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.

Risk factors for ground-level falls differ by sex.

BACKGROUND: The populations of many developed countries have been aging in recent years, resulting in increasing numbers of elderly-related injuries. Conventionally regarded as minor, injuries from ground-level falls are now associated with a higher risk of death for elderly people. METHODS: The subjects of this study were 15662 adult patients with injuries from ground-level falls who were registered in the Japan Trauma Data Bank between 2007 and 2013. Logistic regression analysis was used to evaluate the effects of age, sex, Injury Severity Score, and Revised Trauma Score (RTS) on inhospital mortality. Patients aged 60 years or older were further categorized into 4 subgroups by age and sex, and the effect of the presence of injuries of Abbreviated Injury Scale greater than or equal to 3 in each region on inhospital mortality was analyzed. RESULTS: Logistic regression analysis for inhospital mortality showed significant interactions between sex and age and between sex and RTS, and subgroup analysis by sex was, therefore, performed. The odds ratio (95% confidence interval) for inhospital mortality compared with patients older than 60 years was 2.75 (1.90-3.96) for men aged 60 to 79 years and 5.44 (3.77-7.85) for men 80 years or older and 1.46 (0.83-2.58) for women aged 60 to 79 years and 2.32 (1.35-4.01) for women 80 years or older. The odds ratios (95% confidence interval) for RTS less than 7.840 was 6.89 (5.56-8.55) for men and 9.97 (7.59-13.10) for women. CONCLUSIONS: The effects of age and RTS on inhospital mortality of patients after ground-level falls differed by sex.

Serum concentration of eperisone hydrochloride correlates with QT interval.

BACKGROUND: Eperisone hydrochloride is a centrally acting muscle relaxant prescribed for muscle stiffness that acts by depressing the activities of α and γ efferent neurons in the spinal cord and supraspinal structures. Although a case of eperisone-induced severe QT prolongation had been reported, the relationship between serum eperisone concentration and QT interval remains obscure. OBJECTIVE: The aim of this study was to investigate the relationship between serum eperisone concentration and QT interval. METHODS: Four patients who overdosed on eperisone were admitted to our hospital between January 2010 and December 2011. We took simultaneous serial measurements of serum eperisone concentration and QT interval in the intensive care unit. In total, 22 measurement points were plotted for these patients. We analyzed the correlation between the serum eperisone concentration and corrected QT (QTc) interval. RESULTS: Three men and one woman (mean age, 50 years) overdosed on eperisone with an average dose of 3087.5 mg (therapeutic dose, 150 mg/day). The mean QTc interval at arrival was 592 ms (range, 444-825 ms), and the mean serum eperisone concentration at arrival was 1257.5 ng/mL (range, 14.5-4120.0 ng/mL). The correlation coefficient was 0.833 between serum eperisone concentration and QTc interval (P < .001). CONCLUSION: Serum eperisone concentration correlates with QTc interval in patients who overdose on eperisone.

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.

Safety of cannabidiol products as a social issue: A case series.

Background: Cannabidiol (CBD) products have increased in popularity in Japan in recent years, particularly among young people. Some CBD products contain tetrahydrocannabinol (THC), the main ingredient of cannabis, and its analogs, which are illegal in Japan and have become a social issue. This report discusses the safety of CBD products. Case Presentation: Five patients with symptoms of CBD ingestion, including nausea, presented to our hospital. Three of the products these patients ingested contained THC. Metabolites of THC were detected in the blood and urine of all three patients, although there were some discrepancies in the urine drug screening test (DS10®). These examination results differed even when the same product was consumed. Conclusion: CBD products are unsafe and may unintentionally contain THC. It is also important to understand that CBD can turn into THC, and the effective time needed to conduct urine drug screening.

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.

Reduction of immunocompetent T cells followed by prolonged lymphopenia in severe sepsis in the elderly.

