Differences in code status practice patterns among emergency clinicians working in Japan and the United States.

OBJECTIVE: This study aimed to examine self-reported code-status practice patterns among emergency clinicians from Japan and the U.S. METHODS: A cross-sectional questionnaire was distributed to emergency clinicians from one academic medical center and four general hospitals in Japan and two academic medical centers in the U.S. The questionnaire was based on a hypothetical case involving a critically ill patient with end-stage lung cancer. The questionnaire items assessed whether respondent clinicians would be likely to pose questions to patients about their preferences for medical procedures and their values and goals. RESULTS: A total of 176 emergency clinicians from Japan and the U.S participated. After adjusting for participants' backgrounds, emergency clinicians in Japan were less likely to pose procedure-based questions than those in the U.S. Conversely, emergency clinicians in Japan showed a statistically higher likelihood of asking 10 out of 12 value-based questions. CONCLUSION: Significant differences were found between emergency clinicians in Japan and the U.S. in their reported practices on posing procedure-based and patient value-based questions. PRACTICE IMPLICATIONS: Serious illness communication training based in the U.S. must be adapted to the Japanese context, considering the cultural characteristics and practical responsibilities of Japanese emergency clinicians.

A Case Study of Non-specialist Disease Management Using Teladoc Health Support: A Case Report.

In Japan, there is a shortage of emergency medicine specialists, often leading non-specialists (physicians who treat conditions outside their area of specialty) to handle cases outside their expertise, which can cause challenges and necessitate specialist support. Starting from December 2023, the St. Marianna University Hospital, which has emergency medicine specialists, began offering overnight emergency outpatient support to Kawasaki Municipal Tama Hospital using the Teladoc HEALTH Mini Cart telemedicine device (Teladoc Health, Inc., CA, USA). The case involved a 44-year-old male with a history of peritonsillar abscess and incisional drainage presented with pharyngeal pain. The treating physician at the Kawasaki Municipal Tama Hospital and a neurologist (the supported physician) examined the patient at 9 PM. An enlarged right tonsil was noted, and a peritonsillar abscess was suspected, prompting a contrast-enhanced CT scan. The results confirmed a 1 cm right peritonsillar abscess. Faced with the decision to transfer the patient to a higher medical facility, the supported physician consulted with the support physician through a Teladoc HEALTH Mini Cart. The St. Marianna University Hospital's emergency physician (supporting physician) used the Teladoc HEALTH Mini Cart to assess the patient's overall condition, blood tests, and CT images and advise on antibiotic treatment. A visit to the ear, nose, and throat expert (ENT) the following day was considered sufficient. The supported physician received feedback that the use of the Teladoc HEALTH Mini Cart reduced the burden of nighttime transfers for otolaryngological conditions, which can take several hours. This finding suggests that remote medical support can affect Japan's emergency medical system.

Onlinization of a simulation course that includes minor emergency procedures.

Aim: We attempted to convert a simulation course held on-site for primary care physicians to learn about the initial treatment of minor emergencies, including some common surgical procedures, to an online format. Methods: We reviewed the subjects covered in the course and evaluated whether it was "decision-making" or "technical skills" that had been primarily taught as simulation-based training for each subject, and then supplemented the contents accordingly. Results: As a result, satisfaction levels with the online course were comparable to those with the on-site course as measured by a postcourse questionnaire (97.6% [83/85 participants] rating it as "excellent" or "good" on a 5-point Likert scale postcourse questionnaire). Conclusion: We showed that it is reasonable to offer simulation in place of in-person training even for some procedures that were once assumed to be difficult to teach online. Of note, the online course is not just a replacement for the on-site course; it can offer other benefits, including opportunities for those who have difficulty attending courses due to distance or work-related reasons. After the COVID-19 pandemic period, both onsite and online courses can be held, allowing participants to choose the style of course that best suits their situation.

Benefits and harms of drug treatment for type 2 diabetes: systematic review and network meta-analysis of randomised controlled trials.

