point injection in the upper trapezius has not been described previously. We present a case of DNM after a trigger point injection in the upper trapezius. A 70-year-old man visited the emergency department with chest discomfort and fever after a trigger point injection in the left upper trapezius. Chest computed tomography showed evidence of DNM, and antibiotic therapy was immediately administered intravenously. Because of the risk of sudden death, poor prognosis due to underlying disease, and his age, he declined surgical treatment and died of septic shock. Although trigger point injections are generally considered safe, caution should be used in patients with an underlying disease or in the elderly. Early diagnosis, broad-spectrum antibiotics, and aggressive surgical management are essential to improve the prognosis.

'Not quite out of the woods': potential for misdiagnosis of delayed neurologic syndrome of carbon monoxide poisoning as relapse of mental illness

OBJECTIVE

The aim of this paper is to provide an overview of the delayed neurologic syndrome of carbon monoxide poisoning and its clinical importance in psychiatric settings.

METHOD

A brief review of carbon monoxide poisoning is presented with a focus on the delayed neurologic syndrome and a case of deliberate self- poisoning is described.

RESULTS

As in the case described, the delayed manifestations of carbon monoxide poisoning can resemble a relapse of psychiatric illness.

CONCLUSIONS

In cases of carbon monoxide poisoning it is important to consider the delayed neurologic syndrome as misdiagnosis could lead to inappropriate treatment and worsened outcome.

Coagulofibrinolytic Changes in Patients with Post-cardiac Arrest Syndrome

Whole-body ischemia and reperfusion due to cardiac arrest and subsequent return of spontaneous circulation constitute post-cardiac arrest syndrome (PCAS), which consists of four syndromes including systemic ischemia/reperfusion responses and post-cardiac arrest brain injury. The major pathophysiologies underlying systemic ischemia/reperfusion responses are systemic inflammatory response syndrome and increased coagulation, leading to disseminated intravascular coagulation (DIC), which clinically manifests as obstruction of microcirculation and multiple organ dysfunction. In particular, thrombotic occlusion in the brain due to DIC, referred to as the "no-reflow phenomenon," may be deeply involved in post-cardiac arrest brain injury, which is the leading cause of mortality in patients with PCAS. Coagulofibrinolytic changes in patients with PCAS are characterized by tissue factor-dependent coagulation, which is accelerated by impaired anticoagulant mechanisms, including antithrombin, protein C, thrombomodulin, and tissue factor pathway inhibitor. Damage-associated molecular patterns (DAMPs) accelerate not only tissue factor-dependent coagulation but also the factor XII- and factor XI-dependent activation of coagulation. Inflammatory cytokines are also involved in these changes via the expression of tissue factor on endothelial cells and monocytes, the inhibition of anticoagulant systems, and the release of neutrophil elastase from neutrophils activated by inflammatory cytokines. Hyperfibrinolysis in the early phase of PCAS is followed by inadequate endogenous fibrinolysis and fibrinolytic shutdown by plasminogen activator inhibitor-1. Moreover, cell-free DNA, which is also a DAMP, plays a pivotal role in the inhibition of fibrinolysis. DIC diagnosis criteria or fibrinolysis markers, including d-dimer and fibrin/fibrinogen degradation products, which are commonly tested in patients and easily accessible, can be used to predict the mortality or neurological outcome of PCAS patients with high accuracy. A number of studies have explored therapy for this unique pathophysiology since the first report on "no-reflow phenomenon" was published roughly 50 years ago. However, the optimum therapeutic strategy focusing on the coagulofibrinolytic changes in cardiac arrest or PCAS patients has not yet been established. The elucidation of more precise pathomechanisms of coagulofibrinolytic changes in PCAS may aid in the development of novel therapeutic targets, leading to an improvement in the outcomes of PCAS patients.

Biphasic and protracted anaphylaxis to iodinated contrast media

OBJECTIVES

To investigate the prevalence of biphasic and protracted anaphylaxis to iodinated contrast media (ICM), their risk factors and practical observation duration for detecting biphasic reaction.

METHODS

145 patients with ICM anaphylaxis from January 2005-February 2016 were retrospectively categorised into uniphasic, biphasic (anaphylaxis recurrence within 72 h after resolution of initial anaphylaxis) and protracted (anaphylaxis >5 h) reaction groups. Multivariate regression analyses of potential risk factors were performed. We calculated negative predictive value (NPV) for biphasic reactions and additional person-hours required to detect one case during post-anaphylaxis observation.