OBJECTIVE: To investigate the immunological changes caused by severe sepsis in elderly patients. DESIGN: One-year, prospective observational study. SETTING: Emergency department and intensive care unit of a single university hospital. PATIENTS: Seventy-three patients with severe sepsis and 72 healthy donors. MEASUREMENTS AND MAIN RESULTS: In elderly septic patients (aged 65 yr and over), 3-month survival was significantly reduced compared with that for adult patients (18-64 yr) (60% vs. 89%, p < 0.01). We found that lymphopenia was prolonged for at least 21 days in elderly nonsurvivors of sepsis, while the number of lymphocytes recovered in both adult and elderly survivors of sepsis. In order to examine the immunological status of septic patients, blood samples were collected within 48 hrs of diagnosis of severe sepsis, and peripheral blood mononuclear cells were purified for flow cytometric analysis. T cell levels were significantly reduced in both adult and elderly septic patients, compared with those in healthy donors (56% and 57% reduction, respectively). Interestingly, the immunocompetent CD28+ subset of CD4+ T cells decreased, whereas the immunosuppressive PD-1+ T cells and the percentage of regulatory T cells (CD4+ T cells that are both Foxp3+ and CD25+) increased in elderly patients, especially nonsurvivors, presumably reflecting the initial signs of immunosuppression. CONCLUSION: Reduction of immunocompetent T cells followed by prolonged lymphopenia may be associated with poor prognosis in elderly septic patients.

Portal venous gas on computed tomography imaging in patients with decompression sickness.

BACKGROUND: It has been reported that portal venous gas is rarely found on computed tomography (CT) imaging in patients with decompression sickness (DCS). However, we propose that this is not true because we have encountered several patients with DCS who presented with portal venous gas on CT before hyperbaric oxygen therapy (HBOT). Here, we review our charts and present these patients' characteristics. CASES: We treated 37 patients with DCS from April 2007 to September 2011. Nine of these 37 patients underwent CT (thoracic, abdominal, or both) on admission because of dyspnea and other reasons. In four of nine patients, portal venous gas was incidentally found on CT. All patients were male, and three of them were SCUBA (self-contained underwater breathing apparatus) divers. Most of the patients did not have abdominal complaints. Three of four patients presented with gas in other abdominal areas (e.g., mesentery or inferior vena cava). HBOT (United States Navy Treatment Table 6) was performed in all patients, and abdominal CT performed after HBOT in three of four patients revealed the complete disappearance of portal venous gas and other venous gases. One patient died, and the remaining patients survived without any complications. CONCLUSIONS: Most patients with DCS do not require CT examination before HBOT. However, if all patients with DCS undergo abdominal CT, the presence of portal venous gas in these patients may no longer be a rare finding. Although routine CT is not required for patients with DCS, it might be helpful for diagnosis.

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.

Sudden asphyxia caused by retropharyngeal hematoma after blunt thyrocervical artery injury.

BACKGROUND: Retropharyngeal hematomas are often associated with blunt cervical spine injury. Generally, they improve with conservative treatment; however, rarely, airway obstruction occurs due to delayed swelling of retropharyngeal hematoma. OBJECTIVES: To report a case of sudden asphyxia due to retropharyngeal hematoma caused by blunt thyrocervical artery injury. CASE REPORT: A 30-year-old woman was admitted to the Emergency Department of Tokai University Hospital 4h after injury in a motor vehicle collision. On arrival, she had severe dyspnea and neck swelling; thereafter, a 26-mm-thick retropharyngeal swelling was visualized on lateral cervical plain X-ray study, extending from C1 anterior vertebrae to mediastinum. Emergency intubation was performed for the asphyxia. Because extravasation of contrast agent was observed in the hematoma on emergency contrast-enhanced computed tomography (CT) scan, emergency angiography was performed, from which we diagnosed a hemorrhage from the right thyrocervical artery. CONCLUSION: If a patient with a non-displaced cervical spine injury suffers airway obstruction due to retropharyngeal hematoma, vigorous hemorrhage from a thyrocervical artery injury should be considered as the cause, and emergency contrast-enhanced CT scan of the neck should be performed after emergent tracheal intubation.

