Peak C-reactive protein levels do not predict 30-day mortality for bacteremia: A retrospective cohort study.

INTRODUCTION: Although peak C-reactive protein (CRP) levels are correlated with the prognosis of some diseases, there have been no reports regarding the association between peak CRP levels and mortality in patients with bacteremia. The present study aimed to determine the association between peak CRP levels and prognosis in patients with bacteremia. METHODS: This retrospective cohort study was conducted in a single tertiary hospital and included patients with bacteremia admitted to the emergency department from November 2012 to March 2017. Cox regression analysis was performed to examine the association between peak CRP levels and 30-day mortality. We also performed propensity score adjustment using potential confounding factors. RESULTS: One hundred fifty-nine patients were included in the study. Peak CRP levels were significantly higher in the ß-hemolytic streptococci (P = 0.001) and Streptococcus pneumoniae (P = 0.003) groups. The C-statistic of the multivariate logistic regression model for the propensity score was 0.88. For 30-day mortality, peak CRP levels >20 mg/dL did not show significance in the Cox regression analysis (hazard ratio, 0.866; 95% confidence interval, 0.489-1.537; P = 0.62). Even after propensity score adjustment, no significance was noted (hazard ratio, 0.865; 95% confidence interval, 0.399-1.876; P = 0.71). CONCLUSIONS: Peak CRP levels were not an independent predictor of mortality in patients with bacteremia in the emergency department. Clinicians should consider that patients with extremely high peak CRP levels do not necessarily have high mortality and vice versa.

[Emergency medical services in a hyper-aged society].

The number of people aged 65 and older in Japan has reached 23.3%. The annual rate of presentations to hospital emergency departments(ED) has increased substantially and older patients are represented in this increase. By 2060 the number of people aged 65 and over is expected to double to 40%, and ED transfers and hospital admissions will increase significantly. Facilities will need to plan to accommodate increasingly greater demands for ED and hospital services.

Isolated right ventricular takotsubo cardiomyopathy presenting as acute right ventricular failure: A case report.

Background: Takotsubo cardiomyopathy (TTC) is a non-ischaemic cardiomyopathy, characterized by transient wall motion abnormalities of the left ventricle. Although biventricular involvements are common with a poor prognosis, isolated right ventricular (RV) involvement of TTC is a rare, and its diagnosis remains challenging. Case presentation: We encountered a case of isolated RV-TTC presenting as acute RV failure, with progression to cardiogenic shock requiring intensive treatment. Conflicting echocardiographic findings of RV asynergy with RV enlargement despite normal left ventricular wall motion and mild tricuspid regurgitation led to the correct diagnosis. Finally, the patient showed complete recovery with normalization of cardiac structure and function. Conclusions: This case underscores the clinical significance of considering isolated RV-TTC as a new distinct variant form of TTC in terms of presentation, diagnostic findings, differential diagnosis, treatment strategy, and prognosis.

False-negative rate of SARS-CoV-2 RT-PCR tests and its relationship to test timing and illness severity: A case series.

Objective: To determine the false-negative rate of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reverse-transcription polymerase chain reaction (RT-PCR) test results, and to describe the characteristics of coronavirus disease 2019 (COVID-19) patients with false-negative results. Methods: We validated SARS-CoV-2-positive RT-PCR test results performed in hospitalized patients between February 1 and August 31, 2020 and classified the patients according to disease severity. Results: In total, 2038 SARS-CoV-2 RT-PCR tests were performed on 1890 patients. Of these, 145 patients had positive results and were diagnosed with COVID-19. Among the 145 patients with COVID-19, the initial RT-PCR tests were negative in five patients. Of these, three had moderate illness and were initially tested in the early stage of disease, and two had severe illness and were initially tested in the late stage of disease, when RT-PCR testing has lower sensitivity due to viral clearance. Conclusions: These findings suggest that false-negative results can be caused by both observer errors and by low viral RNA levels in the later stages of disease, after the infection has cleared. Clinicians should be aware that patients with COVID-19 can have negative RT-PCR test results in the later stages of infection.

Case Report: Spontaneous Postpartum Quadruple Cervicocephalic Arterial Dissection With a Heterozygous COL5A1 Variant of Unknown Significance.

Pregnancy-associated cervicocephalic arterial dissection is rare, and its pathophysiology remains poorly understood. Despite the hypothesized contribution to pathogenesis, connective tissue diseases and genetic factors are rarely identified in clinical cases. We describe a case of postpartum arterial dissection involving all four cervicocephalic arteries resulting in acute cerebral infarction. The patient underwent successful endovascular thrombectomy and angioplasty and recovered fully without sequelae. Genetic screening for connective tissue diseases identified a heterozygous missense COL5A1 variant with unknown clinical significance. Two genetically related family members later developed arterial abnormalities, and one of them tested positive for the same COL5A1 gene variant as our patient, while the other was scheduled for genetic testing. The extensive clinical presentation of our patient and the prevalence of arterial abnormalities in her family warrant further assessment of the association between the identified COL5A1 gene variant and the pathogenesis of arterial dissections.

