Comorbidity burden and outcomes after mechanical thrombectomy for large vessel occlusion: A retrospective analysis.

OBJECTIVES: Patients with acute ischemic stroke (AIS) often have an accumulation of pre-existing comorbidities, but its clinical impact on outcomes after mechanical thrombectomy (MT) remains unknown. Therefore, we examined whether comorbidity burden before AIS onset could predict clinical outcomes after MT. METHODS: In this retrospective cohort, we enrolled consecutive patients with community-onset AIS who underwent MT between April 2016 and December 2021. To evaluate each patient's comorbidity burden, we calculated Charlson comorbidity index (CCI), then classified the patients into the High CCI (≥ 3) and the Low CCI (< 3) groups. The primary outcome was a good neurological outcome at 90 days, defined as a modified Rankin scale 0-2 or no worse than the previous daily conditions. All-cause mortality at 90 days and hemorrhagic complications after MT were also compared between the two groups. We estimated the odds ratios and their confidence intervals using a multivariable logistic regression model. RESULTS: A total of 388 patients were enrolled, of whom 86 (22.2%) were classified into the High CCI group. Patients in the High CCI group were less likely to achieve a good neurological outcome (adjusted odds ratio of 0.26 [95% confidence interval, 0.12-0.58]). Moreover, symptomatic intracranial hemorrhage was more common in the High CCI (14.0% vs. 4.6%; adjusted odds ratio, 4.10 [95% confidence interval, 1.62-10.3]). CONCLUSIONS: Comorbidity burden assessed by CCI was associated with clinical outcomes after MT. CCI has the potential to become a simple and valuable tool for predicting neurological prognosis among patients with AIS and MT.

Predictive performance of the sequential organ failure assessment score for in-hospital mortality in patients with end-stage kidney disease in intensive care units: A multicenter registry in Japan.

INTRODUCTION: There is limited evidence regarding whether the performance of the Sequential Organ Failure Assessment (SOFA) score differs between patients with and without end-stage kidney disease (ESKD) in intensive care units (ICUs). METHODS: We used a multicenter registry (Japanese Intensive care Patient Database) to enroll adult ICU patients between April 2018 and March 2021. We recalibrated the SOFA score using a logistic regression model and evaluated its predictive ability in both ESKD and non-ESKD groups. The primary outcome was in-hospital mortality. RESULTS: 128 134 patients were enrolled. The AUROC of the SOFA score was lower in the ESKD group than in the non-ESKD group [0.789 (95% CI, 0.774-0.804) vs. 0.846 (95% CI, 0.841-0.850)]. The calibration plot revealed good performance in both groups. However, it overestimated in-hospital mortality in ESKD groups. CONCLUSION: The SOFA score demonstrated good predictive ability in patients with and without ESKD, but it overestimated the in-hospital mortality in ESKD patients.

Helicobacter cinaedi Infections in Emergency Departments: A Descriptive Study.

AIM: Helicobacter cinaedi, a Gram-negative spiral bacterium, is a rare cause of bacteremia in humans. Unfortunately, little is known about H. cinaedi infections in emergency departments (EDs). We aimed to describe the clinical features of H. cinaedi infections in the ED. METHODS: We conducted a descriptive study at the ED of Kobe City General Hospital (KCGH) in Japan between November 2011 and December 2020. We included all ED patients with H. cinaedi infections. We retrospectively obtained the patient data from electronic medical records and described the patient characteristics, clinical course, and management of H. cinaedi infections. RESULTS: A total of 22 patients in the ED were diagnosed with H. cinaedi infections, and all of them were detected through blood cultures. The chief complaints were vague: fever (18/22, 81.8%), chills (10/22, 45.5%), and localized pain or tenderness (8/22, 36.4%). Patients with complicated cases were also reported in the ED; three patients had vertebral osteomyelitis, two had infected aortic aneurysms, and another two had infected cysts (renal cyst and pancreatic cyst with concomitant empyema). Tetracycline (minocycline) was primarily prescribed and administered intravenously in five of 15 (33.3%) and orally in nine of 20 (45.0%) patients. Only one (4.5%) patient required surgical interventions. None of the patients died in the hospital. CONCLUSIONS: We reported the clinical features of H. cinaedi infections in the ED. Although some patients developed complicated infections, the prognosis was not poor under appropriate treatment, and most of them were successfully treated with antibiotics, primarily tetracycline.

