Injury to a cardiopulmonary resuscitation provider by sternal wire.

Background: Median sternotomy is a common surgical procedure during cardiac and pulmonary surgeries. There are many reports of patient injury associated with wire breakage. However, there are only a few reports of healthcare worker injuries by sternal wire. Case Presentation: A patient in his 70s, having a history of thoracic aorta replacement, collapsed suddenly and paramedics started mechanical chest compression. On hospital arrival, the emergency department nurse attempted to initiate manual chest compression but was injured by a sternal wire protrusion on the patient's chest. The emergency physician placed gauze on the sternal wire and continued manual chest compression, but the patient died. Conclusion: To prevent this injury, cardiopulmonary resuscitation (CPR) providers should consciously check the patient's chest. If they observe wire exposure, they should immediately place a gauze, pad or consider performing mechanical chest compression. Safety measures such as the installing rubber pads in the AED should be considered.

Diphenyl-tetrazol-propanamide Derivatives Act as Dual-Specific Antagonists of Platelet CLEC-2 and Glycoprotein VI.

BACKGROUND: Platelet C-type lectin-like receptor 2 (CLEC-2) induces platelet activation and aggregation after clustering by its ligand podoplanin (PDPN). PDPN, which is not normally expressed in cells in contact with blood flow, is induced in inflammatory immune cells and some malignant tumor cells, thereby increasing the risk of venous thromboembolism (VTE) and tumor metastasis. Therefore, small-molecule compounds that can interfere with the PDPN-CLEC-2 axis have the potential to become selective antiplatelet agents. METHODS AND RESULTS: Using molecular docking analysis of CLEC-2 and a PDPN-CLEC-2 binding-inhibition assay, we identified a group of diphenyl-tetrazol-propanamide derivatives as novel CLEC-2 inhibitors. A total of 12 hit compounds also inhibited PDPN-induced platelet aggregation in humans and mice. Unexpectedly, these compounds also fit the collagen-binding pocket of the glycoprotein VI molecule, thereby inhibiting collagen interaction. These compounds also inhibited collagen-induced platelet aggregation, and one compound ameliorated collagen-induced thrombocytopenia in mice. For clinical use, these compounds will require a degree of chemical modification to decrease albumin binding. CONCLUSION: Nonetheless, as dual activation of platelets by collagen and PDPN-positive cells is expected to occur after the rupture of atherosclerotic plaques, these dual antagonists could represent a promising pharmacophore, particularly for arterial thrombosis, in addition to VTE and metastasis.

Massive haemothorax and haemorrhagic shock due to cervical vascular injury caused by a seat belt.

A woman in her 50s was transported to our hospital after experiencing a road traffic crash that led to a massive haemothorax and haemorrhagic shock due to a cervical vascular injury caused by the seat belt. Contrast-enhanced CT of the chest showed extravascular leakage of the contrast medium from the vicinity of the right subclavicular area and fluid accumulation in the thoracic cavity. The patient was intubated, and a thoracic drainage catheter was placed. She underwent angiography and embolisation of the right costocervical trunk, right thyrocervical trunk and right suprascapular artery using a gelatine sponge and 25% N-butylcyanoacrylate-Lipiodol. She was extubated on the second day after stabilisation of the respiratory and circulatory status. In cases where the bleeding vessel is known and an emergency thoracotomy can serve as a backup, embolisation by interventional radiology should be considered the initial treatment approach.

Comparison of serum and whole blood concentrations in quetiapine overdose cases.

This study aimed to compare whole blood and serum concentrations of quetiapine in acute poisoning cases. Authentic whole blood and respective serum samples were routinely collected from patients diagnosed with blood poisoning at our University Hospital. Accordingly, whole blood and serum paired samples from nine patients (one male and eight female patients) were analyzed for quetiapine using liquid chromatography-mass spectrometry (LC-MS). Quetiapine concentrations in whole blood and serum samples ranged widely from 5.4 to 2780 ng/mL and 9.9 to 2500 ng/mL, respectively. The whole blood/serum concentration ratio was 0.5-1.1 and increased together with an increase in whole blood and serum quetiapine concentrations. The ratio was reversed at around 2500 ng/mL to > 1. Our findings suggest that whole blood concentrations are more useful than serum concentrations in diagnosing quetiapine poisonings.

Two Cases of Minor Blunt Splenic Injury Accompanied with Unexpected Fatal Delayed Splenic Rupture.