Case studies of SARS-CoV-2 treated with favipiravir among patients in critical or severe condition.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak is rising globally. However, clinically effective antiviral treatments are not established. Favipiravir may prevent pneumonia and acute respiratory distress syndrome aggravation. We describe SARS-CoV-2-positive patients, two of whom were in a critical condition and one of whom was in a severe condition, who were administered favipiravir for their deteriorating conditions and cured.

[Tension pneumothorax associated with re-intubation through percutaneous tracheostoma site].

Percutaneous tracheostomy (PT) has become popular recently, but occasionally cannula exchange can be difficult and hazardous. A 55-year-old woman with pontine hemorrhage was admitted to our ICU after oral intubation. On the 3 rd day, PT was performed with no complication to prepare for prolonged airway management. On the 14 th day, surgical removal of the pontine hematoma was scheduled. Since our neurosurgeon requested a prone position with maximal neck anteflexion, she was re-intubated orally and the tracheostomy cannula was removed during the operation. At the end of the operation, the tracheostoma had already been narrowed and re-insertion of a narrower tracheostomy cannula was unsuccessful even with bronchoscopic guidance. Following several attempts, her Spo2 gradually decreased and her blood pressure dropped. A chest X-ray showed right pneumothorax and a chest drainage tube was inserted. Posterior tracheal wall injury was suspected, though the exact injury site was not identified bronchoscopically. She was treated conservatively because no air leak was observed after advancing the oral tube. Three weeks later, surgical tracheostomy was performed without major abnormal findings. A small tracheostoma characteristic of PT might be associated with an increased risk of delayed airway complication. Cannula exchange should be performed more carefully after PT compared with surgical tracheostomy.

[Case report of repeated acetaminophen overdosing with various symptoms].

A 32-yr-old woman with acute gastritis and migraine used Naron commonly (the principal ingredients are acetaminophen and bromvalerylurea) and had been taking about 3g of acetaminophen daily for several days before admission. She was hospitalized with severe diffuse abdominal pain. On physical examination she had a peritoneal sign and laboratory studies showed elevated liver enzymes, hypophosphatemia, hypokalemia and low blood urea nitrogen(BUN). Serum acetaminophen level was 5.5 microg/mL on admission, so she seemed to be suffered from not only single ingestion but also repeated overdosing. Although we needed for aggressive phosphate and potassium repletion for about a week, all symptoms were distinguished after she quitted acetaminophen ingestion. In addition to hepatic dysfunction, renal failure and disseminated intravascular coagulopathy, we should pay attention to various symptoms like in this case when treating for a acetaminophen poisoning.

Investigation and treatment of pulmonary embolism as a potential etiology may be important to improve post-resuscitation prognosis in non-shockable out-of-hospital cardiopulmonary arrest: report on an analysis of the SOS-KANTO 2012 study.

Background: The prognosis of non-shockable out-of-hospital cardiac arrest is worse than that of shockable out-of-hospital cardiac arrest. We investigated the associations between the etiology and prognosis of non-shockable out-of-hospital cardiac arrest patients who experienced the return of spontaneous circulation after arriving at hospital. Methods and Results: All subjects were extracted from the SOS-KANTO 2012 study population. The subjects were 3,031 adults: (i) who had suffered out-of-hospital cardiac arrest, (ii) for whom there were no pre-hospital data on ventricular fibrillation/pulseless ventricular tachycardia until arrival at hospital, (iii) who experienced the return of spontaneous circulation after arriving at hospital. We compared the patients' prognosis after 1 and 3 months between various etiological and presumed cardiac factors. The proportion of the favorable brain function patients that developed pulmonary embolism or incidental hypothermia was significantly higher than that of the patients with presumed cardiac factors (1 month, P < 0.0001 and P < 0.0001, respectively; 3 months, P = 0.0018 and P < 0.0001, respectively). In multiple logistic regression analysis, pulmonary embolism and incidental hypothermia were found to be significant independent prognostic factors for 1- and 3-month survival and the favorable brain function rate. Conclusions: In patients who suffer non-shockable out-of-hospital cardiac arrest, but who experience the return of spontaneous circulation after arriving at hospital, the investigation and treatment of pulmonary embolism as a potential etiology may be important for improving post-resuscitation prognosis.

[A case of acute ethanol intoxication with remarkable hyperglycemia by "ume-shu", a Japanese apricot liquor made with a large amount of sugar].

A 19-year-old woman ingested 2.2 L of "umeshu", a Japanese apricot liquor made with a large amount of sugar. She was unconscious and in shock. The estimated blood ethanol concentration was 607 mg/dl, and the blood glucose level was 576 mg/dl. Because her respiration and circulation was highly suppressed, blood purification was indicated. Continuous hemodiafiltration (CHDF) was performed instead of hemodialysis because her hemodynamics was unstable. After CHDF was instituted, her blood glucose level reduced to normal range, and her consciousness became alert. CHDF was effective in eliminating ethanol and stabilizing her hemodynamics within an early stage. Though acute ethanol intoxication is known to inhibit glucogenesis, leading to hypoglycemia, marked hyperglycemia was seen in this case. Ingestion of a large amount of glucose-rich liquor and being in shock seemed to be the causes of hyperglycemia.