Treatment Delay of Febrile Urinary Tract Infections Among Infants With Respiratory Symptoms

OBJECTIVE

To evaluate whether antibiotic treatment of febrile urinary tract infection (UTI) is delayed in febrile infants with respiratory symptoms compared with those without.

STUDY DESIGN

Data of infants 2-24 months of age diagnosed with UTI from March 1, 2012 to May 31, 2023 were collected from our hospital's medical charts and triage records. Patients with known congenital anomalies of the kidney and urinary tract or a history of febrile UTI were excluded. Patients were classified as having respiratory symptoms if they had any of the following symptoms or clinical signs: cough, rhinorrhea, pharyngeal hyperemia and otitis media. Time to first antibiotic treatment from fever onset was compared between patients with and without respiratory symptoms. A Cox regression model was constructed to adjust for potential confounders.

RESULTS

A total of 214 patients were eligible for analysis. The median age of the eligible patients was 5.0 months (interquartile range: 3.0-8.8) and 118 (55%) were male. There were 104 and 110 patients in the respiratory symptom and no respiratory symptom groups, respectively. The time to first antibiotic treatment was significantly longer in the group with respiratory symptoms (51 hours vs. 21 hours). Respiratory symptoms were significantly associated with a longer time to first treatment after adjustment for age and sex in the Cox regression model (hazard ratio = 0.63, 95% confidence interval: 0.47-0.84).

CONCLUSIONS

Treatment of febrile UTI infants with respiratory symptoms tends to be delayed. Pediatricians should not exclude febrile UTI even in the presence of respiratory symptoms.

Corrigendum: Association of airway obstruction with first-pass success and intubation-related adverse events in the emergency department: multicenter prospective observational studies

[This corrects the article DOI: 10.3389/fmed.2023.1199750.].

First-Pass Success of Video Laryngoscope Compared With Direct Laryngoscope in Intubations Performed by Residents in the Emergency Department

BACKGROUND

The video laryngoscope (VL) has been widely used for intubation in the emergency department (ED). However, their effectiveness remains controversial, particularly among airway management performed by residents in the ED.

METHODS

We aimed to examine whether the use of VL, compared to a direct laryngoscope (DL), was associated with higher first-attempt intubation success among intubations performed by residents in the ED. This is a secondary analysis of the data from a prospective, observational, multicentre study of 15 Japanese EDs from April 2012 through March 2020. We included all adult patients who underwent intubation with VL or DL by residents (postgraduate years ≤5) in the ED. The outcome measures were first-pass success and intubation-related adverse events (overall, major, and minor adverse events). To determine the association of VL use with each of the outcomes, we constructed logistic regression models with generalized estimating equations to account for patients clustering within the ED, adjusting for patient demographics, primary indications, intubation difficulty, and intubation methods.

RESULTS

Of 5,261 eligible patients who underwent an initial intubation attempt by residents, 1,858 (35%) patients were attempted with VL. Intubations performed with VL had a non-significantly higher first-pass success rate than those with DL (77% vs. 64%; unadjusted odds ratio (OR)=1.20; 95% CI=0.87-1.65; P=0.27). This association was significant after adjustment for potential confounders (adjusted OR, 1.33; 95% CI, 1.06-1.67; P=0.01). As for adverse events, the use of VL was associated with a lower rate of any (adjusted OR=0.67; 95% CI=0.51-0.86; P=0.002) and minor (adjusted OR=0.69; 95% CI=0.55-0.87; P=0.002) adverse events.

CONCLUSION

The use of VL was associated with a higher first-attempt success rate and a lower rate of any adverse events compared to that with DL among intubations performed by residents in the EDs.

Conservative treatment of traumatic finger amputations using negative-pressure wound therapy

Replantation is widely regarded as the first choice of treatment for finger amputations. However, if the fingertip of a traumatic finger amputation is missing after an injury, the following procedures are often performed to reconstruct this portion: flap surgery, stump surgery, or conservative treatment, including occlusive dressings. To our knowledge, no existing English literature reports using negative-pressure wound therapy (NPWT) to treat traumatic finger amputations. We postulated that NPWT may be applied as a conservative treatment for traumatic finger amputations, promoting the growth of granulation tissue and achieving early epithelialization of the fingertips. Among the case series of five patients, we included six injured fingers comprising two index, two middle, and two ring fingers. The fingertip of each traumatic finger amputation was either missing or highly crushed, making replantation impossible. To preserve finger length with conservative treatment, we adapted an NPWT device for finger amputations. It took an average of 22.7 days for the fingertips to epithelialize. Immediately after epithelialization, there was a slight decrease in sensory perception; however, all patients showed good recovery of sensory perception after 3 months. Range of motion remained unrestricted, with no reduction in grip strength. Patients were highly satisfied with their fingertip appearance. The regenerated nail exhibited slight deformation and shortening. No complications were observed. Our novel study regarding this new conservative treatment and its outcomes revealed that healing was achieved in a relatively short period; therefore, NPWT may serve as a new conservative treatment option in the future.

Association of airway obstruction with first-pass success and intubation-related adverse events in the emergency department: multicenter prospective observational studies

Background

Airway obstruction is a relatively rare but critical condition that requires urgent intervention in the emergency department (ED). The present study aimed to investigate the association of airway obstruction with first-pass success and intubation-related adverse events in the ED.

Methods

We analyzed data from two prospective multicenter observational studies of ED airway management. We included adults (aged ≥18 years) who underwent tracheal intubation for non-trauma indications from 2012 through 2021 (113-month period). Outcome measures were first-pass success and intubation-related adverse events. We constructed a multivariable logistic regression model adjusting for age, sex, modified LEMON score (without airway obstruction), intubation methods, intubation devices, bougie use, intubator's specialty, and ED visit year with accounting for patients clustering within the ED.

Results

Of 7,349 eligible patients, 272 (4%) underwent tracheal intubation for airway obstruction. Overall, 74% of patients had first-pass success and 16% had intubation-related adverse events. The airway obstruction group had a lower first-pass success rate (63% vs. 74%; unadjusted odds ratio [OR], 0.63; 95% CI, 0.49-0.80), compared to the non-airway obstruction group. This association remained significant in the multivariable analysis (adjusted OR 0.60, 95%CI 0.46-0.80). The airway obstruction group also had a significantly higher risk of adverse events (28% vs. 16%; unadjusted OR, 1.93; 95% CI, 1.48-2.56, adjusted OR, 1.70; 95% CI, 1.27-2.29). In the sensitivity analysis using multiple imputation, the results remained consistent with the main results: the airway obstruction group had a significantly lower first-pass success rate (adjusted OR, 0.60; 95% CI, 0.48-0.76).