Contrast blush (CB) is an area with a density higher than the organ parenchyma in the arterial phase of contrast-enhanced computed tomography (CT). CB may be a sign of contrast medium extravasation, pseudoaneurysm, arteriovenous fistula, or other conditions; however, the indications for treatment remain unclear. Nevertheless, CB could be used to indicate a fatal scenario, such as delayed splenic rupture. Here, we present two multiple-injury cases of fatal delayed splenic rupture following the nonoperative management of a minor splenic injury. In both cases, despite morphological CT findings being minor on admission, CB was observed, and both patients could not rest owing to factors such as older age, a head injury, and drunkenness. Furthermore, in the CB case that indicated pseudoaneurysm, delayed splenic rupture occurred much earlier after the injury compared to the other case without the possibility of pseudoaneurysm. In conclusion, we recommend transcatheter arterial embolization be urgently performed in a case wherein the presence of a pseudoaneurysm is highly probable and factors such as multiple injuries and inability to rest are involved.

Severe Sacral Region Pressure Ulcer Infection Treated in Negative Pressure Wound Therapy with Instillation and Dwelling: A Case Report.

We report a case of severe sacral osteomyelitis and sepsis with pressure ulcer infection treated with negative pressure wound therapy with instillation and dwelling (NPWTi-d) V.A.C.ULTA® from an early stage. Case: A 76-year-old man, bedridden because of dementia and an old cerebral infarction, was treated in a nursing facility for a sacral region pressure ulcer. He had a fever for three days and was transferred to the emergency department. The quick SOFA (sequential organ failure assessment) score at the hospital visit was three points. A coccyx and black mud-formed necrotic tissue attached to the sacral region pressure ulcer with a strong putrid odor sloughed off. Sacral region pressure ulcer infection, sepsis, disseminated intravascular coagulation, and purulent sacral osteomyelitis were diagnosed, and urgent debridement was performed. We treated the patient with meropenem, clindamycin, and vancomycin, and we performed irrigation debridement every day and transduced the V.A.C.ULTA® care system from AOD9, that led to good granulation at the infection site. The wound area underwent simple closure on AOD35 and the patient was transferred to the medical treatment hospital. Since dressing change is relatively easy in the emergency department of a secondary medical care institution with little man power, V.A.C.ULTA® therapy may be useful in treating severe cases of pressure ulcer infections.

Analysis of Grade Classification for Prehospital Injury Severity Scores Applied in Shonan-area Medical Control Council.

OBJECTIVE: To clarify the usefulness of grade classification for injury severity scores applied in Shonan-area Medical Control Council. METHODS: The participants included 11,668 injury cases that occurred in this jurisdiction from April to September 2016. Multivariate analysis was performed using "severity at the time of the disease" a s the response variable. The AUC-ROC was also compared with and without Grade classification, and potential improvements in discrimination ability were examined. RESULTS: There were 11,271 subjects in the "mild/moderate" group and 397 subjects in the "severe/dead" group. Almost all explanatory variables were significant and independent risk factors in the multivariate analysis, and the "Load & Go adaptation" had a particularly high odds ratio of 20.2. Discrimination ability improved (AUC-ROC: 0.773 VS. 0.787) when Grade classification was added to the conventional pre-hospitalization evaluation items. CONCLUSION: Load & Go adaptation has a great influence on severity, and discrimination ability is improved through Grade classification.

Importance of a Collaboration Agreement in the Management of Physician-Staffed Helicopters.

OBJECTIVE: The purpose of this study was to present the management of 3 physician-staffed helicopters (helicopter emergency medical service [HEMS]) in 3 different requests in eastern Shizuoka based on a collaboration agreement and to investigate the current state of dispatches based on the agreement. METHODS: We investigated 3 incidents managed simultaneously by HEMS based on the collaboration agreement by inquiry to the bases, which were located in eastern Shizuoka, Yamanashi, and Kanagawa. We also investigated all records on the management of HEMS based on the collaboration agreement since the contract was made in 2014 by inquiry to the Shizuoka prefectural government. RESULTS: Three simultaneous flight requests were successfully completed. The total number of dispatches based on the collaboration agreement was 112 flights for 7 years from 2014 to 2020. The most frequent reason for request was overlapping request (n = 71). The prefecture with the highest number of requests was Shizuoka (n = 79), where medical resources were limited and the most frequent disease was trauma (n = 93). CONCLUSION: The present study reports how 3 HEMS were operated simultaneously for 3 different requests. To use medical resources effectively, including HEMS, the collaboration agreement among neighboring prefectures was very important, especially for areas in which medical resources are limited.

The Evaluation of Helicopter Emergency Medical Services With a Physician for Acute Myocardial Infarction in Japan: A Registry-Based Study of Prognosis and Time Reduction.