Neurologic outcome and location of cardiac arrest in out-of-hospital cardiac arrest patients who underwent extracorporeal cardiopulmonary resuscitation: A multicentre retrospective cohort in Japan.

Aim: We examined the association between the location of cardiac arrest and outcomes of patients with out-of-hospital cardiac arrest (OHCA) who underwent extracorporeal cardiopulmonary resuscitation (ECPR). Methods: This was a secondary analysis of SAVE-J II, a multicentre retrospective registry with 36 participating institutions across Japan, which enrolled adult patients with OHCA who underwent ECPR. The outcomes of interest were favourable neurologic outcome at discharge. We compared the outcome between OHCA cases that occurred at residential and public locations, using a multilevel logistic regression model allowing for the random effect of each hospital. Results: Among 1,744 enrolled OHCAs, 809 and 935 occurred at residential (house: 603; apartment: 206) and public (street: 260; workplace: 210; others: 465) locations, respectively. The proportion of favourable neurologic outcomes was lower in OHCAs at residential locations than those at public locations (88/781 (11.3%) vs.131/891 (14.7%); adjusted odds ratio, 0.72 [95% confidence interval, 0.53-0.99]). However, subgroup analyses for patients with EMS aged <65 years call to hospital arrival within 30 minutes or during daytime revealed less difference between residential and public locations. Conclusion: When cardiac arrests occurred at residential locations, lower proportions of favourable neurologic outcomes were exhibited among patients with OHCA who underwent ECPR. However, the event's location may not affect the prognosis among appropriate and select cases when transported within a limited timeframe.

Etiology and clinical characteristics of patients with severely impaired consciousness in prehospital settings: A retrospective study.

Aim: To examine the causes of patients with severely impaired consciousness and the clinical characteristics in prehospital settings that are useful for differential diagnosis, especially stroke. Methods: We retrospectively examined patients aged ≥16 years with Japan Coma Scale III-digit codes during paramedic contact and transported to our hospital between January 2018 and December 2018. Furthermore, we examined background and physical findings of patients at final diagnosis, and also examined factors associated with stroke. Results: Overall, 227 patients were included in this study. One hundred and twelve patients (49.3%) were male, and the median age was 71 years (interquartile range, 50-83 years). Stroke was the most common cause (30%). Intoxication and psychiatric disorders were significantly more common in younger patients (p < 0.01). Systolic blood pressure was the highest in patients with stroke. Mortality was the highest in stroke (55.9%). Systolic blood pressure, airway compromise, and ocular abnormalities were factors associated with stroke, with odds ratios of 1.03 (95% confidence interval [CI], 1.02-1.04), 6.88 (95% CI, 3.02-15.64), and 3.86 (95% CI, 1.61-9.27), respectively. Conclusion: Stroke was the most common cause of severely impaired consciousness. Age could be a useful indicator to consider intoxication and psychiatric disorders. Systolic blood pressure, airway compromise, and ocular abnormalities were factors associated with stroke in the prehospital setting.

Bowel obstruction secondary to internal hernia in a hereditary angioedema patient: a case report.

BACKGROUND: Gastrointestinal attacks are frequent symptoms in patients diagnosed with hereditary angioedema (HAE). Cases of self-limited bowel intussusception and unneeded exploratory laparotomy due to lack of knowledge about HAE have been reported. Furthermore, after the introduction of C1-esterase inhibitor (C1-INH) concentrate, the recommended medication for HAE attacks, treatment has become typically medical in nature. We share a rare case where operative exploration was indicated to resolve a mechanical small bowel obstruction secondary to an HAE attack. CASE REPORT: An 80-year-old woman with HAE presented with lower left abdominal pain, vomiting, and nausea. Computed tomography (CT) showed edema of the small bowel and stomach as well as possible signs of mechanical small bowel obstruction. The patient was treated with C1-INH concentrate but showed only mild signs of relief, warranting diagnostic laparoscopy. Intraoperative findings showed internal herniation and strangulation of the small bowel caused by adhesions forming a band. After surgical intervention, no bowel resection was needed. CONCLUSION: Although C1-INH concentrate remains the principal treatment for HAE, gastrointestinal attacks may potentially cause surgical emergencies.

