Impact of COVID-19 pandemic on the care of severe burns in Japan: Repeated survey of specialized burn care facilities.

BACKGROUND: The spread of coronavirus disease 2019 (COVID-19), which began in 2020, has had a major impact on healthcare systems. The spread of COVID-19 has been reported to have affected the readiness to treat patients with burns worldwide. However, the existing reports have evaluated burn care status within a limited time period during the pandemic, and no report clarifies the change in the impact of infection status on burn care from the beginning of the pandemic to the present. METHODS: Japanese Society for Burn Injuries-accredited burn care facilities were surveyed using questionnaires on April 9-23, 2020; June 23-July 6, 2020; July 9-21, 2021; and January 21-31, 2022. Differences between groups were evaluated using Friedman's test or Bonferroni's multiple comparison test, as appropriate. RESULTS: From the 103 facilities included in the study, we received 85, 55, 56, and 58 responses in the first, second, third, and fourth surveys, respectively. We could continuously observe 34 facilities. The rate of acceptance of patients with severe burns improved significantly over time (P < 0.05). However, in the second and third surveys, there was an increase in the number of respondents who did not accept patients with burns irrespective of COVID-19 status. CONCLUSIONS: The number of facilities treating patients with burns who have COVID-19 is increasing; however, COVID-19 care may negatively impact routine burn care. It is necessary to continuously examine medical resource allocation through methods such as information sharing by academic societies.

Two cases of life-threatening arrhythmia induced by risperidone: evaluation of risperidone and 9-hydroxy-risperidone concentrations.

Cases: Case 1: A 20-year-old woman suffering a suspected overdose was transported to the hospital. She presented bradycardia with wide QRS waves and QT prolongation, followed by cardiac arrest. Extracorporeal cardiopulmonary resuscitation was implemented, improving circulation. Risperidone and 9OH-RIS levels were 9.6 ng/mL and 127.6 ng/mL, respectively. Case 2: A 54-year-old woman was hospitalized for femoral fracture and underwent surgery. Her electrocardiogram showed bradycardia and complete AV block. Risperidone and 9OH-RIS levels were 3.2 ng/mL and 61.4 ng/mL, respectively. Outcome: In both cases, only serum concentration of 90H-RIS were elevated. Conclusion: Arrhythmia related to risperidone has proven rare but sometimes fatal. Serum concentrations of risperidone and the metabolite 9-hydroxy-risperidone (9OH-RIS) during these events are seldom documented. As 9OH-RIS shows pharmacological activity equivalent to risperidone, it may induce life-threatening arrhythmia (regardless of the intake dosage). It is critical to evaluate the serum concentration of 9OH-RIS in suspected risperidone toxicity.

Food poisoning associated with Kudoa septempunctata.

BACKGROUND: Kudoa septempunctata is a recently identified cause of food poisoning. We report three cases of food poisoning due to ingestion of this parasite. CASE REPORTS: Among the 358 people exposed during the same catered meal, 94 (including our 3 patients) developed vomiting and diarrhea within 1-9 h after ingestion of raw muscle from contaminated aquacultured olive flounders (Paralichthys olivaceus). These symptoms occurred frequently but were temporary; only 1 patient was hospitalized for dehydration and was discharged 2 days later. CONCLUSION: In Japan, cases of food poisoning due to eating olive flounder have increased during recent years. This increase should prompt heightened awareness among clinicians diagnosing food poisoning.

A case of Strongyloides hyperinfection associated with tuberculosis.

Strongyloidiasis is a parasitic infection that occurs in tropical regions. Hyperinfection, which is an accelerated autoinfection, is often associated with an immunosuppressive state, such as HTLV-1 infection or steroid use. Immunosuppression can also lead to reactivation of tuberculosis infection. These infections may have interacted as a result of impaired cellular immunity. A 28-year-old Nepali male was referred to our hospital for slight abdominal pain and high fever. An abdominal CT scan showed ascites and intestinal swelling. He was admitted with suspected gastroenteritis. Results of stool microscopy on the third day of hospitalization revealed abundant strongylid larvae. We diagnosed a Strongyloides hyperinfection and prescribed ivermectin. Although the numbers of strongylid organisms in the patient's stool soon diminished, his temperature remained high. After receiving a second dose of ivermectin on day 17, he was transferred to a nearby hospital for observation, where he was noted to have massive pleural effusion. He returned to our hospital where his pleural effusion was found to be positive for adenosine deaminase (ADA), and he was diagnosed with a tuberculosis infection. Strongyloides hyperinfection can occur in a non-endemic region. It can be associated with tuberculosis infection possibly due to impaired cellular immunity. It is important to consider other possible infections when treating a patient with an infection associated with impaired cellular immunity.