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.

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.

Autopsy Case Report of Severe COVID-19 Pneumonia at a General Municipal Hospital.

We present the autopsy procedure and findings of severe coronavirus disease 2019 (COVID-19) pneumonia in an 85-year-old man. The patient required intubation immediately after admission for severe COVID-19 pneumonia. He had severe hypoxia that did not improve despite treatment with remdesivir, corticosteroids, and appropriate mechanical ventilation. On day 13, the patient developed sudden hypercapnia. His renal dysfunction subsequently worsened and became associated with hyperkalemia, and he passed away on day 15. An autopsy was performed to clarify the cause of the hypercapnic hypoxia. None of the medical personnel involved in the autopsy developed symptoms of COVID-19. Histologic examination showed various stages of diffuse alveolar damage throughout the lungs, with intra-alveolar hemorrhage in the upper zones. Microscopic examination of the kidneys revealed acute tubular necrosis. There was no significant systemic thrombosis. The autopsy findings were consistent with those typical of COVID-19.

Efficacy of portable and percutaneous cardiopulmonary bypass rewarming versus that of conventional internal rewarming for patients with accidental deep hypothermia.

OBJECTIVE: Since 2001, at our institution, a portable and percutaneous cardiopulmonary bypass system has been used for rewarming of patients with accidental deep hypothermia. Before 2001, a conventional internal rewarming technique was used. The aim of this research is to examine the efficacy of portable and percutaneous cardiopulmonary bypass for rewarming of patients with accidental severe hypothermia and compare it with that of conventional rewarming methods. DESIGN: Historical study. SETTING: The exclusive emergency medical center and trauma center level 1 in Western Kanagawa, Japan. PATIENTS: From April 1992 to March 2009, 70 patients with accidental deep hypothermia (core temperature <28°C) were transferred to our hospital. Two patients presented with intracranial hemorrhage on initial head computed tomography scans. These two patients were excluded because each required an emergency operation. Therefore, 68 patients were included in this study. We compared patients' clinical characteristics and outcomes. The parameters included the following: sex, age, vital signs on arrival to our hospital (Glasgow coma Scale scores, systolic blood pressure, heart rate, respiratory rate, core temperature), electrocardiogram on arrival to our hospital, rewarming speed, time of rewarming until 34°C was reached, ventricular fibrillation occurrence rate during rewarming, cause of cold environmental exposure, Glasgow Outcome Scale scores, and mortality. In addition, we divided the conventional and portable and percutaneous cardiopulmonary bypass rewarming groups into two categories depending on whether cardiopulmonary arrest occurred on arrival to our hospital. We also compared the survival rate and average Glasgow Outcome Scale scores for each group. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients' clinical backgrounds did not differ significantly between the conventional and portable and percutaneous cardiopulmonary bypass rewarming groups. Glasgow Outcome Scale scores and survival rates of the portable and percutaneous cardiopulmonary bypass rewarming group patients, irrespective of whether cardiopulmonary arrest was experienced on arrival to our hospital, were significantly higher than those of the conventional rewarming group. CONCLUSIONS: Portable and percutaneous cardiopulmonary bypass rewarming can improve the mortality rates and Glasgow Outcome Scale scores of accidental deep hypothermia patients.

Comparative study of nifekalant versus amiodarone for shock-resistant ventricular fibrillation in out-of-hospital cardiopulmonary arrest patients.