Association between ICU admission during off-hours and in-hospital mortality: a multicenter registry in Japan.

BACKGROUND: The effect of ICU admission time on patient outcomes has been shown to be controversial in several studies from a number of countries. The imbalance between ICU staffing and medical resources during off-hours possibly influences the outcome for critically ill or injured patients. Here, we aimed to evaluate the association between ICU admission during off-hours and in-hospital mortality in Japan. METHODS: This study was an observational study using a multicenter registry (Japanese Intensive care PAtient Database). From the registry, we enrolled adult patients admitted to ICUs from April 2015 to March 2019. Patients with elective surgery, readmission to ICUs, or ICU admissions only for medical procedures were excluded. We compared in-hospital mortalities between ICU patients admitted during off-hours and office-hours, using a multilevel logistic regression model which allows for the random effect of each hospital. RESULTS: A total of 28,200 patients were enrolled with a median age of 71 years (interquartile range [IQR], 59 to 80). The median APACHE II score was 18 (IQR, 13 to 24) with no significant difference between patients admitted during off-hours and those admitted during office-hours. The in-hospital mortality was 3399/20,403 (16.7%) when admitted during off-hours and 1604/7797 (20.6%) when admitted during office-hours. Thus, off-hours ICU admission was associated with lower in-hospital mortality (adjusted odds ratio 0.91, [95% confidence interval, 0.84-0.99]). CONCLUSIONS: ICU admissions during off-hours were associated with lower in-hospital mortality in Japan. These results were against our expectations and raised some concerns for a possible imbalance between ICU staffing and workload during office-hours. Further studies with a sufficient dataset required for comparing with other countries are warranted in the future.

Patient-centered outcomes at hospital discharge in mechanically ventilated COVID-19 patients in Kobe, Japan: A single-center retrospective cohort study.

BACKGROUND: Apart from saving the lives of coronavirus disease (COVID-19) patients on mechanical ventilation (MV), recovery from the sequelae of prolonged MV (PMV) is an emerging issue.c METHODS: We conducted a retrospective study among consecutive adult COVID-19 patients admitted to an intensive care unit (ICU) in Kobe, Japan, between March 3, 2020, and January 31, 2021, and received invasive MV. Clinical outcomes included in-hospital mortality and recovery from COVID-19 in survivors regarding organ dysfunction, respiratory symptoms, and functional status at discharge. We compared survivors' outcomes with MV durations of >14 days and ≤14 days. RESULTS: We included 85 patients with a median age of 69 years (interquartile range, 64-75 years); 76 (89%) patients had at least 1 comorbidity, 72 (85%) were non-frail, and 79 (93%) were functionally independent before COVID-19 infection. Eighteen patients (21%) died during hospitalization. At discharge, 59/67 survivors (88%) no longer required respiratory support, 50 (75%) complained of dyspnea, and 40 (60%) were functionally independent. Of the survivors, 23 patients receiving MV for >14 days had a worse recovery from COVID-19 at discharge compared with those on MV for ≤14 days, as observed using the Barthel index (median: 35 [5-65] vs. 100 [85-100]), ICU mobility scale (8 [5-9] vs. 10 [10-10]), and functional oral intake scale (3 [1-7] vs. 7 [7-7]) (P < 0.0001). CONCLUSION: Although four-fifths of the patients survived and >50% of survivors demonstrated clinically important recovery in organ function and functional status during hospitalization, PMV was related to poor recovery from COVID-19 at discharge.

The necessity of lumbar puncture in adult emergency patients with fever-associated seizures.