OBJECTIVE: To compare the benefits and harms of drug treatments for adults with type 2 diabetes, adding non-steroidal mineralocorticoid receptor antagonists (including finerenone) and tirzepatide (a dual glucose dependent insulinotropic polypeptide (GIP)/glucagon-like peptide-1 (GLP-1) receptor agonist) to previously existing treatment options. DESIGN: Systematic review and network meta-analysis. DATA SOURCES: Ovid Medline, Embase, and Cochrane Central up to 14 October 2022. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Eligible randomised controlled trials compared drugs of interest in adults with type 2 diabetes. Eligible trials had a follow-up of 24 weeks or longer. Trials systematically comparing combinations of more than one drug treatment class with no drug, subgroup analyses of randomised controlled trials, and non-English language studies were deemed ineligible. Certainty of evidence was assessed following the GRADE (grading of recommendations, assessment, development and evaluation) approach. RESULTS: The analysis identified 816 trials with 471 038 patients, together evaluating 13 different drug classes; all subsequent estimates refer to the comparison with standard treatments. Sodium glucose cotransporter-2 (SGLT-2) inhibitors (odds ratio 0.88, 95% confidence interval 0.83 to 0.94; high certainty) and GLP-1 receptor agonists (0.88, 0.82 to 0.93; high certainty) reduce all cause death; non-steroidal mineralocorticoid receptor antagonists, so far tested only with finerenone in patients with chronic kidney disease, probably reduce mortality (0.89, 0.79 to 1.00; moderate certainty); other drugs may not. The study confirmed the benefits of SGLT-2 inhibitors and GLP-1 receptor agonists in reducing cardiovascular death, non-fatal myocardial infarction, admission to hospital for heart failure, and end stage kidney disease. Finerenone probably reduces admissions to hospital for heart failure and end stage kidney disease, and possibly cardiovascular death. Only GLP-1 receptor agonists reduce non-fatal stroke; SGLT-2 inhibitors are superior to other drugs in reducing end stage kidney disease. GLP-1 receptor agonists and probably SGLT-2 inhibitors and tirzepatide improve quality of life. Reported harms were largely specific to drug class (eg, genital infections with SGLT-2 inhibitors, severe gastrointestinal adverse events with tirzepatide and GLP-1 receptor agonists, hyperkalaemia leading to admission to hospital with finerenone). Tirzepatide probably results in the largest reduction in body weight (mean difference -8.57 kg; moderate certainty). Basal insulin (mean difference 2.15 kg; moderate certainty) and thiazolidinediones (mean difference 2.81 kg; moderate certainty) probably result in the largest increases in body weight. Absolute benefits of SGLT-2 inhibitors, GLP-1 receptor agonists, and finerenone vary in people with type 2 diabetes, depending on baseline risks for cardiovascular and kidney outcomes (https://matchit.magicevidence.org/230125dist-diabetes). CONCLUSIONS: This network meta-analysis extends knowledge beyond confirming the substantial benefits with the use of SGLT-2 inhibitors and GLP-1 receptor agonists in reducing adverse cardiovascular and kidney outcomes and death by adding information on finerenone and tirzepatide. These findings highlight the need for continuous assessment of scientific progress to introduce cutting edge updates in clinical practice guidelines for people with type 2 diabetes. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42022325948.

Nail Gun Injury of the Trachea and Spinal Cord.

INTRODUCTION: A 26-year-old man was impaled by a nail after a nail gun accident. He was fully conscious with weakness and loss of sensation in the extremities. Cervical computed tomography showed a 9-centimeter long nail penetrating the spinal cord. The nail was removed surgically six hours after the incident. Neurological deficits gradually improved, and at three-month follow-up the patient had completely recovered from muscle weakness and reported only mild sensory deficits in the bilateral sole of his foot. DISCUSSION: This case showed a favorable neurological course, which may be attributed to the fact that the cervical spinal cord injury did not involve the corticospinal tracts and anterior horn.

Changes in the Treatment for Out-of-Hospital Cardiac Arrest During the Initial Stage of the COVID-19 Outbreak in Japan.