Prospective evaluation of three different diagnostic criteria for disseminated intravascular coagulation.

There are three different diagnostic score systems for disseminated intravascular coagulation (DIC) established by the Japanese Ministry Health and Welfare (JMHW), the International Society on Thrombosis and Haemostasis (ISTH) and the Japanese Association for Acute Medicine (JAAM). The JMHW criteria are still used in Japan. In the present study, all three diagnostic criteria were used to prospectively evaluate 413 patients with different underlying diseases of DIC who were treated at the Mie University Hospital (JMHW, n= 166; ISTH, n=143; JAAM, n=291). The odds ratio (95% confidence interval) for death was 1.88 (1.22 - 2.90) in JMHW, 2.55 (1.65 - 3.95) in ISHT and 1.99 (1.19 - 3.32) in JAAM. The platelet count, prothrombin time, fibrin and fibrinogen degradation products and fibrinogen were significantly important for diagnosis of DIC by all three diagnostic criteria. Haemostatic molecular markers were significantly high in all patients and were useful for the diagnosis of DIC. The JAAM diagnostic criteria displayed a high sensitivity for DIC and the ISTH overt-DIC diagnostic criteria displayed a high specificity for DIC. All three diagnostic criteria for DIC were related to a poor patient outcome.

[Possible role of pharmacists in emergency medical care].

Emergency medicine is an interdisciplinary area that covers medical care in an emergency room, trauma center and intensive care unit. It also provides prehospital emergency medical service and disaster medicine. Pharmacists are expected to play major roles as a member of the emergency medical team. The roles of pharmacist include inventory management, formulary management, administration guidance, medication delivery, identification of a tablet, analysis of intoxicating substance, and therapeutic drug monitoring. During disaster response, accompanying disaster relief team to provide supervision for stock and prescription of medications could also be an important mission of a pharmacist. As a member of the emergency medical team, knowledge and skills for effective communication is essential to discuss patients' condition and therapeutic strategy with other healthcare providers. Basic life support and first-aid ability are mandatory to all the medical professionals who take care of patients. Safety and security management at the emergency or disaster scene is another important requirement. We hope more pharmacists will join the emergency and disaster medicine and contribute to extend a hand to the sufferers.

Postmortem computed tomography is an informative approach for prevention of sudden unexpected natural death in the elderly.

INTRODUCTION: Less than 10% of unnatural death cases have been examined by autopsy in Japan. In particular, the causes of death in the elderly have not yet been actively investigated. Here, we evaluated the possible use of postmortem computed tomography (PMCT) to investigate the causes of sudden unexpected natural death (SUND) in the elderly. METHODS AND SUBJECTS: Death cases confirmed within 24 hours since the onset of symptoms at the Emergency Department of Mie University Hospital were defined as sudden death cases. A total of 212 sudden death cases, including 175 SUND cases, that occurred in a 3-year period from September 2006 to August 2009 were investigated. RESULTS AND DISCUSSION: The number of sudden death cases was highest in patients in their seventies (56 cases, 26%), followed by patients in their eighties and sixties. Sudden death occurred more in men than in women in their fifties to seventies, while it occurred more in women than in men over the age of 90. PMCT was performed in more than 80% of SUND cases regardless of age of the deceased. The causes in 26 cases (27.1%) were established by PMCT, many of which were hemorrhagic diseases. Signs of aortic aneurysm rupture were detected by PMCT in the thoracic and abdominal areas of 8 patients in their seventies and over, whereas signs were absent in the younger group. Also, more than 18% of sudden death cases in patients in their seventies and over were bathing-related sudden death (BRSD). BRSD was rarely caused by hemorrhagic diseases, suggesting that a drop in blood pressure caused by bathing is an important factor in BRSD. CONCLUSION: PMCT is a method that is relatively acceptable by bereaved families. It is useful for establishing the causes of approximately 30% of the SUND cases examined. The PMCT findings suggested that early detection and treatment of thoracic and abdominal aortic aneurysms and preventive measurements of bathing-related drop in blood pressure are important for the prevention of SUND in the elderly.