Conclusion

Based on these multicenter prospective data, airway obstruction was associated with a significantly lower first-pass success rate and a higher intubation-related adverse event rate in the ED.

Prevalence and Risk Factors of Insomnia and Sleep-aid Use in Emergency Physicians in Japan: Secondary Analysis of a Nationwide Survey

INTRODUCTION

Emergency physicians (EP) are suspected to have a high prevalence of insomnia and sleep-aid use. Most prior studies about sleep-aid use in EPs have been limited by low response rates. In this study our aim was to investigate the prevalence of insomnia and sleep-aid use among early-career Japanese EPs and assess the factors associated with insomnia and sleep-aid use.

METHODS

We collected anonymous, voluntary, survey-based data regarding chronic insomnia and sleep-aid use from board-eligible EPs taking the initial Japanese Association of Acute Medicine board certification exam in 2019 and 2020. We describe the prevalence of insomnia and sleep-aid use and analyzed demographic and job-related factors using multivariable logistic regression analysis.

RESULTS

The response rate was 89.71% (732 of 816). The prevalence of chronic insomnia and sleep-aid use was 24.89% (95% CI 21.78-28.29%) and 23.77% (95% CI 20.69-27.15%), respectively. Factors associated with chronic insomnia were long working hours (odds ratio [OR] 1.02, 1.01-1.03, per one-hour/week), and "stress factor" (OR 1.46, 1.13-1.90). Factors associated with sleep-aid use were male gender (OR 1.71, 1.03-2.86), unmarried status (OR 2.38, 1.39-4.10), and "stress factor" (OR 1.48, 1.13-1.94). The "stress factor" was mostly influenced by stressors in dealing with patients/families and co-workers, concern about medical malpractice, and fatigue.

CONCLUSIONS

Early-career EPs in Japan have a high prevalence of chronic insomnia and sleep-aid use. Long working hours and stress were associated with chronic insomnia, while male gender, unmarried status, and stress were associated with the use of sleep aids.

Tracheobronchial rupture in children due to chest compression

A tracheobronchial rupture can be lethal. Its etiology in children varies and includes blunt trauma and iatrogenic injury. Most of the latter are associated with tracheal intubation, with other, iatrogenic causes scarcely being reported. We herein reported the first case of tracheobronchial rupture caused by chest compression during cardiopulmonary resuscitation. The present case highlights the importance of close follow-up after cardiopulmonary resuscitation, even if the patients are not intubated.

Risk stratification of extravasation during semi-automatic intraosseous device use in a pediatric emergency setting

BACKGROUND

The semi-automatic intraosseous device (EZ-IO®) is useful for safely securing intraosseous access. There are some complications associated with its use but few studies have examined the risk factors. The present study aimed to investigate the risk factors for extravasation as a complication of EZ-IO use in pediatric patients.

METHODS

This study is a secondary analysis of a previous, monocentric, retrospective study conducted in Japan describing the use of EZ-IO in a pediatric emergency department. The patients included in the study were younger than 16 years of age with EZ-IO use at the Tokyo Metropolitan Children's Medical Center between January, 2013 and August, 2018. The factors analyzed included demographic information (sex, age, weight), Glasgow Coma Scale (GCS), diagnosis, bolus infusion, and lidocaine use. The primary endpoint was the odds ratio (OR) and 95% confidence interval (CI) for extravasation incidence.

RESULTS

Seventy-two patients were enrolled; 14 of these had extravasation, 39 (54.2%) had a diagnosis of cardiac arrest, and 50 (69.4%) had a GCS score of 8 or less. Statistical analysis demonstrated that the group with a high GCS score was significantly associated with extravasation: GCS (<13) versus GCS (13≦) (OR: 12.25; 95% CI: 2.54-59.15; p < 0.01), GCS (<8) versus GCS (8≦) (OR: 4.78; 95% CI: 1.34-17.01; p = 0.03).

CONCLUSIONS

A high GCS score was associated with extravasation in EZ-IO use significantly more often than a low GCS score. No significant difference was found in the other endpoints.

Characterization of a xylanase belonging to the glycoside hydrolase family 5 subfamily 35 from Paenibacillus sp. H2C

Corn xylan is resistant to enzymatic hydrolysis due to its complex structure. We characterized PsXyn5A, an enzyme highly active for corn xylan, isolated from Paenibacillus sp. H2C. PsXyn5A is a modular xylanase with a catalytic domain belonging to the glycoside hydrolase family 5 subfamily 35 (GH5_35) and a carbohydrate-binding module family 13 (CBM13) domain. The substrate recognition mechanism of GH5_35 xylanase has not been reported. Analysis of the hydrolysate from rye arabinoxylan (RAX) has shown that the GH5_35 catalytic domain of PsXyn5A recognizes an arabinofuranosyl (Araf) side residue and cleaves the reducing terminal side of Araf-linked xylopyranose. This cleavage specificity is the same as reported for the GH5_34 xylanase from Hungateiclostridium thermocellum (HtXyl5A). Unlike HtXyl5A, PsXyn5A produced Araf-xylopyranose from RAX and did not hydrolyze 33-α-l-Araf-xylotetraose. Deletion of the CBM13 domain significantly decreased the activity toward insoluble corn xylan, indicating that CBM13 plays an essential role in hydrolyzing corn xylan.

Airway management in the pediatric emergency department in Japan: A multicenter prospective observational study

Aim

Tracheal intubation is a vital resuscitation procedure in the pediatric emergency department (ED). Despite its importance, little is known about the current status of emergency airway management in Japan. In this context, we aimed to investigate the airway management characteristics-particularly the location, patient, and provider factors-in the pediatric ED.

Methods

We conducted a multicenter, prospective study of five pediatric EDs in Japan from October 2018 to June 2020. The study included all children (aged ≤18 years) who underwent intubation at the pre-ED or ED setting by physicians and those who were transferred from the ED to the operation room (OR) or pediatric intensive care unit (PICU) for intubation. We described the airway management characteristics according to the location, patient, and provider factors.

Results

Of 231 children, 9 (4%) were transferred to the OR or PICU for airway management. Among the remaining 222 children, 45 were intubated at the pre-ED setting and 177 were intubated in the ED. The overall first-attempt success rate was 72%, with the rate varying by location, patient, and provider factors-for example, 68% at the pre-ED setting, 67% for children <2 years, 56% for children with airway-related anatomical anomalies, and 61% with intubation by a resident physician. Intubation-related adverse events were observed in 17%, most of which were hypoxemia (14%).

Conclusions

Based on data from a multicenter prospective study, the overall first-attempt intubation success rate in pediatric EDs in Japan was 72%, with large variations by location, patient, and provider factors.