OBJECTIVE: Central nervous system (CNS) infections are often suspected in adult patients with fever-associated seizures. However, it is unclear whether lumbar puncture (LP) is routinely required in patients with fever-associated seizures. This study aimed to examine the prevalence of meningitis and encephalitis in adult patients with fever-associated seizures and to evaluate whether LP is routinely required. METHODS: We retrospectively studied patients aged ≥16 years who presented to the emergency department with complaints of seizures and fever above 37.5 °C who were admitted to the hospital between January 2017 and December 2019. LP was performed when the emergency physician suspected meningitis or encephalitis. Neurologists assessed patients with normal cerebrospinal fluid (CSF) findings and those admitted without LP after hospitalization. A neurologist confirmed the diagnoses of meningitis and encephalitis. RESULTS: The study included 148 patients. Ninety-seven patients (65.5%) were male, and the median age was 60 years. LP was performed in 105 patients (70.9%), and 14 (13.4%) had CSF pleocytosis. Meningitis and encephalitis were diagnosed in nine patients (6.1%), of whom four (2.8%) had CNS infections. Patients diagnosed with meningitis and encephalitis were more likely to have Glasgow Coma Scale <13 (P = 0.03) and less likely to have a history of seizures or epilepsy (P = 0.04) and had higher C-reactive protein levels than the other patients (P = 0.02). CONCLUSION: The prevalence of meningitis or encephalitis is relatively low in adult patients with fever-associated seizures. Lumbar puncture is considered unnecessary to be performed routinely, but its indication should be carefully considered with reference to the clinical course, comorbidities, and blood tests. Further validation studies with larger sample sizes are needed to confirm the findings of this study.

Convulsive-like symptoms as initial indications of basilar artery occlusion: A case series study.

BACKGROUND: There is little evidence regarding relevant clinical findings for the early diagnosis of basilar artery occlusion (BAO) in the prehospital setting. We focused on "convulsive-like symptoms", including convulsive seizures and other convulsive-like movements, and examined the frequency and clinical characteristics of patients with BAO having these symptoms as an initial symptom. METHODS: In this single-center case series from 2015 to 2020, we identified patients who underwent endovascular therapy (EVT) for BAO and presented with convulsive-like symptoms between the stroke onset and initiation of emergency medical care. The clinical course and neurological findings were evaluated by reviewing the run sheets of emergency medical services and medical records. RESULTS: Among a total of 32 patients with BAO, 7 (21.9%) developed convulsive-like symptoms before EVT, of whom 6 were men and whose median age was 72 (interquartile range, 69-78) years. These 7 patients had no history of epilepsy or stroke, and the semiology of convulsive-like symptoms was generalized in 6 of them. In only 3 of the 7 cases, emergency medical services could consider the possibility of stroke on scene, and time from hospital arrival to groin puncture was longer in those who were transported without suspicion of stroke. CONCLUSIONS: 21.9% of our patients who underwent EVT for BAO experienced convulsive-like symptoms initially. We should be vigilant in the possibility of BAO when managing the first-time generalized convulsive-like symptoms occurring in older patients, which may enable to adequate triage and better management for patients with acute BAO.

Prehospital stroke notification and endovascular therapy for large vessel occlusion: a retrospective cohort study.

The impact of prehospital notification by emergency medical services (EMS) on outcomes of endovascular therapy (EVT) for large vessel occlusion (LVO) remains unclear. We therefore explored the association between prehospital notification and clinical outcomes after EVT. In this single-center retrospective study from 2016 through 2020, we identified all LVO patients who received EVT. Based on the EMS's usage of a prehospital stroke notification system, we categorized patients into two groups, Hotline and Non-hotline. The primary outcome was good neurological outcome at 90 days; other time metrics were also evaluated. Of all 312 LVO patients, the proportion of good neurological outcomes was 94/218 (43.1%) in the Hotline group and 8/34 (23.5%) in the Non-hotline group (adjusted odds ratio 2.86; 95% confidence interval 1.12 to 7.33). Time from hospital arrival to both tissue plasminogen activator and to groin puncture were shorter in the Hotline group (30 (24 to 38) min vs 48(37 to 65) min, p < 0.001; 40 (32 to 54) min vs 76 (50 to 97) min, p < 0.001), respectively. In conclusion, prehospital notification was associated with a reduction in time from hospital arrival to intervention and improved clinical outcomes in LVO patients treated with EVT.