OBJECTIVE: The aim of this study was to compare the prognosis and time reduction between helicopter emergency medical services (HEMS) with a physician and ground emergency medical services (GEMS) in acute myocardial infarction (AMI) cases. METHODS: This is a registry-based study of the Japan Helicopter Emergency Medical Service Registry from April 1, 2015, to March 31, 2018. RESULTS: A total of 605 cases of AMI were registered in the HEMS group and 794 cases in the GEMS group. In the cases of non-cardiopulmonary arrest (CPA), the prognosis between HEMS and GEMS did not differ significantly. Regarding the road distance, for ranges of 20 to 40 km and > 40 km, the times from the call to the angiography room were significantly shorter with HEMS than GEMS (median 91 vs. 97 minutes, P = .036 and 101 vs. 132 minutes, P = .002, respectively). In cases of CPA, HEMS had a higher rate of return of spontaneous circulation than GEMS (55.3% vs. 36.8%, P = .038), but HEMS had a lower prognosis than GEMS (22.9% vs. 38.9%, P = .036). CONCLUSION: The present study suggested that HEMS had an advantage in reducing the time to angiography in AMI cases of non-CPA. In cases of CPA, HEMS increased the return of spontaneous circulation without improving the prognosis.

Value of standard echocardiography at the bedside for COVID-19 patients in intensive care units: a Japanese single-center analysis.

PURPOSE: In the era of COVID-19, those special settings or indications for which standard transthoracic echocardiography (TTE) can safely produce benefits or advantages over minimized ultrasound imaging procedures need to be identified. Thus, the purpose of this study was to conduct a retrospective analysis with offline comprehensive conventional measurement of bilateral heart function and develop an appropriate prognostic model for in-hospital death. METHODS: We performed a retrospective analysis of 37 consecutive patients with COVID-19, confirmed by real-time reverse-transcriptase polymerase chain reaction assay, who had undergone clinically indicated standard two-dimensional echocardiographic studies in intensive care wards. Offline comprehensive measurement was also performed. We further integrated the echocardiographic findings as paired evidence of vital organ involvement (possible respiratory distress assessed using right ventricular functional parameters, possible myocardial injury assessed using increased wall thickness, effusion or asynergy) and circulatory failure (suspected low flow status assessed using stroke volume index, suspected congestion assessed using elevated right or left atrial pressure). We evaluated its value for in-hospital death along with other echocardiographic findings. RESULTS: The most common features included a normal-sized left atrium and left ventricle with preserved left ventricular ejection fraction, despite deteriorated left ventricular flow volume. Less frequent findings, such as abnormalities in the right heart and left ventricular abnormalities suggesting myocarditis, were observed. Although the single echocardiographic parameters failed to show predictive values for in-hospital death, integration of the echocardiographic findings suggested predictive value (p = 0.04, odds ratio: 12.28). CONCLUSION: Standard TTE at the bedside with offline comprehensive conventional measurement may provide prognostic information that is valuable for the management of patients with COVID-19.

Introducing a Remote Pre-graduate Medical Education Curriculum Planning Workshop During the COVID-19 Pandemic.

PURPOSE: To conduct a thorough online workshop on infection control under COVID-19 and to conduct a questionnaire survey on the online workshop. OBJECTIVE: The Tokai University School of Medicine has held 39 workshops to acquire the curriculum planning ability required as a faculty member of the School of Medicine. Due to the COVID-19 pandemic, this year (2020) we were unable to hold a workshop. Therefore, we attempted an online workshop using Zoom. METHODS: To shorten the amount of time required for the workshop, we excluded some content that was used the previous year. The day passed without any major problems, and both the participants and the individuals in charge of the workshop filled out a questionnaire at the end of the day. RESULTS: Conclusion: Online workshops appear to be a very useful tool in terms of infection control under the COVID-19 pandemic.

Should beta-blockers be continued as a treatment for myocardial infarction in the case of Kounis syndrome?

A 71-year-old male patient reported to our hospital with anaphylactic shock, and the following two issues were focused in this case. First, he was resistant to adrenaline because of taking beta-blocker, and shock was repeated until glucagon administration was initiated. Second, he developed acute coronary syndrome. Two mechanisms contributing to Kounis syndrome were differentiated: 1) adrenaline induced coronary spasm and platelet activation or 2) a mismatch between oxygen supply and demand due to an allergic reaction. Beta-blocker therapy was discontinued because his cardiac function was preserved. Secondary preventive beta-blockers in recovering myocardial infarction with severe anaphylaxis history should be carefully considered.