INTRODUCTION: Cardiopulmonary resuscitation (CPR) for out-of-hospital cardiac arrest (OHCA) patients during the coronavirus disease 2019 (COVID-19) pandemic carries an added risk of COVID-19 infection for healthcare workers. However, because of the shortage of medical supplies and limited evidence of COVID-19 in the initial stages of the pandemic, strategies for the management of OHCA patients may have varied across hospitals. METHOD: A web-based questionnaire was used. The first section collected data about physician characteristics. In the second section, participants responded "Yes" or "No," if they had made changes in the areas of "personal protective equipment (PPE)" or "CPR Algorithm" for OHCA patients (these changes were the personal views of the surveyed respondents). The questionnaire was sent to the members of the Emergency Medicine Alliance mailing list. The response period was from May 22 to June 5, 2020 (the first state of emergency related to COVID-19 was declared on April 7, 2020, in Japan). Participants were asked to indicate their stress level resulting from these changes using the Likert scale ranging from 1 to 10, where 1 = "no stress" and 10 = "severe stress." RESULT: A total of 110 physicians responded during the study period. The majority of participants reported changes in "PPE" (n = 106, 96.4%) and "CPR Algorithm" (n = 86, 78.2%). The reported stress level due to changes in PPE was 8 (IQR 6-9) and due to changes in the CPR algorithm, it was 7 (IQR 5-8). CONCLUSION: Findings of this study suggest that physicians experienced changes in care for OHCA patients and felt stress during the initial stage of the COVID-19 pandemic. Thus, it would be better to list the actual measures that can be undertaken to prepare for any future pandemics.

Effects of short-term upper limb immobilization on sensory information processing and corticospinal excitability.

Several studies have reported the effects of short-term immobilization of the upper limb on the excitability of the primary motor cortex. In a report examining the effects of upper limb immobilization on somatosensory information processing using somatosensory-evoked potentials (SEPs), short-term upper limb immobilization reduced the amplitude and increased the latency of the P45 component recorded over the contralateral sensorimotor cortex of SEPs. However, the effects of upper limb immobilization on other regions involved in somatosensory information processing are unknown. Therefore, we investigated the effects of short-term right upper limb immobilization on sensory information processing, particularly in motor-related areas, by measuring the cortical components of SEPs. We also evaluated the excitability of the primary motor cortex and corticospinal tract as well as motor performance (visual simple reaction time and pinch force) related to these areas. All subjects were divided into two groups: the SEP group, in which the effects of upper limb immobilization on the excitability of somatosensory processing were investigated, and the transcranial magnetic stimulation (TMS) group, in which the effects of upper limb immobilization on the excitability of the corticospinal tract and primary motor cortex were investigated. Motor performance was evaluated in all subjects. We showed that 10-h right upper limb immobilization increased the cortical component of SEPs (N30) in the SEP group and decreased the excitability of the corticospinal tract, but not of the primary motor cortex, in the TMS group. The pinch force decreased after upper limb immobilization. However, the visual simple reaction time did not change between pre- and post-immobilization. The supplementary motor area and premotor cortex are believed to be the source of the N30. Therefore, these results suggest that upper limb immobilization affected somatosensory information processing in motor-related areas. Moreover, 10-h right upper limb immobilization reduced the excitability of corticospinal tracts but not that of the primary motor cortex, suggesting that circuits outside the M1, such as the intra- and inter-hemispheric inhibitory and facilitatory circuits rather than circuits within the M1, may be responsible for the reduced excitability of the central nervous system after restraint.

Intensive care burden of COVID-19 in tertiary care hospitals during the first year of outbreak in Kawasaki City, Japan: A retrospective cohort study.

INTRODUCTION: This study aimed to describe the changes in the intensive care burden of coronavirus disease 2019 (COVID-19) during the first year of outbreak in Japan. METHODS: This retrospective cohort study included COVID-19 patients who received mechanical ventilation (MV) support in two designated hospitals for critical patients in Kawasaki City. We compared the lengths of MV and stay in the intensive care unit (ICU) or high care unit (HCU) according to the three epidemic waves. We calculated in-hospital mortality rates in patients with or without MV. RESULTS: The median age of the sample was 65.0 years, and 22.7% were women. There were 37, 29, and 62 patients in the first (W1), second (W2), and third waves (W3), respectively. Systemic steroids, remdesivir, and prone positioning were more frequent in W2 and W3. The median length of MV decreased from 18.0 days in W1 to 13.0 days in W3 (P = 0.019), and that of ICU/HCU stay decreased from 22.0 days in W1 to 15.5 days in W3 (P = 0.027). The peak daily number of patients receiving MV support was higher at 18 patients in W1, compared to 8 and 15 patients in W2 and W3, respectively. The mortality rate was 23.4%, which did not significantly change (P = 0.467). CONCLUSIONS: The lengths of MV and ICU/HCU stay per patient decreased over time. Despite an increase in the number of COVID-19 patients who received MV in W3, this study may indicate that the intensive care burden during the study period did not substantially increase.