Association between cognitive social capital and all-cause mortality in Great East Japan Earthquake survivors: a prospective cohort study

OBJECTIVES

Cognitive social capital (SC), such as attitude, trust, or norms, may help improve resilience among survivors, thus improving their health. However, the association between cognitive SC and the risk of all-cause mortality among survivors after the natural disaster has never been investigated. The purpose of the present study is to investigate the association between cognitive SC and the risk of all-cause mortality among survivors of the Great East Japan Earthquake (GEJE).

STUDY DESIGN

Prospective cohort study.

METHODS

We conducted a health survey on 1654 residents aged ≥18 years who lived in two areas affected by the GEJE. One year after the GEJE, between June and August 2012, cognitive SC (helping each other, trust, greeting, and solving problems together) was assessed using a self-administrated questionnaire. We divided the subjects into two groups based on response to questionnaire: "high" or "low." We obtained information on death and emigration from the Residential Registration Record and followed up on the participants from June 2012 to November 2020. The Cox proportional hazards regression analysis was used for estimating the multivariate-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for the risk of all-cause mortality according to each cognitive SC indicator.

RESULTS

During the 8.5 years of follow-up, 213 subjects died (12.9%). For greeting, compared with subjects who were "high," subjects who were "low" were significantly associated with the risk of all-cause mortality (HR: 2.92, 95% CI: 1.19-7.17). No statistically significant association was observed for helping each other, trust, and solving problems together.

CONCLUSION

Our findings suggest that perception of greeting may be associated with the risk of all-cause mortality in survivors after natural disasters.

Association of Number of Physician Postgraduate Years With Patient Intubation Outcomes in the Emergency Department

This cohort study examines the association between the number of physician postgraduate years and intubation outcomes among patients undergoing airway management in the emergency department.

Thyroid storm without precipitating factors in a previous healthy child: A case report

The Thyroid Storm (TS) is the severest form of thyrotoxicosis and is associated with a high mortality rate. TS presents with fever, tachycardia, gastrointestinal symptoms, and central nervous system dysfunction and may be overlooked if patients do not present thyrotoxic symptoms or have precipitating factors. We reported a pediatric case of TS with mild proptosis but no obvious precipitating factors in a previously healthy child. A 9-year-old, female patient with a history of attention-deficit hyperactivity disorder presented with the complaint of frequent vomiting. She was alert but lethargic with fever and tachycardia. Physical examination was unremarkable except for coolness in the extremities and a delayed capillary refill time of two seconds. Fluid resuscitation was ineffective in alleviating the tachycardia. Additional history-taking revealed a one-month history of mild proptosis but no other thyrotoxic findings or precipitating factors were found. Markedly elevated thyroxine and triiodothyronine and suppressed thyroid-stimulating hormone on thyroid function tests led to a diagnosis of TS. Methimazole, potassium iodine, bisoprolol, and hydrocortisone were administered. Her vital signs and thyroid functions gradually improved, and she was discharged 18 days after admission without any serious complications. She is currently euthyroid and clinically stable on 5 mg of methimazole at three months after admission. When tachycardia that is resistant to usual resuscitation is found, careful history-taking and physical examination targeting thyroid disorders should be performed to assess for TS.

Association Between Repeated Tracheal Intubation Attempts and Adverse Events in Children in the Emergency Department

STUDY OBJECTIVES

Studies have shown that multiple intubation attempts are associated with a higher risk of intubation-related adverse events. However, little is known about the relationship in children in the emergency department (ED).

METHODS

This is an analysis of the data from 2 prospective, observational, multicenter registries of emergency airway management. The data were collected from consecutive patients who underwent emergency airway management in 19 EDs across Japan from March 2010 to November 2017. We included children 18 years or younger who underwent tracheal intubation in the ED. The primary exposure was the number of intubation attempts (1 vs ≥2). The primary outcome was an adverse event during or immediately after the intubation.

RESULTS

A total of 439 children were eligible for the analysis. Of 279 children with first-pass success, 24 children (9%) had an adverse event. By contrast, of 160 children with ≥2 intubation attempts, 50 children patients (31%) had an adverse event. In the unadjusted model, multiple intubation attempts were significantly associated with a higher rate of adverse events (unadjusted odds ratio, 4.83; 95% confidence interval, 2.57-9.06; P < 0.001). This association remained significant after adjusting for 7 potential confounders and patient clustering within the hospital (adjusted odds ratio, 4.49; 95% confidence interval, 2.36-8.53; P < 0.001). Similar associations were found across different age groups and among children without cardiac arrest (all, P < 0.05).

CONCLUSIONS

In this analysis of large prospective multicenter data, multiple intubation attempts were associated with a significantly higher rate of intubation-related adverse events in children in the ED.

Machine Learning Approaches for Predicting Difficult Airway and First-Pass Success in the Emergency Department: Multicenter Prospective Observational Study

Background

There is still room for improvement in the modified LEMON (look, evaluate, Mallampati, obstruction, neck mobility) criteria for difficult airway prediction and no prediction tool for first-pass success in the emergency department (ED).

Objective

We applied modern machine learning approaches to predict difficult airways and first-pass success.

Methods

In a multicenter prospective study that enrolled consecutive patients who underwent tracheal intubation in 13 EDs, we developed 7 machine learning models (eg, random forest model) using routinely collected data (eg, demographics, initial airway assessment). The outcomes were difficult airway and first-pass success. Model performance was evaluated using c-statistics, calibration slopes, and association measures (eg, sensitivity) in the test set (randomly selected 20% of the data). Their performance was compared with the modified LEMON criteria for difficult airway success and a logistic regression model for first-pass success.

Results

Of 10,741 patients who underwent intubation, 543 patients (5.1%) had a difficult airway, and 7690 patients (71.6%) had first-pass success. In predicting a difficult airway, machine learning models—except for k-point nearest neighbor and multilayer perceptron—had higher discrimination ability than the modified LEMON criteria (all, P≤.001). For example, the ensemble method had the highest c-statistic (0.74 vs 0.62 with the modified LEMON criteria; P<.001). Machine learning models—except k-point nearest neighbor and random forest models—had higher discrimination ability for first-pass success. In particular, the ensemble model had the highest c-statistic (0.81 vs 0.76 with the reference regression; P<.001).

Conclusions

Machine learning models demonstrated greater ability for predicting difficult airway and first-pass success in the ED.

Effects of the new fasting standard on sedation in the pediatric emergency room

BACKGROUND

This study compared adherence to the fasting-time guidelines of the International Committee for the Advancement of Procedural Sedation (ICAPS) and the North American Society of Anesthesiologists (ASA) and complication rates in pediatric patients requiring procedure sedation and analgesia during treatment in the emergency room (ER).

METHODS

This retrospective, single-center study was performed between 2016 and 2020, and enrolled patients who received procedural sedation and analgesia in the ER with the fasting times recommended in the ICAPS and ASA guidelines.