RESULTS

Fifteen patients had biphasic reactions with secondary reactions with similar or milder severity and six had protracted reactions. Most significant risk factors were anaphylaxis duration >40 min for biphasic reactions (odds ratio (OR), 8.65 [95 % CI, 1.05-70.71]; P=0.044), and additional epinephrine administration within 1 h of initial dosing for protracted reactions (OR, 102.0 [95 % CI, 3.40-3057.25]; P=0.008). A 6-h post-anaphylaxis observation produced NPV of 96.4 %, while requiring a minimum of 65.5 additional person-hours to detect one additional case.

CONCLUSION

Biphasic and protracted ICM anaphylaxis developed in 10.3 % and 4.1 %, respectively, with revealing risk factors. Six hours could be practical for post-anaphylaxis observation to detect biphasic reaction.

KEY POINTS

• Incidence of biphasic anaphylaxis in iodinated contrast media anaphylaxis is 10.3 %. • Incidence of protracted anaphylaxis in iodinated contrast media anaphylaxis is 4.1 %. • Initial anaphylaxis >40 min can predict for biphasic anaphylaxis development. • A 6-h post-anaphylactic observation in ICM-related anaphylaxis seems practical.

Thiazide diuretics and the risk of hip fracture after stroke: a population-based propensity-matched cohort study using Taiwan's National Health Insurance Research Database

OBJECTIVES

This study aimed to investigate the association between thiazide use and the risk of hip fracture after stroke.

SETTING

A population-based, propensity-matched cohort study was conducted on the basis of Taiwan's National Health Insurance Research Database.

PARTICIPANTS

Patients with newly diagnosed ischaemic stroke between 2000 and 2011 were included. After propensity score matching, 7470 patients were included, of whom 3735 received thiazides and 3735 did not.

OUTCOME MEASURES

HRs for developing hip fractures within 2 years after stroke were calculated using Cox proportional hazards regression model with adjustments for sociodemographic and coexisting medical conditions.

RESULTS

Overall, patients using thiazides after stroke had a lower risk of hip fracture than those not using thiazides (8.5 vs 13.9 per 1000 person-years, adjusted HR=0.64, 95% CI 0.46 to 0.89, p=0.007). Further sensitivity analysis based on the duration of thiazide use revealed that the risk of hip fracture tended to decrease as the duration of exposure of thiazides increased. However, the effect was significant only in patients with long-term use of thiazides (using thiazides for >365 days within 2 years after stroke), with a 59% reduction in the risk of hip fracture when compared with patients not using thiazide (adjusted HR=0.41, 95% CI 0.22 to 0.79, p=0.008).

CONCLUSIONS

The long-term use of thiazides is associated with a decreased risk of hip fracture after stroke.

Recent trends in 30-day mortality in patients with blunt splenic injury: A nationwide trauma database study in Japan

BACKGROUND

Splenic injury frequently occurs after blunt abdominal trauma; however, limited epidemiological data regarding mortality are available. We aimed to investigate mortality rate trends after blunt splenic injury in Japan.

METHODS

We retrospectively identified 1,721 adults with blunt splenic injury (American Association for the Surgery of Trauma splenic injury scale grades III-V) from the 2004-2014 Japan Trauma Data Bank. We grouped the records of these patients into 3 time phases: phase I (2004-2008), phase II (2009-2012), and phase III (2013-2014). Over the 3 phases, we analysed 30-day mortality rates and investigated their association with the prevalence of certain initial interventions (Mantel-Haenszel trend test). We further performed multiple imputation and multivariable analyses for comparing the characteristics and outcomes of patients who underwent TAE or splenectomy/splenorrhaphy, adjusting for known potential confounders and for within-hospital clustering using generalised estimating equation.

RESULTS

Over time, there was a significant decrease in 30-day mortality after splenic injury (p < 0.01). Logistic regression analysis revealed that mortality significantly decreased over time (from phase I to phase II, odds ratio: 0.39, 95% confidence interval: 0.22-0.67; from phase I to phase III, odds ratio: 0.34, 95% confidence interval: 0.19-0.62) for the overall cohort. While the 30-day mortality for splenectomy/splenorrhaphy diminished significantly over time (p = 0.01), there were no significant differences regarding mortality for non-operative management, with or without transcatheter arterial embolisation (p = 0.43, p = 0.29, respectively).

CONCLUSIONS

In Japan, in-hospital 30-day mortality rates decreased significantly after splenic injury between 2004 and 2014, even after adjustment for within-hospital clustering and other factors independently associated with mortality. Over time, mortality rates decreased significantly after splenectomy/splenorrhaphy, but not after non-operative management. This information is useful for clinicians when making decisions about treatments for patients with blunt splenic injury.