Experiences in organizing Advanced Burn Life Support (ABLS) provider courses in Japan.

The ABLS course sponsored by the ABA has not yet been made available in Japan, although it is strongly desired. During the 3 years between 2006 and 2008, authorized ABLS provider courses were given once a year in Japan as part of preparations to reach an agreement between the ABA and the JSBI for the continuation of ABLS provider courses in Japan. These courses were provided as one of the programs available at the annual meeting of the JSBI. Nine Japanese registered ABLS instructors (including some candidates) acted as lecturers. Two national faculty members and one course coordinator, acting as ABA observers, participated in the first and second courses. In total, 64 physicians (37 emergency physicians, 20 plastic surgeons, 4 intensivists and 3 general surgeons) attended the courses. Course management and instructor behavior were reviewed by the ABA observers and the 64 physicians in attendance using questionnaires. The ABA observers rated the courses as "outstanding" in every aspect (course faculty, facilities, course organization, course conduct, and adherence to ABLS philosophies). The pre-course planning, course conduct, and course evaluations were professional and adhered to the highest educational standards. However, several areas of the ABLS course content may require revision to accommodate differences in standard medical treatment between the United States and Japan. Two percent of the physicians rated the courses as easy, 59% rated the course as moderate, 22% rated the course as slightly difficult, and 6% rated the course as difficult. The courses were generally evaluated as very good by 28% of the physicians and good by 56%. The major opinion regarding the organization of the course in Japan was that the course should have undergone appropriate curriculum changes to accommodate societal differences (including the translation of the course into Japanese) as well as modifications to the disaster management and patient transport sections. Regarding the organization of future ABLS courses in Japan, the active involvement of the JSBI is inevitable. Several areas of the ABLS course content may need to be revised to accommodate differences in standard medical treatment between the United States and Japan. A joint effort between the ABA and the JSBI regarding appropriate curriculum changes to accommodate societal differences as well as modifications to some sections would increase the applicability of the course in Japan.

Efficacy of procalcitonin in the early diagnosis of bacterial infections in a critical care unit.

Procalcitonin (PCT) is a marker of severe bacterial infections and organ failure due to sepsis. The purpose of the present study was to identify the appropriate cutoff level of PCT based on the findings of a blood culture and polymerase chain reaction (PCR). The PCT levels were measured in 116 patients in an intensive care unit who were suspected of having bacteremia, to examine its relationship with a blood culture or PCR. The PCT levels were significantly high in patients with bacteremia, but they were also moderately high in some patients who were positive for fungus DNA. The area under the curve was significantly higher for PCT than for C-reactive protein. The appropriate cutoff values of PCT for bacteremia were 0.38 microg/L for the high negative predictive value and 0.83 microg/L for the high positive predictive value. Procalcitonin was slightly related to mortality, and the combination of a blood culture and PCR was thus found to increase the sensitivity for mortality. These findings suggest that PCT is useful for the diagnosis of bacteremia and that the diagnostic value of PCT in combination a with blood culture and PCR for bacterial infection or mortality further increases.

A fatal case considered to be due to cardiac arrhythmia associated with butane inhalation.

An autopsy case of a 14-year-old boy whose death is considered to be a result of cardiac arrhythmia after butane inhalation and sample preservation for butane analysis are reported. The electrocardiogram taken in the ambulance revealed ventricular fibrillation. There were no autopsy findings as to the cause of death. n-Butane, isobutane and propane were identified in the blood, brain and lung of the cadaver by headspace gas chromatography. Based on these results, the cause of death was concluded to be cardiac arrhythmia due to butane inhalation. As a follow-up, n-butane, isobutane and propane concentrations in the blood kept at -30 degrees C showed the unchanged values with a coefficient of variation of within 10% for 2 weeks.