RESULTS

In total, 857 patients were included. The most frequent indication for procedural sedation and analgesia was fracture reduction in 420 patients (49.0%). Ketamine, the most commonly administered drug, was given to 710 patients (82.8%). Adherence to the ICAPS guidelines was higher (P < 0.01), with 772 (95.7%) and 351 (41.0%) patients, respectively, adhering to the ICAPS and ASA recommendations for food and drink fasting times. Complications occurred in 130 patients (15.2%), including SpO₂ <90% in 75 patients (8.7%) and vomiting in 20 patients (2.3%). No serious complications, such as aspiration, cardiac arrest, or death, occurred. The complication rate between the two groups did not differ significantly, with 50 (14.2%) and 127 (15.5%) patients experiencing complications according to the ICAPS and ASA guidelines, respectively (P = 0.586).

CONCLUSIONS

The fasting recommendations of the ICAPS guidelines, which propose risk stratification to determine the appropriate fasting time for procedural sedation and analgesia, are more tolerable to patients and the rate of adverse events did not appear to be different from that experienced when following the ASA guidelines.

Career satisfaction among acute care resident physicians in Japan

Aim

With the introduction of the new national board certification system, sustainable education of acute care physicians has become an important topic. Prior surveys have addressed the job satisfaction of young acute care physicians. However, there have been limited nationwide surveys. The purpose of this study was to investigate the career satisfaction of senior acute care resident physicians, and to identify factors affecting their career satisfaction.

Methods

An anonymous multiple‐choice questionnaire was administered to candidates at the national board examination in 2018 regarding their career satisfaction. Data were analyzed with factor analysis and multivariable analysis with a logistic regression model to identify factors affecting career satisfaction.

Results

There were 427 respondents and the response rate was 98.2%. There were 332 male respondents (80.8%). Factors that correlated with career satisfaction were training systems, working conditions, personal learning, and stress‐related factors. High job satisfaction was found in 137 (36.6%) of the respondents. Logistic regression analysis showed that the factors significantly associated with high job satisfaction were: training systems (odds ratio [OR] 2.18; 95% confidence interval [CI], 1.43–3.33), working conditions (OR 1.78; 95% CI, 1.25–2.53), and personal learning (OR 1.55; 95% CI, 1.02–2.36). There was no significant correlation between high career satisfaction and intention to switch to another specialty.

Conclusion

High job satisfaction in senior acute care residents requires the development of a teaching environment, an optimized work environment, and encouragement of personal learning.

Pediatric emergency healthcare utilization during the coronavirus disease 2019 pandemic in Tokyo

BACKGROUND

Various public health interventions have been implemented against the coronavirus disease 2019 pandemic. We investigated changes in pediatric emergency healthcare utilization during the current pandemic.

METHODS

Based on data on outpatient healthcare visits to one pediatric emergency department in Tokyo, Japan, the descriptive, cross-sectional study compared the number of emergency department visits in 2020 to the number in the previous 3 years. Data were extracted from the electronic triage reporting system. The primary outcome was the number of emergency department visits. The characteristics of patients by age group were also investigated.

RESULTS

A 40.6% reduction in pediatric emergency healthcare utilization was observed during the study period, with the greatest decrease occurring in the number of visits for fever. However, while the number of patients with a complaint with an exogenous cause decreased, the proportion of these patients increased. Although social activities in the greater community have now almost normalized, and only a slight increase in the number of patients with fever has been reported, the number of emergency department visits remains lower than in previous years as of this writing.

CONCLUSIONS

Public health interventions led to a reduction in emergency department visits, thereby allowing time to redistribute health-care resources.

[A Case of Two Stage taTME for Perforated Rectal Cancer during Chemotherapy]

The patient was a 57-year-old male. He was diagnosed with locally advanced rectal cancer infiltrating the left levator ani muscle. Chemotherapy(S-1 plus L-OHP plus bevacizumab regimen)was started for the purpose of obtaining a negative circumferential radial margin. After the second course, he presented with perforation of the sigmoid colon for which an emergency operation was performed. The perforation was located 5 centimeters above the tumor in the sigmoid colon. We performed partial resection of the sigmoid colon to repair the perforation and create a sigmoid colostomy. CT, after the initial S-1 plus L-OHP plus bevacizumab chemotherapy regimen, revealed tumor shrinkage. Following 2 more courses of chemotherapy( S-1 plus L-OHP regimen), we performed transanal total mesenteric excision(taTME)as curative surgery. R0 resection was achieved. The combined transanal and laparoscopic approach was highly effective for a patient with pan-peritonitis.

Prediction of massive bleeding in pancreatic surgery based on preoperative patient characteristics using a decision tree

Massive intraoperative blood loss (IBL) negatively influence outcomes after surgery for pancreatic ductal adenocarcinoma (PDAC). However, few data or predictive models are available for the identification of patients with a high risk for massive IBL. This study aimed to build a model for massive IBL prediction using a decision tree algorithm, which is one machine learning method. One hundred and seventy-five patients undergoing curative surgery for resectable PDAC at our facility between January 2007 and October 2020 were allocated to training (n = 128) and testing (n = 47) sets. Using the preoperatively available data of the patients (34 variables), we built a decision tree classification algorithm. Of the 175 patients, massive IBL occurred in 88 patients (50.3%). Binary logistic regression analysis indicated that alanine aminotransferase and distal pancreatectomy were significant predictors of massive IBL occurrence with an overall correct prediction rate of 70.3%. Decision tree analysis automatically selected 14 predictive variables. The best predictor was the surgical procedure. Though massive IBL was not common, the outcome of patients with distal pancreatectomy was secondarily split by glutamyl transpeptidase. Among patients who underwent PD (n = 83), diabetes mellitus (DM) was selected as the variable in the second split. Of the 21 patients with DM, massive IBL occurred in 85.7%. Decision tree sensitivity was 98.5% in the training data set and 100% in the testing data set. Our findings suggested that a decision tree can provide a new potential approach to predict massive IBL in surgery for resectable PDAC.

Applicability of composite materials for space radiation shielding of spacecraft

Energetic ion beam experiments with major space radiation elements, ¹H, ⁴He, ¹⁶O, ²⁸Si and ⁵⁶Fe, have been conducted to investigate the radiation shielding properties of composite materials. These materials are expected to be used for parts and fixtures of space vehicles due to both their mechanical strength and their space radiation shielding capabilities. Low Z materials containing hydrogen are effective for shielding protons and heavy ions due to their high stopping power and large fragmentation cross section per unit mass. The stopping power of the composite materials used in this work is intermediate between that of aluminum and polyethylene, which are typical structural and shielding materials used in space. The total charge-changing cross sections per unit mass, σ_UM, of the composite materials are 1.3-1.8 times larger than that of aluminum. By replacing conventional aluminum used for spacecraft with commercially available composite (carbon fiber / polyether ether ketone), it is expected that the shielding effect is increased by ∼17%. The utilization of composite materials will help mitigate the space radiation hazard on future deep space missions.