Identification and quantification of mepirapim and acetyl fentanyl in authentic human whole blood and urine samples by GC-MS/MS and LC-MS/MS

PURPOSE

We encountered a curious case in which two male subjects self-administered mepirapim plus acetyl fentanyl by different routes, i.e., intravenously and by inhalation. We have thus established a detailed procedure for quantification of mepirapim and acetyl fentanyl in whole blood and urine specimens using gas chromatography (GC)-tandem mass spectrometry (MS/MS).

METHODS

The GC-MS/MS method was validated for linearity, extraction recovery, accuracy, and precision. Liquid chromatography-MS/MS was also used for identification of the target compounds.

RESULTS

Good linearity and reproducibility were achieved in the range of 20-1000 ng/g for both target compounds in both matrices. The concentrations of mepirapim in heart whole blood, femoral vein whole blood, and urine of the deceased individual with administration by intravenous injection were 593, 567, and 527 ng/g, respectively; those of acetyl fentanyl were 155, 125, and 126 ng/g, respectively. The mepirapim and acetyl fentanyl concentrations in the urine specimen of the surviving individual who had administered them by inhalation were 4900 and 570 ng/g, respectively.

CONCLUSIONS

To our knowledge, with the exception of a brief mention of a mepirapim concentration in a serum sample in emergency medicine, there are no reported data on the identification and quantification of mepirapim in biological samples. Mepirapim is a new synthetic cannabinoid. The concentration profiles of unchanged mepirapim in whole blood and urine were quite different and unique. A detailed clarification of such uniqueness is under way in our laboratory.

Improvements in Patient Acceptance by Hospitals Following the Introduction of a Smartphone App for the Emergency Medical Service System: A Population-Based Before-and-After Observational Study in Osaka City, Japan

Background

Recently, the number of ambulance dispatches has been increasing in Japan, and it is therefore difficult for hospitals to accept emergency patients smoothly and appropriately because of the limited hospital capacity. To facilitate the process of requesting patient transport and hospital acceptance, an emergency information system using information technology (IT) has been built and introduced in various communities. However, its effectiveness has not been thoroughly revealed. We introduced a smartphone app system in 2013 that enables emergency medical service (EMS) personnel to share information among themselves regarding on-scene ambulances and the hospital situation.

Objective

The aim of this study was to assess the effects of introducing this smartphone app on the EMS system in Osaka City, Japan.

Methods

This retrospective study analyzed the population-based ambulance records of Osaka Municipal Fire Department. The study period was 6 years, from January 1, 2010 to December 31, 2015. We enrolled emergency patients for whom on-scene EMS personnel conducted hospital selection. The main endpoint was the difficulty experienced in gaining hospital acceptance at the scene. The definition of difficulty was making ≥5 phone calls by EMS personnel at the scene to hospitals until a decision to transport was determined. The smartphone app was introduced in January 2013, and we compared the patients treated from 2010 to 2012 (control group) with those treated from 2013 to 2015 (smartphone app group) using an interrupted time-series analysis to assess the effects of introducing this smartphone app.

Results

A total of 600,526 emergency patients for whom EMS personnel selected hospitals were eligible for our analysis. There were 300,131 emergency patients in the control group (50.00%, 300,313/600,526) from 2010 to 2012 and 300,395 emergency patients in the smartphone app group (50.00%, 300,395/600,526) from 2013 to 2015. The rate of difficulty in hospital acceptance was 14.19% (42,585/300,131) in the control group and 10.93% (32,819/300,395) in the smartphone app group. No change over time in the number of difficulties in hospital acceptance was found before the introduction of the smartphone app (regression coefficient: −2.43, 95% CI −5.49 to 0.64), but after its introduction, the number of difficulties in hospital acceptance gradually decreased by month (regression coefficient: −11.61, 95% CI −14.57 to −8.65).

Conclusions

Sharing information between an ambulance and a hospital by using the smartphone app at the scene was associated with decreased difficulty in obtaining hospital acceptance. Our app and findings may be worth considering in other areas of the world where emergency medical information systems with IT are needed.

Resuscitative endovascular balloon occlusion of the aorta for major abdominal venous injury in a porcine hemorrhagic shock model

BACKGROUND

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a rescue maneuver for unstable patients with noncompressible hemorrhage below the diaphragm. The efficacy of REBOA in the setting a major abdominal venous injury is unknown. Our objective was to examine the use of REBOA in a large animal model of major abdominal venous injury and characterize any impact on the hemodynamics, rate and volume of hemorrhage, and survival.