Efficacy of awake prone positioning for severe illness coronavirus disease 2019 patients: a propensity score-adjusted cohort study.

AIM: Awake prone positioning (PP) in patients with coronavirus disease 2019 (COVID-19) can improve oxygenation. However, evidence showing that it can prevent intubation is lacking. This study investigated the efficacy of awake PP in patients with COVID-19 who received remdesivir, dexamethasone, and anticoagulant therapy. METHODS: This was a two-center cohort study. Patients admitted to the severe COVID-19 patient unit were included. The primary outcome was the intubation rate and secondary outcome was length of stay in the severe COVID-19 unit. After propensity score adjustment, we undertook multivariable regression to calculate the estimates of outcomes between patients who received awake PP and those who did not. RESULTS: Overall, 108 patients were included (54 [50.0%] patients each who did and did not undergo awake PP), of whom 25 (23.2%) were intubated (with awake PP, 5 [9.3%] vs. without awake PP, 20 [37.0%]; P < 0.01). The median length of stay in the severe COVID-19 unit did not significantly differ (with awake PP, 5 days vs. without awake PP, 5.5 days; P = 0.68). After propensity score adjustment, those who received awake PP had a lower intubation rate than those who did not (odds ratio, 0.22; 95% confidence interval, 0.06-0.85; P = 0.03). Length of stay in the severe COVID-19 patient unit did not differ significantly (adjusted percentage difference, -24.4%; 95% confidence interval, -56.3% to 30.8%; P = 0.32). CONCLUSION: Awake PP could be correlated with intubation rate in patients with COVID-19 who are receiving remdesivir, dexamethasone, and anticoagulant therapy.

Development of Clinical Skills and Confidence Questionnaire for Triage and Action Minor Emergency Course: Test-Retest Exam.

AIM: The Triage and Action (T&A) minor emergency course was developed to improve the clinical skills of Japanese non-specialist physicians for minor emergent problems. Currently, the course quality is evaluated only by a self-reported satisfaction questionnaire. This study described a new clinical skills and confidence questionnaire to evaluate its validity and reliability. METHODS: The web-based questionnaire was evaluated by 103 physicians identified from a mailing list as having taken the T&A minor emergency course. The clinical experience and confidence (CEC) questionnaire was prepared, and its content and contextual validity were validated using a clinical sensibility test (CST). Reliability was assessed by the interclass correlation coefficient after two weeks via a follow-up CEC questionnaire. RESULTS:  Of the 103 physicians contacted 44 (42.7%) responded to the questionnaire, 36 (40.8%) to the follow-up CEC questionnaire, and 33 (32.0%) to both questionnaires; 28 (27.2%) participants took the clinical sensibility test. Five questions which asked the total number of patients treated within six months showed fair agreement on the reliability test. All answers to the questions in the CST were favorable. CONCLUSION: We removed every question which asked the total number of patients treated for various minor emergencies within six months from CEC. Consequently, the new questionnaire was shown to be contextually well validated and reliable. We will use the CEC questionnaire to improve our course, which we hope to demonstrate improved primary care for selected minor conditions.

Relationship Between Motor Function, DTI, and Neurophysiological Parameters in Patients with Stroke in the Recovery Rehabilitation unit.