Intraoperative Allogeneic Red Blood Cell Transfusion Negatively Influences Prognosis After Radical Surgery for Pancreatic Cancer: A Propensity Score Matching Analysis

OBJECTIVE

We aimed to investigate the real impact of allogeneic red blood cell transfusion (ABT) on postoperative outcomes in resectable pancreatic ductal adenocarcinoma (PDAC) patients.

METHODS

Of 128 patients undergoing resectable PDAC surgery at our facility, 24 (18.8%) received ABT. Recurrence-free survival (RFS) and disease-specific survival (DSS), before and after propensity score matching (PSM), were compared among patients who did and did not receive ABT.

RESULTS

In the entire cohort, ABT was significantly associated with decreased RFS (P = 0.002) and DSS (P = 0.014) before PSM. Cox regression analysis identified ABT (risk ratio, 1.884; 95% confidence interval, 1.015-3.497; P = 0.045) as an independent prognostic factor for RFS. Univariate and multivariate analysis identified preoperative hemoglobin value, preoperative total bilirubin value, and intraoperative blood loss as significant independent risk factors for ABT. Using these 3 variables, PSM analysis created 16 pairs of patients. After PSM, the ABT group had significantly poorer RFS rates than the non-ABT group (median, 9.8 vs 15.8 months, P = 0.022). Similar tendencies were found in DSS rates (median, 19.4 vs 40.0 months, P = 0.071).

CONCLUSIONS

This study revealed certain negative effects of intraoperative ABT on postoperative survival outcomes in patients with resectable PDAC.

Prognosis of ultrasonographic low-grade pediatric appendicitis treated with supportive care

BACKGROUND

A previous report proposed ultrasonography-based classification as a promising means of predicting pediatric spontaneously resolving appendicitis. The present study investigated the long-term prognosis of supportive care for low-grade appendicitis identified by ultrasonography, defined as an appendix with a smooth submucosal layer irrespective of blood flow or an appendix with an irregular layer and increased blood flow.

METHODS

The present, retrospective cohort study enrolled patients under 16 years of age with acute appendicitis at a children's hospital between October 2010 and September 2016. The inclusion criteria were ultrasonography findings showing an appendix with (1) full visualization, (2) a diameter ≥6 mm, (3) a smooth submucosal layer or an irregular layer with increased blood flow, and (4) no appendiceal mass, abscess, or perforation. The exclusion criteria were: (1) a history of acute appendicitis, (2) antibiotic administration within 72 hours before diagnosis, and (3) antibiotic administration or surgery before supportive care. The primary outcome was the event-free duration, defined as a period of supportive care alone with no additional intervention or recurrence of appendicitis.

RESULTS

One hundred and eighty-two patients were enrolled. The median Alvarado score was 7 (interquartile range, 6-8), and the median follow-up duration in event-free cases was 1,922 days (interquartile range, 1,347-2,614 days). The event-free rate was 75.0%, 67.0%, and 62.5%, at 1, 2, and 5 years, respectively.

CONCLUSION

The long-term, event-free rate exceeded 60% in patients with low-grade appendicitis defined by ultrasonography who received neither surgery nor antibiotic treatment. Most recurrences occurred within 2 years of the initial diagnosis.

[A Case of Descending Colon and Rectal Cancer with Acute Myeloid Leukemia Performed Robot‒Assisted Hartmann's Procedure]

The case is a 68‒year‒old male, who had been diagnosed with acute myeloid leukemia(AML)prior to rectal cancer surgery, was referred to our hospital for treatment in July 2019. We planned to treat the AML first, and then the colorectal cancer. After completion of 1 course of CAG therapy(cytarabine, aclarubicin, G‒CSF), his white blood cell count increased sufficiently, so he underwent a robot‒assisted Hartmann operation in October. A second course of CAG therapy was started 15 days postoperatively. However, he was then diagnosed with exacerbation of the AML; remission induction therapy (daunorubicin, cytarabine)was started in November. In December, he developed a fever and abdominal pain, and on CT scan, it was discovered that an abscess had formed around the rectal resection site. Myelosuppression from AML led to prolonged sepsis; and by January 2020, the sepsis was systemic. His actual cause of death was given as circulatory failure. We report this, because only a few cases on the treatment of overlapping AML and colorectal cancers can be found in the literature.

Association of advanced age with intubation-related adverse events in the emergency department: a multicentre prospective observational study

BACKGROUND

While the older population accounts for an increasing proportion of emergency department (ED), little is known about intubation-related adverse events in this high-risk population. We sought to determine whether advanced age is associated with a higher risk of intubation-related adverse events in the ED.

METHODS

This is an analysis of data from a prospective, 15-centre, observational study-the second Japanese Emergency Airway Network (JEAN-2) study. The current analysis included adult (aged ≥18 years) patients who underwent intubation in the ED between 2012 and 2018. The primary exposure was age (18-39, 40-64, 65-74, 75-84 and ≥85 years). The primary outcome was overall intubation-related adverse events during or immediately after an intubation. Adverse events were further categorised into major (hypotension, hypoxaemia, oesophageal intubation, cardiac arrest, dysrhythmia and death) and minor (endobronchial intubation, oesophageal intubation with early recognition, dental/lip trauma, airway trauma and regurgitation) adverse events. We constructed multivariable logistic regression models adjusting for seven potential confounders with generalised estimating equations that account for patients clustering within the ED.

RESULTS

Among 9714 patients eligible for the analysis, 15% were aged ≥85 years, and 16% had adverse events. In the unadjusted models, advanced age was not significantly associated with the risk of overall adverse events. In the adjusted models, the association was significant (adjusted OR 1.41 in age ≥85 years (95% CI, 1.09 to 1.81) compared with age 18-39 years). Specifically, older patients had a significantly higher risk of major adverse events (adjusted OR in age ≥85 years 2.65 (95% CI, 1.78 to 3.94)), which was driven by the association of advanced age with an increased risk of hypotension (adjusted OR in ≥85 years, 5.69 (95% CI, 3.13 to 10.37)). By contrast, advanced age was not associated with minor adverse events.

CONCLUSION

Based on the data from a prospective multicentre study, advanced age was associated with higher risks of major adverse events.

The Management of Pediatric Genital Injuries at a Pediatric Emergency Department in Japan

OBJECTIVES

Genital injuries among children are often associated with consumer products or specific activities. There are few descriptive studies from Asia on pediatric genital injuries seen in the emergency department (ED). The aim of this study was to describe the characteristic features of accidental genital injuries among children.