METHODS

Ten swine (35-55 kg) underwent a controlled and validated hemorrhage and ischemia/reperfusion injury protocol to produce shock physiology. Animals were randomly assigned to a control arm (N = 5) or a treatment (REBOA) arm (N = 5). An injury was then created in the common iliac vein. Bleeding was allowed for 60 seconds and the balloon was then inflated in the REBOA arm. Hemodynamics were recorded for 45 minutes or until death. Blood loss was verified post-mortem and bleeding rate calculated.

RESULTS

All animals demonstrated shock physiology at the time of randomization. There were no differences between control versus REBOA animals in baseline mean arterial pressure (42 vs. 50), pH (7.29 vs. 7.26), lactate (6.19 vs. 6.26), or INR (1.2 vs. 1.3, all p = NS). REBOA animals demonstrated immediate improvements in mean arterial pressure (50.6 vs. 97.2, p = 0.04). The mean survival time was 4.1 minutes for controls (100% died) versus 40.1 minutes for REBOA (p < 0.01). There was no difference in total blood loss (mean 630 mL for both). The rate of bleeding was significantly lower in the REBOA animals (control 197 mL/min vs. REBOA 14 mL/min, p = 0.02).

CONCLUSION

In the setting of an abdominal venous injury, REBOA improved hemodynamics and lengthened survival time. Blood loss was similar between groups but the rate of bleeding was markedly decreased with REBOA. REBOA appears effective for central venous injuries and provides a sustained period of stabilization and window for surgical intervention.

Phenotyping the Immune Response to Trauma: A Multiparametric Systems Immunology Approach

OBJECTIVE

Trauma induces a complex immune response that requires a systems biology research approach. Here, we used a novel technology, mass cytometry by time-of-flight, to comprehensively characterize the multicellular response to trauma.

DESIGN

Peripheral blood mononuclear cells samples were stained with a 38-marker immunophenotyping cytometry by time-of-flight panel. Separately, matched peripheral blood mononuclear cells were stimulated in vitro with heat-killed Streptococcus pneumoniae or CD3/CD28 antibodies and stained with a 38-marker cytokine panel. Monocytes were studied for phagocytosis and oxidative burst.

SETTING

Single-institution level 1 trauma center.

PATIENTS OR SUBJECTS

Trauma patients with injury severity scores greater than 20 (n = 10) at days 1, 3, and 5 after injury, and age- and gender-matched controls.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Trauma-induced expansion of Th17-type CD4 T cells was seen with increased expression of interleukin-17 and interleukin-22 by day 5 after injury. Natural killer cells showed reduced T-bet expression at day 1 with an associated decrease in tumor necrosis factor-β, interferon-γ, and monocyte chemoattractant protein-1. Monocytes showed robust expansion following trauma but displayed decreased stimulated proinflammatory cytokine production and significantly reduced human leukocyte antigen - antigen D related expression. Further analysis of trauma-induced monocytes indicated that phagocytosis was no different from controls. However, monocyte oxidative burst after stimulation increased significantly after injury.

CONCLUSIONS

Using cytometry by time-of-flight, we were able to identify several major time-dependent phenotypic changes in blood immune cell subsets that occur following trauma, including induction of Th17-type CD4 T cells, reduced T-bet expression by natural killer cells, and expansion of blood monocytes with less proinflammatory cytokine response to bacterial stimulation and less human leukocyte antigen - antigen D related. We hypothesized that monocyte function might be suppressed after injury. However, monocyte phagocytosis was normal and oxidative burst was augmented, suggesting that their innate antimicrobial functions were preserved. Future studies will better characterize the cell subsets identified as being significantly altered by trauma using cytometry by time-of-flight, RNAseq technology, and functional studies.

Crowned Dens Syndrome as a cause of acute neck pain: a Case Report and Review of the Literature

Crowned dens syndrome (CDS) is a rare clinical entity characterized by acute neck pain due to calcification around the odontoid process of the axis in “crown-like” configuration. Crystalline deposition in cervical vertebrae is less well known disease entity and only a limited number of cases have been reported to date. I here present a case of 79-year- old woman who developed acute severe neck pain and stiffness. Cervical computed tomography (CT) scan detected periodontoid calcification and a diagnosis of Crowned dens syndrome was made. Crowned dens syndrome should be considered in the differential diagnosis of acute neck pain, particularly in old age patients.

Factors associated with the difficulty in hospital acceptance among elderly emergency patients: A population-based study in Osaka City, Japan

AIM

We aimed to investigate prehospital factors associated with difficulty in hospital acceptance among elderly emergency patients.