OBJECTIVES: We investigated the relationship between pyramidal tract evaluation indexes (i.e., diffusion tensor imaging, transcranial magnetic stimulation (TMS)-induced motor-evoked potential (MEP), and central motor conduction time (CMCT) on admission to the recovery rehabilitation unit) and motor functions at discharge in patients with ischemic or hemorrhagic stroke. MATERIALS AND METHODS: Seventeen patients were recruited (12 men; 57.9 ± 10.3 years). The mean fractional anisotropy (FA) values of the right and left posterior limbs of the internal capsule were estimated using a computer-automated method. We determined the ratios of FA values in the affected and unaffected hemispheres (rFA), TMS-induced MEP, and the ratios of CMCT in the affected and unaffected hemispheres (rCMCT) and examined their association with motor functions (Fugl-Meyer Assessment (FMA) and Action Research Arm Test (ARAT)) at discharge. RESULTS: Higher rFA values of the posterior limb of the internal capsule on admission to the recovery rehabilitation unit led to a better recovery of upper limb function (FMA: r = 0.78, p < 0.001; ARAT: r = 0.74, p = 0.001). Patients without MEP had poorer recovery of upper limb function than those with MEP (FMA: p < 0.001; ARAT: p = 0.001). The higher the rCMCT, the poorer the recovery of upper limb function (ARAT: r = -0.93, p < 0.001). However, no association was observed between the pyramidal tract evaluation indexes and recovery of lower limb motor function. CONCLUSIONS: Evaluating the pyramidal tract is useful for predicting upper limb function prognosis, but not for lower limb function prognosis.

Euglycemic diabetic ketoacidosis due to a strict low-carbohydrate diet during treatment with sodium-glucose cotransporter 2 inhibitors.

BACKGROUND: Euglycemic diabetic ketoacidosis is a critical clinical presentation that can occur during treatment with sodium-glucose cotransporter 2 inhibitors. However, little is known regarding how a low-carbohydrate diet in combination with this treatment can increase the risk for this condition. Here, we report a case of euglycemic diabetic ketoacidosis in a patient treated with sodium-glucose cotransporter 2 inhibitors after initiation of a low-carbohydrate diet. CASE PRESENTATION: A 54-year-old woman who was taking canagliflozin was transferred to our hospital with severe dyspnea. She had been started on a strict low-carbohydrate diet for 6 days before admission. Laboratory evaluation revealed severe ketoacidosis and a blood glucose level of 196 mg/dL. After her symptoms improved, she was diagnosed with type 1 diabetes mellitus. CONCLUSION: Although low-carbohydrate diets are recommended for patients with diabetes mellitus, physicians should exercise great caution in recommending low-carbohydrate diets to patients undergoing treatment with sodium-glucose cotransporter 2 inhibitors.

Orbiting and In-Situ Lidars for Earth and Planetary Applications.

At NASA Goddard Space Flight Center, we have been developing spaceborne lidar instruments for space sciences. We have successfully flown several missions in the past based on mature diode pumped solid-state laser transmitters. In recent years, we have been developing advanced laser technologies for applications such as laser spectroscopy, laser communications, and interferometry. In this article, we will discuss recent experimental progress on these systems and instrument prototypes for ongoing development.

Error analysis for lidar retrievals of atmospheric species from absorption spectra.

We generalize a model for retrieving atmospheric constituents from lidar absorption spectra measured at any laser frequency channels. Random and systematic retrieval errors from measurement noise and model bias, respectively, are analyzed parametrically and numerically to provide deeper insight. By placing four or more channels symmetrically around the absorption peak, retrieval errors from a common laser frequency shift and spectral baseline tilt can be eliminated. By solving for the frequency shift and spectral baseline tilt, atmospheric retrievals degrade only slightly even when such channels are shifted substantially out of symmetry. An etalon can thus be used for the wavelength stabilization.

New D-dimer threshold for Japanese patients with suspected pulmonary embolism: a retrospective cohort study.