METHODS

A retrospective chart review of children aged 15 years or younger who visited our ED for genital injuries between March 2010 and November 2014 was conducted. Data on age, arrival time at the ED, location of the incident, mechanism of injury, objects, injured organ, consultation with specialists, emergency operation, sedation at the ED, and outcomes were collected and analyzed.

RESULTS

One hundred seventy-nine patients were included in this analysis. Girls comprised 71% of the subject pool. The median age was 6 years (interquartile range, 4-9 years). Straddle injuries were the most common form of injury (56%). Male genital injuries occurred mostly outdoors (64%). Common consumer products associated with pediatric genital injuries were furniture (21%), exercise equipment (17%), and bicycles (15%). Thirty-two patients were examined by a surgeon, gynecologist, or urologist. The most commonly injured organs were the penis (55%) in boys and the labia (60%) in girls. Most patients (93%) were treated at the ED and discharged.

CONCLUSIONS

The characteristics of accidental genital injuries among Japanese children were similar to those of children in other countries. The strategy for preventing genital injuries used in the West might be applicable to the East Asian context.

Ultrasound-guided nasogastric tube placement in a pediatric emergency department

Nasogastric tube (NGT) insertion is commonly performed in pediatric emergency care. Point-of-care ultrasound is used for confirming NGT insertion, but reports of its use in the pediatric emergency department (ED) are scarce. We describe our experience of ultrasound-guided NGT placement in a pediatric ED. The study pool consisted of twelve patients and the NGT tip was successfully visualized in the esophagus and gastric cardia in all cases, demonstrating that ultrasound has the potential to be a useful alternative to conventional methods of NGT insertion in the pediatric ED.

Complete Republication: Fall Injury while the Parent Is Operating a Bicycle with an Infant in a Baby Carrier

Introduction

Pediatric emergency physicians commonly experience cases of infantile trauma as a result of a child falling from the arms or the back of a parent while the parent is operating a bicycle.

Methods

1. We conducted a retrospective case-series study which included children younger than 1 year who were injured after falling from the arms or the back of the parent while the latter was operating a bicycle. 2. We conducted a dynamics experiment by recreating the circumstances of the accident using dummies representing a 6-month-old infant being carried on the back of the mother. We assessed the score of the Head Injury Criterion (HIC) and the maximum impact load on the head of the dummy infant.

Results

1. We found eight injured patients, two of whom required intensive care. One of the latter experienced neurological sequelae. 2. The HIC score and the maximum impact load varied from 7.7 to 17.0 and 2.26 to 3.47 times the reference values for 6-month-old infants, respectively.

Conclusions

Our study revealed that a strong impact on an infant's head can result in severe head trauma due to the mechanics of the injury type studied. Preventive strategies for the safe transportation of infants are needed.

Investigation of shielding material properties for effective space radiation protection

Geant4 Monte Carlo simulations were carried out to investigate the possible shielding materials of aluminum, polyethylene, hydrides, complex hydrides and composite materials for radiation protection in spacecraft by considering two physical parameters, stopping power and fragmentation cross section. The dose reduction with shielding materials was investigated for Fe ions with energies of 500 MeV/n, 1 GeV/n and 2 GeV/n which are around the peak of the GCR energy spectrum. Fe ions easily stop in materials such as polyethylene and hydrides as opposed to materials such as aluminum and complex hydrides including high Z metals with contain little or no hydrogen. Attenuation of the primary particles in the shielding and fragmentation into more lightly charged and therefore more penetrating secondary particles are competing factors: attenuation acts to reduce the dose behind shielding while fragmentation increases it. Among hydrogenous materials, ⁶Li¹⁰BH₄ was one of the more effective shielding materials as a function of mass providing a 20% greater dose reduction compared to polyethylene. Composite materials such as carbon fiber reinforced plastic and SiC composite plastic offer 1.9 times the dose reduction compared to aluminum as well as high mechanical strength. Composite materials have been found to be promising for spacecraft shielding, where both mass and volume are constrained.

Pediatric Case of Successful Point-of-Care Ultrasound-Guided Nasogastric Tube Placement

BACKGROUND

Nasogastric tube (NGT) placement is commonly performed in pediatric emergency care and is classically confirmed by any one of several methods, among which auscultation or aspiration and radiography comprise the currently recognized as the reference standard. Point-of-care ultrasound (POCUS) is used to confirm NGT insertion, especially in adults or prehospital patients, but reports of its use in the pediatric emergency department (ED) are still scarce. We report a case of successful POCUS-guided NGT placement in a pediatric ED.

CASE REPORT

A 3-year-old male undergoing remission therapy for acute lymphocytic leukemia presented to our ED with fever and decreased appetite. Tumor lysis syndrome was diagnosed, and endotracheal intubation was required because of the need for emergency hemodialysis for hypercalcemia. Because of difficulty in guiding the tube through the nose, ultrasound-guided placement was attempted. In the transverse view over the neck below the level of the cricoid cartilage, the 10-Fr NGT was visualized under ultrasound guidance as it passed through the esophagus. Subsequently, the entry of the NGT tip into the gastric cardia was confirmed on the subxiphoid longitudinal view. A chest radiograph confirmed the presence of the NGT in the stomach. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although the utility of POCUS for NGT placement was reported in adult patients, reports of its use in pediatric cases are still few. POCUS is a real-time, noninvasive, time-saving procedure that can be a useful alternative to radiography for confirming correct NGT placement.

Isolation of four xylanases capable of hydrolyzing corn fiber xylan from Paenibacillus sp. H2C

Corn fibre xylan (CX) shows high resistance to enzymatic hydrolysis due to its densely decorated side chains. To find enzymes capable of hydrolyzing CX, we isolated a bacterial strain (named H2C) from soil, by enrichment culture using non-starch polysaccharides of corn as the sole carbon source. Analysis based on the 16S rRNA sequence placed strain H2C within genus Paenibacillus. Enzymes were purified from supernatant of culture broth of strain H2C based on solubilizing activities toward CX. Four enzymes, Xyn5A, Xyn10B, Xyn11A, and Xyn30A, were successfully identified, which belong to glycoside hydrolase (GH) families, 5, 10, 11, and 30, respectively. Phylogenetic analysis classified Xyn5A in subfamily 35 of GH family 5, a subfamily of unknown function. Their activities toward beechwood xylan and/or wheat arabinoxylan indicated that these enzymes are β-1,4-xylanases. They showed high solubilizing activities toward a feed material, corn dried distiller’s grains with solubles, compared to five previously characterized xylanases.