Serum potassium level as a biomarker for acute caffeine poisoning.

AIM: Acute caffeine poisoning presents with hypokalemia, although a relationship between potassium levels and blood concentrations of caffeine has not been established. A correlation between serum potassium level and blood caffeine concentration could establish serum potassium as a simple marker to assess caffeine toxicity in patients with acute toxicity. We investigated whether serum potassium, a symptom of acute caffeine poisoning, could be a parameter correlated with blood caffeine levels. METHODS: We enrolled 85 patients treated for acute caffeine poisoning between January 2012 and March 2019 with blood caffeine levels measured after an overdose of a caffeine-containing over-the-counter drug and for whom serum potassium levels were available. We examined the correlation between serum potassium and blood caffeine concentration. A receiver operating characteristic curve was created with serum potassium values to stratify participants into two groups by blood caffeine concentrations: <20 or ≥20 mg/L (toxic dose) and <80 or ≥80 mg/L (lethal dose). The lethal cut-off value was calculated. RESULTS: The correlation coefficient between serum potassium level and blood caffeine concentration was -0.612 (R 2 = 0.374), indicating a negative correlation. The areas under the curve at blood caffeine concentrations of 20 mg/L (toxic dose) and 80 mg/L (lethal dose) and serum potassium levels were 0.716 and 0.888 (sensitivity, 0.829 and 0.919; specificity, 0.568 and 0.818; cut-off, 3.3 mEq/L and 2.9 mEq/L), respectively. CONCLUSION: Serum potassium levels are associated with blood caffeine concentrations; K+ of 3.3 mEq/L and 2.9 mEq/L indicate acute caffeine poisoning in the toxic and lethal dose, respectively.

Optimal Treatment for Diverticulum-like Projections of the Retrohepatic Inferior Vena Cava Occurring after Inferior Vena Cava Packing: A Case Report.

INTRODUCTION: Although the outcomes of patients with retrohepatic inferior vena cava (IVC) injury have improved because of damage control (DC) strategies, some rare complications have been observed. CASE PRESENTATION: We present the case of a 35-year-old man with diverticulum-like projections (DLPs) of the retrohepatic IVC that occurred following peri-IVC packing based on DC strategies. The DLPs were treated conservatively with anticoagulant therapy and he recovered completely. CONCLUSIONS: Caution must be exercised regarding such rare complications after abbreviated surgery. Conservative therapy may be the optimal treatment for patients with DLPs of the retrohepatic IVC after peri-IVC packing.

Podoplanin is indispensable for cell motility and platelet-induced epithelial-to-mesenchymal transition-related gene expression in esophagus squamous carcinoma TE11A cells.

BACKGROUND: The transmembrane glycoprotein podoplanin (PDPN) is upregulated in some tumors and has gained attention as a malignant tumor biomarker. PDPN molecules have platelet aggregation-stimulating domains and, are therefore, suggested to play a role in tumor-induced platelet activation, which in turn triggers epithelial-to-mesenchymal transition (EMT) and enhances the invasive and metastatic activities of tumor cells. In addition, as forced PDPN expression itself can alter the propensity of certain tumor cells in favor of EMT and enhance their invasive ability, it is also considered to be involved in the cell signaling system. Nevertheless, underlying mechanisms of PDPN in tumor cell invasive ability as well as EMT induction, especially by platelets, are still not fully understood. METHODS: Subclonal TE11A cells were isolated from the human esophageal squamous carcinoma cell line TE11 and the effects of anti-PDPN neutralizing antibody as well as PDPN gene knockout on platelet-induced EMT-related gene expression were measured. Also, the effects of PDPN deficiency on cellular invasive ability and motility were assessed. RESULTS: PDPN-null cells were able to provoke platelet aggregation, suggesting that PDPN contribution to platelet activation in these cells is marginal. Nevertheless, expression of platelet-induced EMT-related genes, including vimentin, was impaired by PDPN-neutralizing antibody as well as PDPN deficiency, while their effects on TGF-ß-induced gene expression were marginal. Unexpectedly, PDPN gene ablation, at least in either allele, engendered spontaneous N-cadherin upregulation and claudin-1 downregulation. Despite these seemingly EMT-like alterations, PDPN deficiency impaired cellular motility and invasive ability even after TGF-ß-induced EMT induction. CONCLUSIONS: These results suggested that, while PDPN seems to function in favor of maintaining the epithelial state of this cell line, it is indispensable for platelet-mediated induction of particular mesenchymal marker genes as well as the potentiation of motility and invasion capacity.

Urinary glucose and ketone bodies as indicators of acute caffeine poisoning.