BACKGROUND: In the diagnosis of pulmonary embolism (PE), the D-dimer threshold is based on studies conducted in Western countries, where the incidence rate is 5 times higher than that in Asian countries, including Japan. If we could elevate the D-dimer threshold based on the low pre-test probability in the Japanese population, we could omit the computed tomography pulmonary angiography (CTPA) which might lead to radiation exposure and contrast-induced nephropathy. Therefore, we aimed to determine a new D-dimer threshold specific to Japanese individuals. METHODS: We conducted a retrospective cohort study at an emergency department in Japan, using medical charts collected from January 2013 to July 2017. We included patients whose D-dimer were measured for suspicion of PE with low or intermediate probability of PE and CTPA were performed. The primary outcome was failure rate of the new D-dimer threshold, defined as the rate of PE detected by CTPA among patients with D-dimer under the new threshold ranging from 1000 to 1500 µg/L by 100. The new D-dimer threshold was appropriate if the upper limit of 95% confidence interval of the failure rate of PE was approximately 3%. RESULTS: In 395 patients included, the number of patients with PE was 24 (the prevalence was 6.1%). If the D-dimer threshold was 1100 µg/L, the failure rate was 0% (0/119), the upper limit of the 95% confidence interval of the failure rate was 3.1%, and 30% (119/395) of the CTPA might be omitted. CONCLUSION: The new D-dimer threshold could safely exclude PE. This result can be generalized to other Asian populations with a lower incidence of PE. Further prospective studies will be needed.

Comparison of acute vertigo diagnosis and treatment practices between otolaryngologists and non-otolaryngologists: A multicenter scenario-based survey.

Acute vertigo is a common problem in emergency departments. However, clinical strategies of acute vertigo care vary among care providers. The aim of the study was to investigate differences in diagnosis [Dix-Hallpike test, the head impulse, nystagmus, and the test of skew (HINTS) procedure, and imaging modalities] and treatment (pharmacological treatments and the Epley maneuver) by otolaryngologists and non-otolaryngologists in emergency medicine settings. We used a multicenter case-based survey for the study. Four clinical vignettes of acute vertigo (posterior canal benign paroxysmal positional vertigo, vestibular neuritis, Meniere disease, and nonspecific vertigo) were used. Total 151 physicians from all study sites participated in the study. There were 84 non-otolaryngologists (48 emergency physicians and 36 internists) and 67 otolaryngologists. The multivariate analysis indicated that otolaryngologists ordered fewer CT scans (odds ratio (OR), 0.20; 95% confidence interval (CI), 0.07-0.53) and performed fewer HINTS procedures (OR, 0.17; 95% CI, 0.06-0.46), but used the Dix-Hallpike method more often (OR, 2.36; 95% CI, 1.01-5.52) for diagnosis compared to non-otolaryngologists. For treatment, otolaryngologists were less likely to use the Epley method (OR, 0.19; 95% CI, 0.07-0.53) and metoclopramide (OR, 0.09; 95% CI, 0.01-0.97) and more likely to use sodium bicarbonate (OR, 20.50; 95% CI, 6.85-61.40) compared to non-otolaryngologists. We found significant differences in the acute vertigo care provided by non-otolaryngologists and otolaryngologists from a vignette-based research. To improve acute vertigo care, educational systems focusing on acute vertigo are needed.

IV crystalloid fluid for acute alcoholic intoxication prolongs ED length of stay.

OBJECTIVES: Acute alcohol intoxication is often treated in emergency departments by intravenous crystalloid fluid (IVF), but it is not clear that this shortens the time to achieving sobriety. The study aim was to investigate the association of IVF infusion and length of stay in the ED. METHODS: This single-center retrospective cohort study was conducted in Japan and included patients aged ≥20years of age and treated for acute alcohol intoxication without or with IVF. The primary outcome was the length of the ED stay and the treatments were compared by time-to-event analysis. RESULTS: A total of 106 patients, 42 treated without IVF and 64 with IVF. The baseline characteristics of the two groups were similar. Kaplan-Meier analysis and the generalized Wilcoxon test found no significant difference between the two treatments in the time to ED discharge. The median time was 189 (IQR 160-230) minutes without IVF and 254.5 (203-267 minutes with IVF; p=0.052). A Cox proportional hazards regression model adjusted for potential confounding variables found that patients treated with IVF were less likely to be discharged earlier than those treated without IVF (HR 0.54, 95% CI: 0.35-0.84, p=0.006). CONCLUSIONS: IVF for treatment of acute alcoholic intoxication prolonged ED length of stay even after adjustment for potential confounders. Patients given IVF for acute alcohol intoxication should be selected with care.