Abbreviations : CX: corn fibre xylan; DDGS: corn dried distiller’s grains with solubles

Metered-dose inhaler ipratropium bromide for children with acute asthma exacerbation: A prospective, non-randomized, observational study

BACKGROUND

Ipratropium bromide (IB), when administered with β2-agonists, is effective in reducing hospital admissions of children presenting to the emergency department (ED) with severe asthma. While IB is commonly delivered in its nebulized form, using a metered-dose inhaler (MDI), can, reportedly, shorten patients' length of stay in the ED. However, the effectiveness and safety of IB administration using an MDI with a spacer have not been established. This study aimed to investigate the effectiveness and safety of MDI-delivered IB in pediatric patients with acute asthma exacerbation.

METHODS

This prospective, non-randomized, observational study included patients aged ≥4 years with a history of severe asthma exacerbation. Patients received IB via MDI with a spacer three times at 20-min intervals. IB use was determined by the physicians' treatment policy. Propensity score matching was used to adjust the confounding factors related to IB administration.

RESULTS

Of the 158 patients, 88 were treated with IB and 70 were treated without IB. A propensity score-matching analysis extracted 54 patients from each group. We found no statistical difference in the admission rate of the two groups (IB group: 25.9% vs non-IB group: 31.5%; P = 0.67). The post-treatment modified pulmonary index scores (mean ± SD) were also similar (IB: 6.6 ± 2.0 vs non-IB: 6.3 ± 2.5; P = 0.53). Only one patient (1.0%) treated with IB experienced vomiting, which resolved spontaneously.

CONCLUSION

The metered-dose inhaler IB was ineffective in reducing the admission rate possibly because it was less effective than a nebulizer for IB inhalation.

[Gallbladder Cancer with Multiple Liver Metastases Completely Responding to Gemcitabile plus Cisplatin Chemotherapy-A Case Report]

A 59-year-old man was diagnosed with cholecystolithiasis and cholecystitis and underwent cholecystectomy. The pathological findings were moderately differentiated adenocarcinoma(pT2)in the gallbladder fundus. Sixteen days after surgery, he visited our hospital due to jaundice. Abdominal enhanced CT and EOB-MRI revealed multiple liver metastases and lymph node metastases in the hepatoduodenal ligament that we deemed to be unresectable. A metallic stent was inserted for bile duct obstruction, and he underwent chemotherapy with gemcitabine plus cisplatin(GC). After 12 courses of GC, the metastatic lesions disappeared, and the patient showed complete response. FDG-PET/CT showed FDG uptake in the hepatoduodenal ligament and we subsequently decided to perform surgery. He underwent resection of the extrahepatic bile duct and regional lymphadenectomy. The pathological findings revealed no residual carcinomas in the bile duct or lymph nodes. We are continuing chemotherapy at present, and the patient is alive with no signs of recurrence at 1 year and 3 months following the diagnosis of multiple liver metastases.

Cells from a GDF5 origin produce zonal tendon-to-bone attachments following anterior cruciate ligament reconstruction

Following anterior cruciate ligament (ACL) reconstruction surgery, a staged repair response occurs where cells from outside the tendon graft participate in tunnel integration. The mechanisms that regulate this process, including the specific cellular origin, are poorly understood. Embryonic cells expressing growth and differentiation factor 5 (GDF5) give rise to several mesenchymal tissues in the joint and epiphyses. We hypothesized that cells from a GDF5 origin, even in the adult tissue, would give rise to cells that contribute to the stages of repair. ACLs were reconstructed in Gdf5-Cre;R26R-tdTomato lineage tracing mice to monitor the contribution of Gdf5-Cre;tdTom+ cells to the tunnel integration process. Anterior-posterior drawer tests demonstrated 58% restoration in anterior-posterior stability. Gdf5-Cre;tdTom+ cells within the epiphyseal bone marrow adjacent to tunnels expanded in response to the injury by 135-fold compared with intact controls to initiate tendon-to-bone attachments. They continued to mature the attachments yielding zonal insertion sites at 4 weeks with collagen fibers spanning across unmineralized and mineralized fibrocartilage and anchored to the adjacent bone. The zonal attachments possessed tidemarks with concentrated alkaline phosphatase activity similar to native entheses. This study established that mesenchymal cells from a GDF5 origin can contribute to zonal tendon-to-bone attachments within bone tunnels following ACL reconstruction.

[Successful Treatment of Necrotizing Fasciitis Due to Ascending Colon Cancer-A Case Report]

A 70-year-old woman was brought to our hospital by ambulance because of severe groin pain on the right side. Computed tomography scan revealed a tumor in the ascending colon, intraperitoneal abscess spread to the subcutaneous tissues, and a large amount of pneumoderma. She was diagnosed with necrotizing fasciitis caused by penetration of ascending colon cancer and underwent lavage and drainage, right hemicolectomy, end ileostomy, and debridement of necrotic tissues on emergency. Postoperatively, she underwent debridement and irrigation at the bedside every day, but the necrotizing tissues spread. Debridement under general anesthesia was repeated on postoperative day 8. On postoperative day 20, negative pressure wound therapy(NPWT)was initiated to manage the exudates and wound condition, and healthy granulation tissues formed gradually. After 4 weeks, she underwent split-thickness skin graft implantation. The postoperative course was uneventful, and she was discharged from the hospital. She is currently on chemotherapy and has been alive for 1 year and 3 months after the first operation.

Diagnostic Accuracy of a 3-Point Ultrasound Protocol to Detect Esophageal or Endobronchial Mainstem Intubation in a Pediatric Emergency Department

OBJECTIVES

The aim of this study was to evaluate the diagnostic accuracy of the 3-point approach with ultrasonography for confirming endotracheal tube (ETT) placement in pediatric patients.

METHODS

This was a prospective study conducted at a tertiary care center in Japan between March 2014 and March 2016. Children aged 0 to 18 years requiring endotracheal intubation in our emergency department (ED) who underwent ultrasonography for confirming ETT placement were enrolled. Patients who had already undergone a tracheotomy or intubation before arrival at our ED or who had severe neck injuries hindering ultrasonography were excluded. Quantitative capnography and portable chest x-ray imaging were used as the reference standard for the confirmation of proper ETT placement. The main outcome was the diagnostic accuracy of the 3-point approach with ultrasonography for detecting inappropriate ETT placement.

RESULTS

In total, 68 patients were enrolled. The median age was 17 months (interquartile range, 8-40), and 51.4% were males. Three (4.4%) and 7 (10.3%) patients had esophageal and endobronchial mainstem intubation, respectively. The patients received emergency intubation due to a dysfunction of the central nervous system (45.6%) or respiratory failure (22.0%). The sensitivity and specificity of esophageal versus tracheal intubation was 100% (95% confidence interval [CI], 54.9%-100.0%) and 100% (95% CI, 97.9%-100.0%), respectively, whereas for endobronchial mainstem intubation versus tracheal intubation, the sensitivity and specificity was 85.7% (95% CI, 56.7%-96.0%) and 98.3% (95% CI, 94.8%-99.5%), respectively. Agreement between the reviewers was high (kappa coefficient, 0.78).