METHODS

We reviewed ambulance records in Osaka City from January 2013 through December 2014, and enrolled all elderly emergency patients aged ≥65 years who were transported by on-scene emergency medical service personnel to a hospital that the personnel had selected. The definition of difficulty in hospital acceptance was to the requirement for ≥4 phone calls to hospitals by emergency medical service personnel before receiving a decision from the destination hospitals. Prehospital factors associated with difficulty in hospital acceptance were examined through logistic regression analysis.

RESULTS

During the study period, 72 105 elderly patients were included, and 13 332 patients (18.5%) experienced difficulty in hospital acceptance. In the simple linear regression model, hospital selection time increased significantly with an increasing number of phone calls (R²  = 0.774). In the multivariable analysis, older age (P for trend <0.001), calls from a healthcare facility (adjusted odds ratio [AOR] 1.23, 95% confidence interval [CI] 1.15-1.32), night-time (AOR 2.17, 95% CI 2.08-2.26) and weekend/holidays (AOR 1.43, 95% CI 1.38-1.49) were significantly associated with difficulty in hospital acceptance. A positive association was observed between gastrointestinal emergency-related symptoms and difficulty in hospital acceptance among elderly patients with symptoms of internal disease (AOR 1.71, 95% CI 1.53-1.91).

CONCLUSIONS

In Japan, which has a rapidly aging population, a comprehensive strategy for elderly emergency patients, especially for advanced age groups or nursing home residents, is required. Geriatr Gerontol Int 2017; 17: 2441-2448.

Helistroke: neurointerventionalist helicopter transport for interventional stroke treatment: proof of concept and rationale

BACKGROUND AND PURPOSE

It is increasingly recognized that time is one of the key determinants in acute stroke outcome when interventional stroke therapy is applied. With increasing device efficacy and understanding of imaging triage options, reducing pre-treatment time loss may be a critical component of improving interventional stroke outcomes for the population at large. Time sensitive procedures such as organ harvest have transported physicians to the patient site to improve time to procedure. Applying this same principle to interventional stroke management may be a valid paradigm.

METHODS

Previous logistical deliberation with hospital and Medevac companies was carried out to provide the rationale and funding for helicopter transfer of a neurointerventionalist to an in-network hospital with an on-site angiographic suite. An appropriate patient with large vessel occlusion and an NIH Stroke Scale score >8 was identified. MRI was performed, then the Medevac transport system was activated and the intervention was carried out. Times were collected during the case and assessed for time efficiency.

RESULTS

The proof of concept case was identified and Medevac was consulted at 12:13 after verifying that no in-house emergencies would prevent physician departure. Weather clearance was obtained and stroke intervention confirmed as a go at 12:24. Groin puncture occurred at 13:07 and the intervention was completed at 13:41. The total time from decision-to-treat to groin puncture was 43 min and groin closure was completed at 77 min from decision-to-treat.

CONCLUSIONS

This proof of concept case is presented for logistical, financial and use-case analysis. As it is a first case, times can likely be improved. We assert that this model may be another option in the spoke-and-hub design of stroke systems of care.

Intended and unintended use of cathinone mixtures

INTRODUCTION

Cathinones are one of the most popular categories of new psychoactive substances (NPS) consumed. Cathinones have different pharmacological activities and receptor selectivity for monoamine transporters based on their chemical structures. They are incorporated into NPS mixtures and used with other NPS or 'traditional' drugs. Cathinone use represents significant health risks to individuals and is a public health burden.

METHODS

Evidence of poly-NPS use with cathinones, seizure information, and literature analyses results on NPS mixtures was systematically gathered from online database sources, including Google Scholar, Scopus, Bluelight, and Drugs-Forum.

RESULTS AND DISCUSSION

Results highlight the prevalence of NPS with low purity, incorporation of cathinones into NPS mixtures since 2008, and multiple members of the cathinone family being present in individual UK-seized samples. Cathinones were identified as adulterants in NPS marketed as being pure NPS, drugs of abuse, branded products, herbal blends, and products labelled "not for human consumption." Toxicity resulting from cathinone mixtures is unpredictable because key attributes remain largely unknown. Symptoms of intoxication include neuro-psychological, psychiatric, and metabolic symptoms. Proposed treatment includes holistic approaches involving psychosocial, psychiatric and pharmacological interventions.

CONCLUSION

Raising awareness of NPS, education, and training of health care professionals are paramount in reducing harms related to cathinone use.