Visceral disseminated varicella zoster infection: a rare cause of acute abdomen in a patient with well-controlled diabetes mellitus-a case report.

BACKGROUND: Visceral disseminated varicella zoster virus (VZV) infections frequently affect immunocompromised patients. Diabetes mellitus has been associated with VZV infection, and most cases of disseminated infection involve patients with poorly controlled blood glucose levels. It initially presents as severe abdominal pain, which is evaluated as an acute abdomen, however, the cause is typically unidentified due to unremarkable computed tomography (CT) findings. We report a case of visceral disseminated VZV infection in a patient with well-controlled diabetes mellitus with fat stranding around the celiac and superior mesenteric artery on CT. CASE PRESENTATION: A 61-year-old Japanese woman with well-controlled diabetes mellitus presented to the emergency department with severe abdominal pain that gradually worsened. She had stable vital signs and skin rashes, suggestive of varicella. Abdominal CT showed fat stranding around the celiac and superior mesenteric arteries. The patient tested positive for the VZV antigen and was diagnosed with a visceral disseminated VZV infection. Acyclovir was administered, and the patient was discharged on the 14th day. CONCLUSIONS: Visceral disseminated VZV infection may affect patients with well-controlled diabetes mellitus and causes acute abdomen. Periarterial fat stranding on CT is associated with abdominal pain due to visceral disseminated VZV infection.

Premorbid Clinical Frailty Score and 30-day mortality among older adults in the emergency department.

OBJECTIVES: The association between frailty and short-term prognosis has not been established in critically ill older adults presenting to the emergency department. We sought to examine the association between premorbid frailty and 30-day mortality in this patient population. METHODS: This is a retrospective observational study on older adults aged over 75 who were triaged as Level 1 resuscitation with subsequent admissions to intermediate units or intensive care units (ICUs) in a single critical care center, from January to December 2019. We excluded patients with out-of-hospital cardiac arrest or those transferred from other hospitals. Frailty was evaluated by the Clinical Frailty Scale (CFS) from the patients' chart reviews. The primary outcome was 30-day mortality, and we examined the association between frailty scored on the CFS and 30-day mortality using a multivariable logistic regression model with CFS 1-4 as a reference. RESULTS: A total of 544 patients, median age: 82 years (interquartile rang 78 to 87), were included in the study. Of these, 29% were in shock and 33% were in respiratory failure. The overall 30-day mortality was 15.1%. The adjusted risk difference (95% confidence interval [CI]) in mortality for CFS 5, CFS 6, and CFS 7-9 was 6.3% (-3.4 to 15.9), 11.2% (0.4 to 22.0), and 17.7% (5.3 to 30.1), respectively; and the adjusted risk ratio (95% CI) was 1.45 (0.87 to 2.41), 1.85 (1.13 to 3.03), and 2.44 (1.50 to 3.96), respectively. CONCLUSION: The risk of 30-day mortality increased as frailty advanced in critically ill older adults. Given this high risk of short-term outcomes, ED clinicians should consider goals of care conversations carefully to avoid unwanted medical care for these patients.

Development and external validation of a deep learning-based computed tomography classification system for COVID-19.

BACKGROUND: We aimed to develop and externally validate a novel machine learning model that can classify CT image findings as positive or negative for SARS-CoV-2 reverse transcription polymerase chain reaction (RT-PCR). METHODS: We used 2,928 images from a wide variety of case-control type data sources for the development and internal validation of the machine learning model. A total of 633 COVID-19 cases and 2,295 non-COVID-19 cases were included in the study. We randomly divided cases into training and tuning sets at a ratio of 8:2. For external validation, we used 893 images from 740 consecutive patients at 11 acute care hospitals suspected of having COVID-19 at the time of diagnosis. The dataset included 343 COVID-19 patients. The reference standard was RT-PCR. RESULTS: In external validation, the sensitivity and specificity of the model were 0.869 and 0.432, at the low-level cutoff, 0.724 and 0.721, at the high-level cutoff. Area under the receiver operating characteristic was 0.76. CONCLUSIONS: Our machine learning model exhibited a high sensitivity in external validation datasets and may assist physicians to rule out COVID-19 diagnosis in a timely manner at emergency departments. Further studies are warranted to improve model specificity.