CONCLUSION

The 3-point approach with ultrasonography was a feasible method for detecting esophageal and endobronchial mainstem intubation in pediatric patients.

Factors associated with successful rescue intubation attempts in the emergency department: an analysis of multicenter prospective observational study in Japan

Aim

It remains unclear whether physicians should change intubation approaches after the failed first attempt. We aimed to determine the rescue intervention approaches associated with a higher success rate at the second attempt in the emergency department (ED).

Methods

We analyzed the data from a prospective, multicenter, observational study – the second Japanese Emergency Airway Network Study. The current analysis included all patients who underwent emergency intubation from February 2012 through November 2017. We defined a rescue intubation attempt as a second intubation attempt with any change in intubation approaches (i.e., change in methods, devices, or intubators) from the failed first attempt. The outcome measure was second‐attempt success.

Results

Of 2,710 patients with a failed first attempt, 43% underwent a second intubation attempt with changes in intubation approach (i.e., rescue intubation). Rescue intubation attempts were associated with a higher second‐attempt success rate compared to non‐rescue intubation attempts (adjusted odds ratio [OR], 1.78; 95% confidence interval [CI], 1.50–2.12). The rescue intubation approaches associated with a higher second‐attempt success were changes from non‐rapid sequence intubation (RSI) to RSI (adjusted OR, 2.04; 95% CI, 1.12–3.75), from non‐emergency medicine (EM) residents to EM residents (adjusted OR, 2.02; 95% CI, 1.44–2.82), and from non‐EM attending physicians to EM attending physicians (adjusted OR, 2.82; 95% CI, 2.14–3.71).

Conclusions

In this large multicenter study, rescue interventions were associated with a higher second‐attempt success rate. The data also support the use of RSI and backup by EM residents or EM attending physicians to improve the airway management performance after a failed attempt in the ED.

Validation of the PECARN head trauma prediction rules in Japan: A multicenter prospective study

BACKGROUND

Head trauma in children is one of the most common causes for emergency department visits. Although most trauma cases are minor, identifying those patients who have clinically important traumatic brain injury (ciTBI) is challenging. The Pediatric Emergency Care Applied Research Network (PECARN) head trauma prediction rules identifying children who do not require cranial computed tomography (CT) were validated and are used all over the world. However, these rules have not been validated with large cohort multicenter studies in Asia.

OBJECTIVES

To investigate whether the PECARN rules can be safely applied to Japanese children.

METHODS

We conducted a multicenter, prospective, observational cohort study. We included children younger than 16 with minor head trauma (Glasgow Coma Scale ≥14) who presented to the six participating centers within 24 h of their injuries between June 2016 and September 2017. The primary analysis was set to calculate the negative predictive value of the patients with very low risk by the PECARN rules, compared with a preset threshold of 99.85%.

RESULTS

We included 6585 children of which 463 (7.0%) had head CT scans performed and 23 (0.35%) had ciTBI. There were two patients with ciTBI who were classified as very low risk. The negative predictive value, calculated as 99.96% (95%CI: 99.86-100.00; P = .019), was significantly superior compared with the preset threshold of 99.85%.

CONCLUSIONS

The PECARN head trauma prediction rules seemed to be safely applicable to Japanese children. Further studies are needed to determine safety in hospitals where physicians do not have expertise in managing children.

Advancing emergency airway management practice and research

Emergency airway management is one of the vital resuscitative procedures undertaken in the emergency department (ED). Despite its clinical and research importance in the care of critically ill and injured patients, earlier studies have documented suboptimal intubation performance and high adverse event rates with a wide variation across the EDs. The optimal emergency airway management strategies remain to be established and their dissemination to the entire nation is a challenging task. This article reviews the current published works on emergency airway management with a focus on the use of airway management algorithms as well as the importance of first‐pass success and systematic use of rescue intubation strategies. Additionally, the review summarizes the current evidence for each of the important airway management processes, such as assessment of the difficult airway, preparation (e.g., positioning and oxygenation), intubation methods (e.g., rapid sequence intubation), medications (e.g., premedications, sedatives, and neuromuscular blockades), devices (e.g., direct and video laryngoscopy and supraglottic devises), and rescue intubation strategies (e.g., airway adjuncts and rescue intubators), as well as the airway management in distinct patient populations (i.e., trauma, cardiac arrest, and pediatric patients). Well‐designed, rigorously conducted, multicenter studies that prospectively and comprehensively characterize emergency airway management should provide clinicians with important opportunities for improving the quality and safety of airway management practice. Such data will not only advance research into the determination of optimal airway management strategies but also facilitate the development of clinical guidelines, which will, in turn, improve the outcomes of critically ill and injured patients in the ED.

Methylxanthine use for acute asthma in the emergency department in Japan: a multicenter observational study

Aim

Methylxanthines are no longer recommended for emergency department (ED) patients with acute asthma according to international guidelines. We aimed to describe the current methylxanthine use for acute asthma and to determine factors related to its use in the ED.

Methods

We undertook a multicenter retrospective study in 23 EDs across Japan. From each participating hospital, we randomly identified 60 ED patients aged 18-54 years with acute asthma from 2009 through 2011. We examined the associations of ED and patient characteristics with methylxanthine use by constructing a multivariable logistic regression model adjusting for a predefined set of ED- and patient-level factors.

Results

Among 1,380 patients, methylxanthines were used for 79 patients (5.7%, 95% confidence interval [CI], 4.6-7.0%). The proportion of methylxanthine treatment varied substantially among EDs, ranging from 0% to 26.1%. In the multivariable analysis, the number of annual ED patients with acute asthma (odds ratio [OR] per 100 increase in annual asthma patients, 0.12; 95% CI, 0.04-0.34; P < 0.001) and having a protocol for asthma treatment (OR 2.91; 95% CI, 1.06-8.00; P = 0.04) at the ED level, and systemic corticosteroid use (OR 6.39; 95% CI, 3.34-12.22; P < 0.001) at the patient level were associated with likelihood of methylxanthine use.

Conclusions

In this multicenter study, approximately 6% of ED patients with acute asthma were treated with methylxanthines, with a wide variation across EDs. The number of annual ED patients with acute asthma was significantly associated with a lower likelihood of methylxanthine use, whereas having an ED asthma treatment protocol and systemic corticosteroid use in the ED were associated with a higher likelihood of methylxanthine treatment.