AIM: In various countries, many fatal health problems have been reported due to high intake of caffeine-rich energy drinks, tablets, and powders. In patients with acute caffeine poisoning, determination of blood caffeine concentration is an important yet difficult task. We aimed to assess whether the presence of glucose and ketone bodies in urine reflected the blood caffeine concentration in patients with acute caffeine poisoning. METHODS: From April 2010 to March 2018, 25 patients with an overdose of only caffeine-rich tablets were admitted to our hospital. Their clinical features were investigated. In addition, we investigated whether the glucose and ketone bodies in the urine reflected blood caffeine concentration in 23 patients who underwent the urine qualitative test at admission. RESULTS: The majority of the patients were young healthy women, whose average caffeine ingestion was 15.6 ± 8.1 g. Initial urine examinations showed glucose in 60% (14/23) of patients and ketone bodies in 57% (13/23) of patients. Ketone bodies or glucose were found in 78% (18/23) of the patients. The correlation between blood caffeine concentration and urinary glucose was R = 0.625, blood caffeine concentration and ketone bodies was R = 0.596, and blood caffeine and both was R = 0.76. CONCLUSION: Urine qualitative test is effective for differential diagnosis and severity assessment of acute caffeine poisoning in patients.

A pull-down and slot blot-based screening system for inhibitor compounds of the podoplanin-CLEC-2 interaction.

Podoplanin, a transmembrane glycoprotein, is overexpressed in certain types of tumors and induces platelet aggregation by binding to C-type lectin-like receptor 2 (CLEC-2) on the platelet membrane. Activated platelets release granule components, which in turn, trigger epithelial-mesenchymal transition and confer invasive capacity to the tumor cells. Therefore, blocking the podoplanin-CLEC-2 interaction by a small-molecule compound is a potential therapeutic strategy to prevent cancer metastasis and invasion. To effectively identify such inhibitory compounds, we have developed a pull-down-based inhibitory compound screening system. An immunoglobulin Fc domain-CLEC-2 fusion protein was used as a bait to capture podoplanin derived from podoplanin-overexpressing HeLa cells in the presence and absence of the test compound. The protein complex was then pulled down using protein A beads. To shorten the turnaround time, increase throughput, and decrease the workload for the operators, centrifugal filter units were employed to separate free and bound podoplanin, instead of using customary aspiration-centrifugation washing cycles. Slot blotting was also utilized in lieu of gel electrophoresis and electrical transfer. Thus, the use of our pull down screening system could facilitate the effective selection of potential inhibitor compounds of the podoplanin-CLEC-2 interaction for cancer therapy. Importantly, our methodology is also applicable to targeting other protein-protein interactions.

Psychiatric Hospitalization after Emergency Treatment for Deliberate Self-Harm is Associated with Repeated Deliberate Self-Harm.

The objective of this study was to evaluate whether treatment at a psychiatric hospital reduces the risk of repeating parasuicide. Participants were 4,483 parasuicide patients admitted to an emergency department between July 2003 and March 2012. We analyzed the effectiveness of psychiatric hospitalization in preventing repeated parasuicide. We adjusted for background factors using multivariate logistic regression. Effects of psychiatric hospitalization upon the likelihood of repeated parasuicide within 1 year varied by age (especially those aged <35 years), indicating that hospitalization was a significant risk factor. We must be mindful of the risk of repeated parasuicide following discharge in young patients and to provide them with ongoing outpatient care and multimodal support.

Multiple Patients With Heatstroke Air Evacuated by Agreement Concerning Collaboration.

On August 30, 2017, the wet-bulb globe temperature was 30°C. Three female military personnel fell unconscious almost simultaneously around noon after a long-distance march that had started at 6 am. The fire department in Gotenba received a 119 call [at 1:16 PM] and requested dispatch of the eastern Shizuoka doctor helicopter (DH) because it would take about 1 hour from the scene to arrive at our hospital by ground ambulance. At that time, the DH of eastern Shizuoka was transporting an injured patient to Kanagawa Prefecture, so the flight dispatcher of the DH of eastern Shizuoka decided to request support DHs from Kanagawa Prefectures based on an agreement concerning collaboration using the DH. The DH of Kanagawa Prefecture met 1 of the patients and transported her to its base hospital. The remaining 2 patients were then transported by the DH of eastern Shizuoka to its base hospital after completing the previous mission. All patients obtained a survival discharge without major complications after receiving proper treatment and rehabilitation. The agreement concerning collaboration using multiple DHs was important in this case, and dispersion transportation was successfully achieved.