Head CT findings and deterioration risk in children with head injuries and Glasgow Coma Scales of 15.

OBJECTIVE: Head injuries are an important problem in pediatric emergency care. The majority of head injuries are mild. Even when abnormalities are noted on computed tomography (CT), most patients have good outcomes. We aimed to evaluate the clinical course of pediatric patients who had head injuries and Glasgow Coma Scale (GCS) scores of 15, in whom abnormal findings were noted on head CT, to determine the impact of radiographic features on the need for hospitalization and clinical progression. METHODS: We retrospectively examined patients under 15 years of age with isolated mild head injuries, GCS scores of 15, and abnormal CT findings, and visited the emergency department between September 2011 and March 2019. RESULTS: Ninety-nine patients were included in the study. The median age was 2 years (0-15 years), and 61 (62%) patients were male. Eighty-six (87%) patients were hospitalized, and the median hospital stay was 1 day (1-10 days). Sixty-eight (69%) patients underwent repeat CT, and 12 (18%) patients showed signs of radiographic progression. These 12 patients had subdural or epidural hematomas, and surgical intervention was required for two patients (2%). In patients with isolated skull fracture or subarachnoid hemorrhage alone, no deterioration was noted radiographically or clinically. CONCLUSION: Pediatric head injuries with GCS scores of 15 may rarely require surgical intervention, even when CT shows abnormalities. In particular, patients diagnosed with isolated skull fracture or subarachnoid hemorrhage on CT may not require routine hospitalization. A validation study is needed to confirm the findings of this study.

High fever or hypotension predicts non-hypoglycemia in patients with impaired consciousness in prehospital settings.

AIM: To evaluate whether vital signs can predict whether hypoglycemia can be eliminated as the cause of impaired consciousness in prehospital settings. METHODS: We extracted the data of patients who underwent blood glucose measurements by paramedics in Kobe City, Japan from April 2015 to March 2019. We used receiver operating characteristic curves and calculated the area under the curve (AUC) to evaluate the validity of the vital signs in distinguishing hypoglycemia. We also calculated stratum-specific likelihood ratios to examine the threshold at which hypoglycemia becomes less likely for each vital sign. RESULTS: Of the 1,791 patients, 1,242 were eligible for analysis. Hypoglycemia was observed in 324 patients (26.1%). Significant differences in each vital sign were noted between the hypoglycemic and non-hypoglycemic groups. Body temperature was moderately accurate in differentiating between the two groups (AUC, 0.71; 95% confidence interval, 0.68-0.74). Furthermore, in patients with systolic blood pressure <100 mmHg and body temperature ≥38°C, it was unlikely that hypoglycemia caused impaired consciousness (stratum-specific likelihood ratios 0.12 and 0.15; 95% confidence intervals, 0.05-0.25 and 0.06-0.35, respectively). CONCLUSION: In the prehospital assessment of patients with impaired consciousness, high fever or hypotension was helpful in differentiating between hypoglycemia and non-hypoglycemia. In particular, body temperature ≥38°C or systolic blood pressure <100 mmHg indicated a low likelihood of hypoglycemia. A validation study is needed to confirm the findings in this study.

Plasma concentration of amitriptyline and metabolites after resuscitation from cardiopulmonary arrest following an overdose: A case report.

It may need to pay attention to the sustention of moderate cardiotoxicity and delayed elevation of plasma 10-hydroxynortriptyline level in severe amitriptyline overdose case.

[Effects of the prehospital care with and without suspecting acute stroke: a single stroke center study].