BACKGROUND: In Japan, intravenous nifekalant (NIF) was often used for direct current cardioversion-resistant ventricular fibrillation (VF), until the use of intravenous amiodarone (AMD) was approved in 2007. The defibrillatory efficacy of NIF and AMD has thus far not been compared for resuscitation. METHODS AND RESULTS: Between August 2007 and April 2009, 403 consecutive out-of-hospital patients with cardiopulmonary arrest were transferred to the Emergency Medical Service of Tokai University. Of these, 30 patients with first defibrillation failure or VF recurrence were enrolled for this NIF/AMD study. The final defibrillation success (and hospital survival rate) was 67% (10/15) in the AMD and 47% (7/15) in the NIF group. The discharge survival rate was 53% (8/15) in the AMD and 21% (4/15) in the NIF group (P = 0.06). Notably, all 4 survivors in the NIF group could take up normal daily life again, whereas this was restricted to only 2 patients from the 11 survivors in the AMD group. The difference is probably partly attributable to longer time from AMD administration to defibrillation success compared with NIF. In the cases of defibrillation failure, VF continued in 4/8 by NIF, however, asystole or pulseless electrical activity occurred in 4/5 patients by AMD. CONCLUSIONS: AMD may be borderline superior over NIF to facilitate defibrillation in out-of-hospital patients with cardiopulmonary arrest. However, from the view point of preservation of brain function, NIF is not inferior to AMD for CPR.

Accuracy of pulse checks in terms of basic life support by lifesavers, as lay persons.

BACKGROUND: The lifesavers responsible for lifesaving at the waterside routinely undergo cardiopulmonary resuscitation (CPR) training, but in Japan, they are considered as lay persons. Lifesavers are likely to have better basic life support skills than lay persons. The objective of this study is to demonstrate that the accuracy of carotid pulse checks by lifesavers is not inferior to that of paramedics and is superior to that of lay persons by using CPR training mannequins. METHODS AND RESULTS: This was an observational study in which the subjects included 48 lifesavers certified by the Japan Lifesaving Association, as well as 16 paramedics and 15 lay persons. The accuracy of the examinees' answers and the time taken to answer in the 3 groups were compared. The accuracy rate was 93% in lifesavers, 94% in paramedics, and the difference was not significant (P=1). The accuracy rate of the lay persons' answers was 63%, with significant differences between this group and the lifesavers (P<0.001) and the paramedics (P<0.001). The average time taken to answer the questions was 6.6 s for the lifesavers and 7.0 s for the paramedics, and the difference was not significant (P=0.44). The average time taken to answer the questions from the lay persons group was 20.5 s, with significant differences between this group and the lifesavers (P<0.001) and the paramedics (P<0.001). CONCLUSIONS: The results of this evaluation, using CPR-training mannequins, to test the accuracy of carotid pulse checks by lifesavers were equivalent to those of paramedics and superior to those of lay persons.

Tako-tsubo-like left ventricular dysfunction with ST-segment elevation after central spinal cord injury: a case report.

The etiology of a novel cardiac syndrome called "tako-tsubo" cardiomyopathy, otherwise known as "acute onset and reversible left ventricular apical wall motion abnormality (ballooning)," is very similar to that of acute myocardial infarction; however, it may also be associated with emotional or physical stress. We report a case of tako-tsubo-like left ventricular dysfunction with ST-segment elevation after trauma. A 69-year-old man was transferred to our hospital after a fall in which he injured his back. He was diagnosed with a central spinal cord injury and was admitted to our Intensive Care Unit. He complained of a sudden chest pain 12 h after the injury. ST-segment elevation was observed on the electrocardiographic monitor, and subsequent 12-lead electrocardiogram demonstrated ST-segment elevation in leads V(2) through V(5). We considered acute myocardial infarction or cardiac contusion to be the cause of this event; therefore, an emergency coronary angiography was performed. However, the angiography revealed no significant coronary artery stenosis. Furthermore, left ventriculography demonstrated severe hypokinesis of the left ventricular apical region, consistent with tako-tsubo-like left ventricular dysfunction. The patient's cardiac function improved gradually, and he was discharged from our hospital on the 18(th) day after admission. Physicians should recognize the syndrome of tako-tsubo-like left ventricular dysfunction, which may result from traumatic stress or chest injury.