We retrospectively examined the differences between paramedic triage and final diagnosis in the cases that were transported to our hospital between May 2016 and March 2019. About 30% of the patients with suspected stroke were diagnosed other than stroke. Some of the patients without suspected stroke were diagnosed with large vessel occlusion and were treated with mechanical thrombectomy. The time from arrival at the hospital to treatment was significantly longer in the patients without suspected stroke than with suspected stroke. To achieve a better prehospital care, we need to accept a wide range of stroke mimics, and to continuously feedback the paramedics about the importance of paralysis, cortical symptoms in stroke.

Clinical characteristics and outcomes of critically ill patients with COVID-19 in Kobe, Japan: a single-center, retrospective, observational study.

PURPOSE: Coronavirus disease 2019 (COVID-19) has placed a great burden on critical care services worldwide. Data regarding critically ill COVID-19 patients and their demand of critical care services outside of initial COVID-19 epicenters are lacking. This study described clinical characteristics and outcomes of critically ill COVID-19 patients and the capacity of a COVID-19-dedicated intensive care unit (ICU) in Kobe, Japan. METHODS: This retrospective observational study included critically ill COVID-19 patients admitted to a 14-bed COVID-19-dedicated ICU in Kobe between March 3, 2020 and June 21, 2020. Clinical and daily ICU occupancy data were obtained from electrical medical records. The last follow-up day was June 28, 2020. RESULTS: Of 32 patients included, the median hospital follow-up period was 27 (interquartile range 19-50) days. The median age was 68 (57-76) years; 23 (72%) were men and 25 (78%) had at least one comorbidity. Nineteen (59%) patients received invasive mechanical ventilation for a median duration of 14 (8-27) days. Until all patients were discharged from the ICU on June 5, 2020, the median daily ICU occupancy was 50% (36-71%). As of June 28, 2020, six (19%) died during hospitalization. Of 26 (81%) survivors, 23 (72%) were discharged from the hospital and three (9%) remained in the hospital. CONCLUSION: During the first months of the outbreak in Kobe, most critically ill patients were men aged ≥ 60 years with at least one comorbidity and on mechanical ventilation; the ICU capacity was not strained, and the case-fatality rate was 19%.

Cost-effectiveness of extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: A multi-centre prospective cohort study.

AIM: Extracorporeal cardiopulmonary resuscitation (ECPR) is an evolving resuscitative method for refractory cardiopulmonary arrests. However, considering the substantial healthcare costs and resources involved, there is an urgent need for a full economic evaluation. We therefore assessed the cost-effectiveness of ECPR for refractory ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT). METHODS: We developed a decision model to estimate lifetime costs and outcomes for out-of-hospital cardiac arrest patients with VF/pVT who received either ECPR or conventional cardiopulmonary resuscitation. Quality-adjusted life-years (QALY) was used as the main outcome measure. This model was a combination of a decision tree model for the acute phase based on a prospective observational study (SAVE-J study), together with a Markov model for long-term follow-up periods extrapolated from published data. To evaluate the robustness of this model, we conducted a comprehensive deterministic sensitivity analysis (DSA) and a probabilistic sensitivity analysis (PSA). RESULTS: ECPR was cost-effective, with an incremental cost of ¥3,521,189 (Є30,227), an incremental effectiveness of 1.34 QALY, and an incremental cost-effectiveness ratio of ¥2,619,692 (Є22,489) per QALY gained. DSA revealed that the present model was most sensitive to probability of Cerebral Performance Category 1 after ECPR (¥2,153,977/QALY to ¥3,186,475/QALY), patient age (¥2,170,112/QALY to ¥3,334,252/QALY), and long-term medical cost for modified Rankin Scale 0 (¥2,280,352/QALY to ¥2,855,330/QALY). PSA indicated ECPR to be cost-effective and below the willingness-to-pay threshold of ¥5,000,000 with an 86.7 % possibility. CONCLUSIONS: ECPR was an economically acceptable resuscitative strategy, and the results of the present study were robust even when considering the uncertainty of all parameters.